By Jennifer Farley, PsyD,
Lindner Center of HOPE, Staff Psychologist

There are a number of reasons someone may undergo a psychological evaluation or assessment. The type of testing that is done depends on the individual’s functioning and the setting in which testing may be pursued. This article will look at the different settings of mental health assessments.

Types of Mental Health Assessment Settings

  • Outpatient
  • Inpatient
  • Residential
  • Children’s Assessments

Psychological Assessment in an Outpatient Setting

Testing from a clinical psychologist in a clinical outpatient setting can be pursued on their own or they may be referred from another clinician (such as a primary care physician or psychiatrist). This type of assessment is for patients with non-immediate mental health concerns. In this case, testing is pursued with the referral question in mind (such as whether someone has Attention Deficit/Hyperactivity Disorder, depression, anxiety, a learning disorder, dementia, cognitive problems due to a medical condition, etc). The psychologist tailors the tests to help determine the person’s functioning in the areas that could be affected by a cognitive or emotional disorder. Tests can range from intellectual assessments to personality measures to behavioral questionnaires (which can be completed by the patient themselves, parents, and/or teachers) to academic achievement measures. Clinicians such as neuropsychologists and developmental psychologists can do all these tests and then add additional measures specific to their specialization (such as when documenting problems related to a head injury or when evaluating for Autism Spectrum Disorder). The psychologist can use this information to make a diagnosis and provide recommendations for treatment of the condition. Often, such as for school-age or college-age patients, recommendations for academic accommodations are also provided.

Psychological Assessment In An Acute Inpatient Unit

Sometimes, psychological testing is completed for patients during an acute inpatient psychiatric hospitalization (when the patient is in a mentally unstable condition). In these cases, testing is often used for diagnostic elucidation to help guide decisions about types of medication to use. Recommendations may also be made about additional assessments or resources to pursue following one’s discharge from the hospital. The clinical psychologist completes these evaluations within a short time, since these acute hospitalizations last (on average) about 7 days, and there are usually just a few measures that are administered. Tests are specific to the question about the individual’s diagnosis and may only include emotional/personality measures.

Psychological Assessment in a Residential Setting

Another setting in which psychological testing may occur is within a residential psychiatric setting. This setting is for patients who are experiencing psychological distress that is not severe enough to warrant an acute inpatient hospitalization. Length of stay in a residential setting can vary from 10 days to several months, depending on the purpose of the stay (i.e., evaluation and/or treatment). The purpose of testing in a residential setting is to help comprehensively understand – by way of several different measures – one’s personality functioning, cognitive functioning (which can include neurocognitive skills such as attention, memory, and executive functioning), and other factors (such as external stressors, substance use, medical conditions, etc.) that have contributed to the patient’s condition(s). The patient’s internal strengths and weaknesses are explored, with the intention of making recommendations for how treatment can be tailored to work with the patient’s strengths to compensate for their weaknesses. The clinical psychologist works closely with the other members of the treatment team (such as the psychiatrist, social worker, and the therapists) to understand the patient, develop a treatment plan, and (if a longer stay) to begin implementing the recommendations. The patient’s progress is then monitored and, if needed, further testing can be done to help assess changes in the patient’s functioning as a result of the treatment.

Psychological Assessment in Childhood

In childhood, early observations of potential problems may come from teachers. Teachers may observe struggles in behavior such as impulsivity, talking or interrupting others during times when there is an age-appropriate expectation of silence, and/or oppositional behaviors towards others. Teachers may also be the first to wonder if a child has an underlying learning or attention disorder. If the teacher’s attempts to help the child are unsuccessful, the teacher may recommend testing in the form of a Multi-Factored Evaluation (MFE). Psychological testing may be part of this evaluation and can include intellectual testing and academic achievement testing by a school psychologist. Parent and teacher questionnaires may also be included in the MFE. Depending on the nature of the child’s observed difficulties, others (such as speech and language therapists and physical therapists) may do their own screening. If findings reveal that the student experiences problems that would make learning difficult, accommodations are then recommended and interventions and/or accommodations are then put in place through a 504 Plan or an Individualized Education Plan. It is noteworthy that clinical diagnoses are NOT made from this type of evaluation and findings and recommendations are specific to helping the child learn better.

