Category: Mental Health

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By: Jennifer B. Wilcox, PsyD
Staff Psychologist, OCD and Anxiety Disorders Program

 

 

 

 

What is compulsive hoarding?

Hoarding Disorder is a psychiatric illness and is considered to be a subtype of Obsessive-Compulsive and Related Disorders. The Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5) defines Hoarding Disorder (HD) as:

Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.

The difficulty of discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.

The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

The hoarding is not attributable to another medical condition and is not better explained by another mental disorder.

 

 

 

 

 

 

How is compulsive hoarding different from normal clutter or collections?

It is not uncommon for people to acquire a few extra possessions from time to time, resulting in occasional clutter. However, while normal clutter or collecting doesn’t usually interfere with a person’s daily functioning, compulsive hoarding often does. Compulsive hoarding also differs from normal clutter or collecting as it tends to become unmanageable, overwhelming, and causes significant distress or family discord. Though collections usually bring people joy and fill them with pride, hoarding often comes with shame and embarrassment.

Why do people hoard things?

Compulsive hoarding is thought to result from a combination of factors including genetics, environmental factors, life experiences, and learned behaviors. The reason one person hoards may not be the same as the reason someone else hoards. Some people who hoard are compulsive shoppers and acquire more things than they need or have room to accommodate. Others may have difficulty categorizing or making decisions about what to do with particular items. Sometimes they can’t remember what they own or where it is, leading to the purchase of duplicate items. Other times people hold on to possessions for emotional or sentimental reasons or get anxious when they discard things. Some people believe that the hoarded items may be useful someday and keep the items despite not needing them currently. The level of insight a person has about their struggles in these areas can vary widely from completely absent insight to good insight.

What types of things do people hoard?

The types of items a person hoards vary based on factors such as the reason they are hoarding and how severe their hoarding issues have become. Some commonly hoarded items include books, newspapers, magazines, boxes, bottles, clothes, food, items purchased in bulk, collectibles or vintage items, furniture, animals, or digital media.

How many people suffer from Hoarding Disorder and who does it affect?

While the exact prevalence of people who suffer from Hoarding Disorder is not certain, it is estimated that it affects approximately 2.5% of the general population. Studies have shown that prevalence rates in men and women are nearly equal and appear to be consistent across developed countries. Most studies report onset between 15 and 19 years of age and show a chronic course over the lifespan.

What is the treatment for Hoarding Disorder?

Hoarding Disorder is treated using Cognitive-Behavioral Therapy (CBT), a type of therapy that allows someone to work with a therapist to shift their thinking patterns and change their behavioral patterns to healthier ones. Randomized controlled trials have shown this to be an effective treatment for hoarding. While the data on the efficacy of medication for Hoarding Disorder is limited, there is some evidence to support the use of medication in the treatment of this disorder. For those hoarders who have limited insight, a Motivational Interviewing (MI) approach can help to foster their motivation and confidence. Finally, working on skills that improve the hoarder’s ability to maintain attention and focus, categorize items, and decision-making can be beneficial in treating Hoarding Disorder.

What can I do to help a loved one who seems to have issues with compulsive hoarding?

It is generally not recommended for family and friends to discard hoarded items without the hoarder’s permission. This can be extremely distressing for a compulsive hoarder and tends to make them upset, anxious, or angry. Instead, it is recommended that friends and family talk to their loved ones about their concerns and help them to seek professional treatment. Additional resources are available at the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA).

Resources:

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

Treatment of Hoarding Disorder

https://instituteofliving.org/programs-services/anxiety-disorders-center/what-we-treat-at-the-adc/compulsive-hoarding

https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder

Postlethwaite, A., Kellett, S., Mataix-Cols, D., 2019. Prevalence of Hoarding Disorder: A systematic review and meta-analysis. Journal of Affective Disorders 256, 309-316.

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The Difference Between CBT and DBT (Cognitive and Dialectical Behavioral Therapies)

Stacey L. Spencer, Ed.D.
Clinical Neuropsychologist, Lindner Center of HOPE
EMDR Trained therapist
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience

 

There are many, many possible types of psychotherapy. Psychotherapy is an optimal treatment method for mental illnesses.  Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) are among the most common psychotherapies.

CBT vs DBT

What is Cognitive Behavioral Therapy?

