Category: Health

Return to blog >

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

Return to blog >

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

Return to blog >

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.

Return to blog >

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

Return to blog >

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

Return to blog >

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

Return to blog >

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

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

What are the ways exercise can benefit us?

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

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

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

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

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

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

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

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

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

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

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

 

Return to blog >

Understanding Trauma

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

Benefits of Yoga as a Practice

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

Benefits of Yoga for Trauma Recovery

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

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

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

In yoga there are two major concepts that can have psychological benefit:

  1. Chitta: the inner processes and capacity of attention and focus inward
  2. Samskaras: the storehouse of past actions, self-beliefs/messages

Yoga for Healing Emotional Trauma

In yoga the use of asanas, pranayama and meditative practice- one works towards awareness and letting go of these unhelpful attachments that are stuck in the mind and body. As we know in people who have survived trauma and emotional trauma can impact the body and leave scars of psychological destruction. Yoga offers a loving message of positivity, self-compassion and promotes a gentle, non-judgmental environment. Letting go of negative self-beliefs has many benefits psychologically.

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

Breathing Easier

Yoga has proven its place in the holistic approach to mental health treatment, and because the only requirement is to be able to breathe, it is accessible to anyone who can breathe. It has been said about yoga, by a great teacher, “the breath is a wonder drug!”

I hope you will consider utilizing a yoga practice for yourself or recommending it to someone who could benefit. And remember, there is HOPE. For more information on other treatments for trauma recovery or information about the Lindner Center of HOPE’s services call (513) 536-4674 or click here.

 

Return to blog >

Christine Collins, MD, Lindner Center of Hope

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

 

 

 

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

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

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

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

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

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

Sources:

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

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

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

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

 

Return to blog >

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

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

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

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

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

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

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