Prior to any psychological testing, the patient (and/or his/ her family) should understand the purpose of psychological assessment and how it can be useful for guiding treatment and other recommendations.

Find out more information on what psychological assessment is here and why it is a critical step of the process towards finding a diagnosis and treatment plan.

Finding Help and HOPE

If you, or someone you know, is experiencing a mental health crisis, there is help available. The first step would be to consult with a health care provider or mental health care specialist. To see how Lindner Center of HOPE can help you decide on the best mental health assessment setting, reach out to us today. We can help you take the next steps. 

 

Self-Discipline, by definition, is the ability to listen and to act based on your inner voice, regardless of how you feel, other influences, or the temptations you face. Discipline is the key to self-mastery. So why is this so hard?

So many people struggle with maintaining healthy choices and keeping to their goals. We have misperceptions that we are supposed to be excited and want to be engaged in these wellness practices. The truth is… discipline is hard. It’s rarely anything that we love to do or get super excited about. It’s often something we internally combat and make excuses for. We will find 100 reasons why we should not deliver or more importantly not show up for ourselves. Breaking into a better emotional and behavioral state is work, hard work. We need to accept that this will always be hard work and something that you must employ, daily or regularly, if you want to feel better and be better!

Research shows that people who have a good sense of discipline are less likely to suffer from major mental health issues and more likely to experience overall increased wellness. Some mental health benefits of being disciplined are it increases depressed moods, it creates less anxiety or stress, it combats drugs or alcohol abuse, it decreases potential for develop eating disorders, and it helps manage obsessive compulsive disorders.

Often mental health practitioners will say, “the key to real therapeutic change is when someone finally figures out how to show up for themselves.” It’s the improved habits and disciplines they enforce on themselves that creates positive change. They learn to be healthier and show up successfully.

The benefit of any discipline consistently comes later. It’s not always in the moment of but the sooner or later future. It will show up in the long term and create a new fondness of self. It’s choosing what I want the most. It will get you to the transformative self. Self- discipline creates confidence and motivation. Confidence being the internal stability of self-worth and motivation being the momentum. Momentum will keep the motivation alive. It will increase your focus making you work harder. Discipline creates a drive to succeed and find joy in the success. By being disciplined you will gain tolerance, patience, and a better sense of self-control. All key traits needed for an overall healthy, happy person to be present every day.

Easy steps to create a discipline:

  1. Set clear goals. Clearly outline what your goal means to you and how you intend to achieve it. Meaning is necessary for a discipline to be initiated.
  1. Make a commitment to yourself. You must have meaning and purpose in this. Knowing you are worth the effort and wanting to get back the control of your life.
  1. Make it apart of your daily routine. It is critical to make time each day and figure out where the discipline will fit into your day. Make a place for it, be consistent. Establishing an autopilot routine is essential for the discipline to occur.

Keeping distractions and temptations away will help you to commit and focus on your goals. Being mindful or purposeful of your attention about what your goals are and when your discipline should take place will help you stay on track. Persevering, staying steadfast through hard times will keep you motivated and keep you from self-sabotaging. Executing or carrying the discipline through will keep you in alignment of success and build the journey of your productive self.

Self-discipline is a practice. It is something that you must demonstrate everyday even if you fail or falter. You must put exertion at it and be available to it. You must practice repeatedly until it becomes an automatic behavior and/or thought. Find the courage to put the work in, be patient, and wait with hope.

By: Kristina Tracy, LISW-S

 

Julie Foster, LISW-S, RN, MEd

There are many types of eating disorders. The most commonly talked about eating disorders are anorexia nervosabulimia nervosabinge-eating disorder, and avoidant restrictive food intake disorder. National Eating Disorders Awareness Week (NEDAW) is an observance to bring awareness to the seriousness of eating disorders across the United States. It is estimated that over 28 million Americans will have an eating disorder in their lifetime. (https://www.womenshealth.gov/nedaw).

So, what can employers and leaders do to help?

Fatphobia and body shaming are so woven into our workplaces that often it goes unchecked. In fact, it is a microaggression normalized by “wellness” programs in the workplace that encourage weight and calorie tracking, weight loss incentives, and “Biggest Loser” competitions.