One that has been in the public sector for decades, and that you’ve likely heard of, is Cognitive Behavioral Therapy (CBT). If you’ve ever gone to therapy, it’s very likely that the therapist you saw practiced CBT. This therapy, also called talk therapy, helps people better understand how thoughts influence our feelings. The goal of CBT is to talk through problems and help frame thoughts differently. CBT is typically time-limited and there are specific goals and homework provided. You might start out with a situation that troubles you, or one you may find troubling. With the guidance of the therapist, you identify the thoughts around the situation and work on finding alternatives and ultimately changing the behaviors in order to feel better. So, it’s thought-feeling-action-focused. Some mental flexibility is involved given that most of these thoughts are automatic and can become engrained.

Cognitive Distortions are often discussed in CBT.  CBT helps us to break up negative thought patterns or “thought traps” that can lead to feelings of anxiety, depression and cause us to avoid. A technique to help one move away from this type of thinking and often employed in CBT is “cognitive shifting”. With the help of awareness in what a person focuses on (in this case, often the negative cognition/thought/belief) the idea is that this helps us learn to shift our focus to something more helpful or innovative. There are many Cognitive Distortions under this umbrella. Examples of catastrophizing could be magnifying or minimizing. I read a good description once of this being a “billowing cloud of everything can go wrong” and believing it inevitably will.  Or in Minimizing when we downplay our successes.

A CBT-oriented therapist might give someone who tends to catastrophize events in their lives, leading to anxiety, for instance, a worksheet and walk through the process with them. This is hypothesized to have evolved as a way to help us survive during the immediate crisis. Now that we have developed higher-level reasoning skills, this can turn against us, as these negative thoughts can turn sticky.

One way to start is to help the client identify what they are currently most worried/anxious about. The client might start by specifying what they imagine will occur without using “what if” statements. Instead, the focus is on the client’s own predictions, e.g., “ I will fail the exam and get kicked out of school.” You ask the client to rate how much they believe this to be true from 0-100%. Next, the client is asked to take a step back and consider the likelihood of the catastrophe to occur. By helping the client to take a step back and assess the fear from a different perspective and re-interpret their concerns, this is called “reframing”.

Working on ways to cope with and manage these fears/anxieties by not diving into them is a strategy that CBT therapists employ. It takes practice and yet studies have shown that finding more balanced ways of managing these types of thoughts can lead to better mental and physical health outcomes. By helping the client to explore the underlying thoughts, emotions and beliefs and problematic thinking, they can work towards a more balanced view of themselves. The hope is that by helping the client change their perception to support more positive thinking, they will reduce distress and suffering and lead a more fulfilling life.

To recap, CBT features the following:

  • Treats emotional response
  • Is time-limited
  • Works best with solid therapist-patient relationship
  • Relies on the application of logic and reason
  • Employs structure to guide tailored treatment

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy (DBT) comes from dialectical theory and is actually a type of CBT.  DBT posits balance; not leaning too hard in one direction or another. This modality was originally created by Dr. Marsha Linehan in her work with people with chronic life-interfering behaviors, like self-harm and chronic suicidal thoughts. It has expanded to help with many other issues. Dialectical Behavioral Therapy techniques utilize individual therapy, group skills class and coaching. Groups emphasize learning specific DBT coping skills and there is homework given in-between to reinforce what was learned.

DBT Coping Skills

The four pillars of DBT coping skills include:

Mindfulness

Emotion Regulation

Distress Tolerance

Interpersonal Effectiveness

Mindfulness is a DBT coping skill that involves living with intentional awareness of the present moment. This includes not trying to push away or reject the moment but to notice it and not attach ourselves to it. As Dr. Linehan describes, this is by “Attending to the experience of each new moment, rather than ignoring the present by clinging to the past or grabbing for the future.” This takes practice and patience and can take many forms. Some examples of mindfulness include meditation in the form of noticing by either opening or focusing the mind. Contemplative prayer (in any spiritual form) is another mindfulness practice along with mindful movement such as yoga, martial arts, hiking, tai chi.

Emotion Regulation involves understanding and naming one’s emotions. By helping to learn to identify emotions, one can hope to gain an understanding of what they do for us. Goals of this are to decrease the frequency of unwanted emotions, the vulnerability to them and decrease emotional suffering.

Distress Tolerance are DBT coping skills for when involved in a crisis situation and the goal is to not make the crisis worse. By utilizing skills of Radical Acceptance, one can achieve freedom from suffering and being “stuck”. This can help by reducing acting on intense emotions and tolerating painful events. These are only utilized in a crisis situation, where the event or experience is highly stressful and short-term.