There is “evidence that weight stigma is a bigger risk to people’s health than weight itself and what they eat.” (Harrison, 2021)

Weight-loss challenges can actually be one manifestation of a hostile work environment.

And anyway, dieting does not work! 95% of those who diet may lose weight in the short term, but they gain that weight back and more within 1 to 5 years. (Fildes et al., 2015)

Instead of weight loss competitions, how about implementing “No diet/body talk zones” and including weight discrimination in workplace diversity and inclusion efforts. Workplace leaders can start to change the office culture by modeling zero tolerance for body shaming and also by  supporting employees who are actively fighting against diet culture. Leaders can fight weight discrimination by examining their hiring practices and normalize not just Health at Every Size (HAES) but also leaning into the truth that size has no bearing on one’s intelligence or work ethic.

How can you shut down body-shaming? Start with yourself. What kind of things do you say, out loud, at work, about your body and what you are, and are not, eating? Change the narrative and speak up when others are making fatphobic comments. What others are eating or not eating is no one’s business. Commenting on someone’s weight in any fashion is not appropriate any more than commenting on anything else about their body.

You wouldn’t agree with   a colleague  making racist or homophobic remarks, so the same should be true if employees are body shaming. Here’s how you could respond:

“Why would you think it’s okay to say something fatphobic like that?” Or, “Why do you think it’s okay to discuss ______’s body?”

Another important part of creating a body-size inclusive culture is to conduct a physical audit of your environment. Are there chairs and workstations to accommodate all sizes of bodies? Are your waiting areas or lobbies welcoming to all sizes of bodies? Do your vending machines sell regular and low-calorie drinks for the same price?

Just like “love is love”, “food is food.” Food is neutral, not good or bad. What you eat does not define you as good or bad or qualify as being good or bad. And it’s no one’s business what or how much someone else is eating, so request employees keep their commentary (which is probably related to their own insecurities) to themselves. It is important for leadership to recognize that it is likely that a percentage of their workforce has, or has had, and eating disorder, and comments about food and size can be very triggering for them. What might seem like a neutral comment (“I can’t believe how bad I was! I ate that whole piece of cake!”) reinforces to someone with an eating disorder that food and eating is bad or shameful.  Or talking about how you haven’t eaten all day as some badge of honor reinforces to others that they are somehow weak or wrong for eating regularly.

It is also important to remember that an eating disorder is a disability, therefore the Equality Act 2010 applies. Eating disorders are the most lethal of all mental illnesses. Managers and colleagues should be aware that individuals with eating disorders, as with any long-term health condition, may have changes their performance.

Reasonable adjustments for those suffering with an eating sidorder could include: flexibility in allowing time off for appointments, working hours or extended lunch or other breaks, consideration of factors such as a place to eat in private or avoiding lunch meetings or other work events involving eating socially.

Compliment people without bringing their weight or bodies into it. Find ways to bond, connect and have conversations with people in the workplace that do not involve food, bodies, or weight loss.

Encourage movement for fun, for change of scenery, for better productivity. Play music, normalize dance breaks.

Why not create a routine where everyone has the opportunity to  get up from their desk at least once every hour and takes a 2 minute walk. But avoid tracking steps or putting a lot of emphasis on competition.

The best way for people to be released from diet culture is to have a community of support. The workplace can become a safe space. If you are concerned an employee may have an eating disorder, there is help at the Lindner Center of Hope 513-536-HOPE.

Binge eating disorder (BED) is the most prevalent eating disorder but remains largely undiagnosed and untreated.  BED is characterized by recurrent episodes of loss of control and consumption of unusually large amounts of food within a short period of time (<=2h).  Episodes are associated with significant emotional distress but are not followed by purging behaviors (vomiting, misuse of laxatives, etc.), which differentiates BED from Bulimia Nervosa.  In addition to psychological distress, BED is associated with medical complications including accelerated weight gain, metabolic abnormalities, functional impairment, and decreased quality of life.  Untreated BED leads to worse clinical outcomes in a variety of medical and psychiatric conditions and poor treatment response in hypertension, diabetes, dyslipidemia, and obesity, which are commonly seen in primary care.  Patients with BED stand to benefit from increased screening, diagnosis, and treatment, particularly patients with type 2 diabetes mellitus (T2DM).

Screening for BED is particularly important in patients with T2DM.  While the prevalence of BED in the general population is estimated around 3%, prevalence is significantly higher in T2DM, where the prevalence of BED is estimated around thirteen times higher than in the general population.  In fact, eating disorders are frequently encountered among patients with T2DM, with prevalence estimated around 20%.  Diagnosis and treatment are important because the presence of binge eating greatly complicates management and is associated with worsened outcomes such as impaired glycemic control, dyslipidemia, and accelerated weight gain.  BED is associated with decreased response to weight loss interventions (including dietary and bariatric surgical procedures), impaired glycemic control, dyslipidemia, and exacerbation of insulin resistance.  Moreover, common pharmacotherapies for diabetes (such as insulin, sulfonylureas, and dietary restraint) have been implicated in the exacerbation of binge eating.

As we have seen, BED is a barrier to achieving treatment goals in T2DM.  It is important to take binge eating into account when selecting treatment.  Reducing the frequency and severity of binge eating can facilitate the achievement of treatment goals in T2DM.  Primary care providers manage most patients with T2DM, but screening and management of BED is still overlooked.  It is necessary to treat patients to decrease the frequency and severity of binge eating to help patients achieve treatment goals for diabetes.  Optimal outcomes in treatment are not possible with untreated BED.  Primary care providers face the challenge of identifying and initiating treatment for this population with complex needs.

Even though BED is an important comorbidity in T2DM, significant barriers to diagnosis and treatment persist.  First, eating disorders are associated with significant stigma and patients may not readily disclose disordered eating behaviors due to shame.  In many cases, patients are aware that some of their eating behaviors are abnormal, but they do not know that they are suffering from a treatable eating disorder.  In addition, primary care providers may overlook binge eating as a possible factor when patients fail to achieve treatment goals despite intensification of treatment.  In addition, primary care providers face time and financial constraints which limit their ability to diagnose, refer and treat.  Finally, there are not enough trained clinicians who can offer specialized medication management, dietary counselling, and psychotherapy for BED.  Medication options are still limited to an FDA approved agent (lisdexamphetamine), plus a couple of drugs used off-label.  However, providers still have options to start addressing the needs of patients with T2DM and BED, including:

Further research is needed to understand the needs of patients with comorbid T2DM and BED as well as to develop treatments to lessen the occurrence of binge eating episodes clinical care guidelines.

The Research Institute at the Lindner Center of HOPE is conducting a clinical trial of an experimental medication for Binge Eating disorder.  No prior diagnosis is required.  For additional information, contact us at 513-536-0700 or visit:  https://redcap.research.cchmc.org/surveys/?s=TP3C4TEA8J

Bibliography

Harris SR, Carrillo M, Fujioka K. Binge-Eating Disorder and Type 2 Diabetes: A Review. Endocr Pract. 2021 Feb;27(2):158-164. doi: 10.1016/j.eprac.2020.10.005. Epub 2020 Dec 13. PMID: 33554873.

Keshen A, Kaplan AS, Masson P, Ivanova I, Simon B, Ward R, Ali SI, Carter JC. Binge eating disorder: Updated overview for primary care practitioners. Can Fam Physician. 2022 Jun;68(6):416-421. English. doi: 10.46747/cfp.6806416. PMID: 35701190; PMCID: PMC9197289.

Winston AP. Eating Disorders and Diabetes. Curr Diab Rep. 2020 Jun 15;20(8):32. doi: 10.1007/s11892-020-01320-0. PMID: 32537669.

Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner

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

 

 

 

 

Emotion regulation refers to the process of generating and maintaining an emotion, as well as the ability to modulate its’ intensity and frequency in order to achieve socioemotional competence and sustain mental health. In modern society, from early age, we learn inhibition to downregulate our emotions (for example, to not cry in public or to not say anything when angry) which often results in emotional restraint. True emotional regulation is reached through focused monitoring, evaluating, and modifying of our emotional reactions and depends on the person’s age, temperamental characteristics and environmental circumstances. Some examples of successfully practicing emotional regulation include being able to calm self-down after something exciting or upsetting happens, sustaining focus on repetitive tasks, refocusing attention on a new task and controlling impulsive behaviors. The skill to emotionally regulate depends significantly on the persons’ age and brain maturity and thus understanding that some of the time the individual is not difficult or spoiled, but developmentally or circumstantially unable to control their emotions can help build empathy and strengthen family systems and relationships.

DOs in Emotional regulation

  • Do create safe space for all emotions- the good, the bad and the ugly. Being happy should be equally accepted in the family as being angry or sad.
  • Do model emotional regulation for your children and peers every time you can. Work on naming your emotion (ex.” I am very upset with you now..”), the reasons for it/ the trigger, if you know it (..”because you hit your sister..”) and the solution you have (..”so I will take a moment to regroup and then we will talk about how I am feeling and what helps me go through it”)
  • Do practice awareness of your reaction to the emotional dysregulation in others. The goal it to learn to respond to their outburst (observe, acknowledge, empathize and work through it) rather than react (yell back or slam the door and leave).
  • Do prepare and reflect. When a challenging situation lays ahead, take the time to prepare yourself and the child for it and afterwards reflect on how preparation and having a rescue plan had helped to minimize emotional outbursts.

DON’Ts in Emotional regulation

  • Don’t expect emotional regulation if the person is hungry, thirsty, tired, lonely or in other way physically unsettled. Emotions are felt in the body and learning how the body reacts to them is a crucial step in recognizing and further regulating them.
  • Don’t ignore or minimize kids’ emotions. They might see overly dramatic, or unnecessary, or inconvenient (airport tantrums, anyone?) but for the child they are real and often intense. Work on acceptance that even if we don’t get it, it is real for them and our job is to validate their struggle/excitement and teach them how to better self-regulate.
  • Don’t pretend you “feel it for them” if you do not. It is ok to state that “I don’t know what you are going through but I am here for you and I am willing to help you out in any way I can”.
  • Don’t try to “fix it” or make it go away or focus on it for too long. Emotions are fleeting, they can feel very intense when they occur, but most of them resolve or lose their overpowering force if the person “stays with it” (recognizes it, tolerates the distress for negative emotions and responds, rather than reacts) for long enough. Learning this skill early on can be truly helpful in adulthood

Practical skills to help with emotional regulation

Mindfulness techniques. There are many ways to focus on the “now” to help tame an emotional outburst. A simple example is the 5-4-3-2-1 Grounding Exercise. It can distract from the anxiety trigger, focus the person on the present moment, and help them relax in their body. Ask the person to : name 5 things they can SEE in the room (have them list them out loud) ; name 4 things they can FEEL (sock on my feet, knots in my belly) ; name 3 things they can HEAR (my voice, radio); name 2 things they can SMELL right now (my coffee) ; name 1 thing they can TASTE (if not in the moment, what did they taste last night) . This can be shortened to 4-3-2-1 or even 3-2-1, depending on the circumstances.

Relaxation techniques– teach yourself and your young ones deep breathing. Yoga Dragon breath and the Camel pose can be a fun quick way to release tension.  Explode like a volcano/ Balloon technique can be practiced anywhere and most children under 10 years of age find is helpful (pretend you explode like a volcano/popped balloon- you can jump up and model the eruption with your hands and make a lot of loud dramatic volcano sounds). Using movement, music and sensory activities can help further relax and refocus one’s brain.

Diligent self-care – emotional regulation is impossible in a body with unmet basic needs, namely being tired, hungry, thirsty, lonely or sick. Daily self-care, particularly getting enough rest depending on the person’s age, should be encouraged and taught by parents, especially to teens and young adults who have more autonomy and can make the connection between being overly tired and overly emotional and further

Kristy L. Hardwick, EdD, LPCC-S Lindner Center of HOPE, Outpatient Therapist

 

 

 

 

 

 

 

 

The sun is shining; the days are longer. Summer is approaching. For some, summer is a break from study or work. For others, it may be an opportunity to take a week of vacation to relax and rejuvenate. Whether it is a two-to-three-month break, or simply more time in the evening to enjoy the sunshine, it is a time for which most look forward. It is often a time of joy, laughter, and reprieve. Summer is associated with rest and play, all of which can promote positive well-being. And I embrace all of it.

However, I am also keenly aware of the various tragedies we have collectively experienced over the recent months. With the “last day of school” and the “first vacation of the summer” pictures also come news of mass shootings, war, and other difficult events. There is exposure to pain and suffering on multiple levels, whether indirectly or directly.

Thus, I get the sense “the sun is shining, but it is also dark!” I find it necessary to acknowledge the current conflicting duality of our reality and the distress which many are experiencing, while sharing a few reminders to help us navigate through.

First, during times like this, it is crucial to recognize it is normal to have a plethora of intense thoughts and feelings, as well as an urge to act. It is also expected there will be differing viewpoints and ways these events affect individuals based on a variety of factors.

Second, it is important to highlight there are times when words are insufficient to convey the depth and intensity of feelings or to comfort adequately. Perhaps we don’t know anyone personally who has been directly affected by one of the current tragedies. Yet, we have been impacted. We may find ourselves juggling varying thoughts and feelings and struggling to put these into words. I would invite us to lean into what we are experiencing in our bodies. Accept there may not be “right words.” However, we can give space for our thoughts and feelings, accepting them as we experience them.  Sitting in silence might be necessary. It might also be helpful to focus on possible actions. For example, if we are feeling helpless, we might brainstorm a way we can make a difference or identify an area where we do have control. We can also find ways to show care, concern, support, and express meaningful presence with others amid the current tragedies.

Perhaps we do know someone who has been directly affected by one of the various tragedies or observe others being more deeply impacted by our current shared experiences. Again, we may not know the “right words” to say to those who have suffered directly from a tragedy or are in more distress. That is okay. There is a reason why words fall short; it is because ultimately, they often do. Thus, instead of getting caught up in “saying the right words,” we can focus on embracing being a meaningful presence. We offer authentic support through honest connection. Even saying, “I don’t know what to say; however, I am here for you,” or “I don’t understand or know the solution, but I am here to listen.” Offering just to be with someone is powerful.

Next, we may experience discomfort when we feel “caught in the middle” of opposing circumstances or even opposing feelings. On the one hand, it is summer. We have plans to relax, find joy, rejuvenate. Yet, we find ourselves surrounded by various tragedies. The degree of impact may vary. We are both impacted and aware of the suffering; yet also are navigating daily lives. We are both excited about summer plans, but also angry and sad about world events. Or we may be struggling with different stressors or difficult life circumstances, but also must continue to function. In these situations, it can be powerful to embrace “both/and.” Often we are influenced to exist in an “either/or” mindset. Either we are happy, or we are sad. Either we are fulfilled, or we are discontent. Yet this negates the complexity of both the outer world, and our inner worlds. Joy and pain can coexist; celebration and grief may show up hand in hand. Vacations are happening in the middle of world conflict. We are both celebrating our young adults graduating college and mourning for those killed in a mass shooting. Embrace and hold space for “both/and.” Multiple, often conflicting, thoughts and feelings can be true at the same time. It is necessary to accept all of them.

Lastly, we can utilize healthy coping skills to navigate these “distressing-at-a-loss-for-words-embracing-both-and” times. Consider strategies which have been helpful in the past, as well as those we may not have utilized previously.

Find ways to express our thoughts and feelings, giving ourselves permission to hold several thoughts and feelings simultaneously, while also releasing them. (Allow time for “both/and.”) Resist the urge to hold them in. Even if we have moments of “no words,” we must find ways to release them in nonverbal ways and then be willing to let words flow when they do come, without judgment. Releasing feelings is an important skill to practice.

Get moving, be active. We cannot separate the various parts of our bodies; they are all interconnected. Moving is good for all areas of our health, increasing endorphins. Research also supports various activities such as yoga, which activates the parasympathetic nervous system, decreasing stress and muscle tension. We can engage in physical activities we love, whether it be swimming, kayaking, or biking.

Be creative. Engaging in novel and creative activities increases dopamine. Make art; write, create music. Simply listening to music has been found to decrease anxiety and stress. (We can even combine the coping skill of releasing and expressing feelings with this one!)

Seek social support. Make connections. We increase the oxytocin (the “love hormone”) in our brains by spending time with family, friends, and pets. We are inherently built to be in relationship with others.

Stick to routine; take the vacations we have planned. Routine helps us stay motivated and organized.

Maintain healthy habits. Sleep/rest. Eat well, hydrate.

Limit social media/news exposure when current events become too distressing.

Seek ways to advocate and get involved in organizations created to assist survivors of events or those which support issues we find important.

And lastly, let us not hesitate in seeking professional help if levels of distress increase, we are unable to function or fulfil roles, unhealthy coping has increased (drug/alcohol use), there is difficulty sleeping or change in appetite, and if experiencing severe hopelessness and suicidal thoughts. We are here to help when the sun is shining but it is also dark.

By: Annie Ward, MSN, PMHNP-BC
Psychiatric Nurse Practitioner, Lindner Center of HOPE

When we think of eating disorders, our society tends to think of individuals in emaciated bodies. Disordered eating is more common than not, and does not discriminate against body size, gender or race. The line between dieting and disordered eating is blurred in our society. There are narratives tightly woven into our culture which lead to disordered eating habits being encouraged, and unfortunately often praised. Sadly, they are only acknowledged as problematic when the physical manifestations become unignorable and when they can no longer be labeled under the guise of “healthy diets”.

One of the most common disordered eating patterns that I encounter in clients (whether they are seeking help for an eating disorder or not) is the binge-restrict cycle. This pattern can start with either binge eating or restricting. Essentially, when we restrict nutrition, our bodies increase our hunger cues as they search for sustenance, to alert you that your body needs food. This can often end up in a binge-eating episode which involves eating a large quantity of food while feeling out of control. Unfortunately, the feeling of lack of control often results in shame, which may then lead to subsequent restriction of nutrition. This may be due to feeling full after a binge or primarily due to shame, but unfortunately fuels the cycle of binge-eating and restricting.

It can be helpful to think about how this cycle was useful for our hunter and gatherer ancestors. They may have gone several days without food, and when they found it, the body wanted to obtain as much nutrition possible, because it didn’t know how long it would have to survive without food again. Their bodies pumped out hunger hormones to protect them and sustain them. Your body works the same way– it cannot identify why it is not getting food. I hope that you wouldn’t expect our ancestors to feel shameful for eating more when they found food- and hope this helps you understand why you should not feel shameful for eating more after a period of restrictive eating. Additionally, our bodies have natural weight settling points and when we restrict, to conserve the energy we have, we slow down our metabolism to conserve resources. This is one reason why diets are overwhelmingly unsuccessful.

In order to learn what your body needs and wants, one of the best things that you can do for yourself is structure regular nutrition throughout the day- regardless of what your eating looked like the day before. Our society certainly defaults to making us believe that we should eat less if we “overdid it” the day before, but this is simply not true. Your body needs and deserves consistent nutrition every day.

If you struggle with fatigue, poor concentration, mood swings, headaches or lightheadedness—these are a few of the ways that inadequate nutrition can present. They can present quickly after your body realizes it needs more fuel, and may not get better until your body can trust that you will consistently give it the nutrition it needs. I would encourage you to explore your relationship with nutrition and how it may be affecting you physically— and mentally.

What should we learn from this? 

  1. If you feel you ate too much of a meal or snack, you should forgive and forget. You deserve to eat all meals and snacks the next day. Returning to a consistent pattern of nutrition will help break the binge-restrict cycle.
  2. Our society promotes “health” but this often gets twisted into unhealthy recommendations which can lead to the binge-restrict cycle. This can then lead to guilt, shame, and eating disorders. Be wary of “healthy” diets.
  3. Consistent nutrition is self-care, and it is not helpful to use nutrition as a form or judgment of self-control

If you are struggling with this, reach out for help with an eating disorder specialist who is knowledgeable about Health at Every Size- you do not have to look a certain way to have an eating disorder or be “sick enough” to get help

By: Jessica Kraft, APRN, PMHNP-BC
Lindner Center of HOPE, Psychiatric Nurse Practitioner

Seasonal affective disorder (SAD) is a type of depression that is more isolated to the changing of the seasons. It can happen in the spring and summer but occurs most commonly in the fall and winter months. We know that everyone is going to have a bad day from time to time, and it’s not uncommon for some to face more challenges in the winter months when the weather is colder and the days are shorter. But when does this become a problem that requires intervention?

What are some of the common symptoms of SAD? 

  • Feeling down or depressed for most of the day, almost every day
  • Less interest in hobbies, social activities, or things that have brought you joy in the past
  • Decreased concentration at home and at work
  • Fatigue, sluggishness, or low energy
  • Sleeping too much or too little
  • Changes in appetite (increased craving for carbohydrates) or changes in weight
  • A general feeling of hopelessness
  • Low self-esteem
  • Thoughts of self-harm or suicide

It is hard to estimate the number of people who have SAD, as many do not know they have it. It’s also thought that the number in recent years has been higher due to the COVID-19 pandemic. Women can be at higher risk for developing SAD as well as those who live further north. SAD most commonly develops in young adulthood, it often runs in families, and can often be co-morbid with other mental health conditions including depression, bipolar, anxiety, ADHD, and eating disorders.

It is not entirely understood what causes SAD, but research indicates that people with SAD may have reduced activity of serotonin, too much melatonin production, or even vitamin D deficiency. Changes in these areas may impact the body’s daily rhythm that is tied to the seasonal night-day cycle. Negative thoughts and feelings about the winter and its associated limitations and stresses are common among people with SAD, as well as others. It is unclear whether these are “causes” or “effects” of the mood disorder, but they can be a useful focus of treatment especially when seeking therapy.

If the above symptoms start to interfere with day-to-day life, it may be beneficial to seek out care for SAD. For some it may be ideal to start with their primary care provider in order to rule out other medical conditions that could be responsible for symptoms of SAD including alterations in thyroid hormones, low blood sugar, anemia, or viral infections like mono. If there is not an identifiable medical cause, seeking psychiatric help may be beneficial.

What are some of the common symptoms of SAD?

  • Light therapy – a common approach to SAD since the 1980s. The thought is that exposure of bright light every day can supplement the lack of natural sunlight/sun exposure in the winter months. Sitting in front of a light box of 10,000 lux daily during the winter months in the morning can be a helpful intervention.
  • Talk therapy – the most common type of talk therapy for SAD is cognitive behavioral therapy (CBT).
  • Vitamin D supplementation – there is mixed research on how helpful supplementation of Vitamin D is for SAD but some find it helpful and a good option to try prior to trying a psychiatric medication.
  • Psychiatric medication – for those who haven’t seen much improvement with light therapy or CBT, psychiatric medication can be an option including SSRIs (Prozac, Zoloft, Lexapro, etc.) or Wellbutrin. It is important to keep in mind that treatment with one of these medications may take several weeks in order to be efficacious, for some up to 6-8 weeks.
  • When doing research on this topic I came across many anecdotal stories from those struggling with SAD and what interventions they tried and found helpful. Some examples included going outside more often, taking a trip, caring for something like a plant or a pet, finding a new hobby or interest, staying social, creating new rituals, consistent exercise, quality nutrition, good sleep, and maintaining a consistent schedule.

What are some of the common symptoms of SAD?

One of the helpful things about treating SAD is the predictability of when symptoms set in compared to other sub-types of depression that are much more variable. Unfortunately there is little research answering the question of whether or not this can be prevented or if there is a significant benefit to starting treatment early. Of the limited data available the medication Wellbutrin was found to be the most helpful intervention to start early.

Sources:

https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder/index.shtml 

https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder 

https://www.yalemedicine.org/news/covid-19-seasonal-affective-disorder-sad 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302868/ 

https://www.sciencedirect.com/science/article/pii/S2215036620303072 

https://forge.medium.com/advice-for-coping-with-seasonal-depression-from-9-people-who-have-it-a5c04fdfe996

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

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

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

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

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

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

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

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

-Your child begins to misbehave at school.

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

What are the ways exercise can benefit us?

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

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

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

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

Toups, M., Carmody, T., Greer, T., Rethorst, C., Grannemann, B., & Trivedi, M. H. (2017). Exercise is an effective treatment for positive valence symptoms in major depression. Journal of affective disorders209, 188–194. https://doi.org/10.1016/j.jad.2016.08.058

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

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

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

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

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

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