Lastly, Interpersonal Effectiveness skills are to help assist with either strengthening current relationships or end destructive ones, to learn to say yes/no effectively, resolve conflicts before they get overwhelming and create and maintain balance in relationships.

The Difference Between CBT vs DBT in Treating Certain Illnesses

Not all mental illnesses respond to treatment in the same way.  The difference between CBT and DBT must be taken into consideration when determining the optimal treatment method for an individual. CBT has been shown to be effective when treating depression, anxiety, obsessive compulsive disorder (OCD), phobias, panic disorder and post-traumatic stress disorder. DBT was created to help people who might be easily dysregulated and tend benefit from learning ways to self-soothe, communicate more effectively with others and find ways to reduce significant distress.

The Difference Between CBT and DBT Treatment Methods

The difference between CBT and DBT are defined. CBT focuses on the connection between thoughts, feelings and behaviors and how they influence each other. DBT emphasizes regulating emotions, being mindful and tolerating the uncomfortable. CBT guides patients to recognize troubling thoughts and redirect them, while DBT helps patients accept themselves, feel safe and manage emotions to avoid harmful behaviors.

When comparing CBT vs DBT, both therapies have aspects of how our thinking influences our emotions and behaviors but are different in their approaches and structure of the therapeutic process. Both modalities are evidenced-based, that is, much research has gone into showing whether they are effective.  When choosing a therapist, as important as it is to find someone in-network or with openings, it’s equally so to know what treatments are most effective for the reasons you’re seeking therapy in the first place. Therefore, asking about CBT vs DBT and which one might work best for you, would be an important next step in this process.  This is the best way to determine if CBT vs DBT are right for you.

Knowing your diagnosis is key to determining what therapy will be most effective for you. However, many people have more than one diagnosis, and sometimes people use a blend of therapy elements to best manage symptoms.

It can be confusing to know what techniques will best help you. CBT and DBT are some of the more common therapy practices, and have been shown to help individuals suffering from a number of mental illnesses.

Choosing to take care of your mental health is just as important as your physical health and finding providers that utilize evidence-based practices will provide you with the best outcomes possible.

For more information about DBT skills group at Lindner Center of HOPE.

 

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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

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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

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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

 

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Christine Collins, MD, Lindner Center of Hope

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

 

 

 

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

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

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

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

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

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

Sources:

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

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

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

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

 

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Thirteen months ago, the world was experiencing the onset of a shared trauma … a pandemic was sweeping over the globe. The actions that were taken to keep people safe included community shut downs, stay at home orders and mandated isolation. Lindner Center of HOPE, like mental health providers around the world, began to see spikes in mental illness and addiction. Individuals who were already struggling with mental illness or a pre-disposition, saw exacerbated symptoms and an increase in severity of illness. People who were managing, saw new onset at higher levels of acuity. As time has passed since the beginning of the pandemic, the trauma has been sustained with higher percentages of people still struggling with mental illnesses and addictions. Additionally, data shows people who have experienced COVID-19 infection are also suffering with co-occurring psychiatric symptoms.

Dr. Paul Crosby, Lindner Center of HOPE

Fortunately, vaccines have been released to protect the population from the physical health threats of COVID-19. However, Lindner Center of HOPE’s President and Chief Operating Officer, Paul R. Crosby, MD, states the vaccine also offers mental health benefits as well.

“The first mental health benefit of the vaccine is simple,” Dr. Crosby said, “since the risk of COVID-19 infection diminishes significantly with vaccination, receiving the vaccine would also protect individuals from co-occurring mental illness that has proven to manifest with COVID-19 infection.”

“The second mental health benefit of the vaccine is the reduction in overall anxiety and stress, as risk and fear of infection is reduced. Vaccinated individuals can lift their isolation from other vaccinated individuals, can begin to see a return to other activities that improve mental health, like more exercise, improved sleep, new experiences through travel and more. A return to these healthier activities can hopefully also lead to a reduction in substance use, overeating or lack of participation in other things that bring joy.”

“The COVID-19 vaccine has significant potential in improving your mental health.”

For individuals experiencing symptoms of mental illness, it is critical to access help. Mental illnesses are common and treatable and no one should struggle alone.

Lindner Center of HOPE in Mason is a comprehensive mental health center providing excellent, patient-centered, scientifically-advanced care for individuals suffering with mental illness. A state-of-the-science, mental health center and charter member of the National Network of Depression Centers, the Center provides psychiatric hospitalization and partial hospitalization for individuals age 12-years-old and older, outpatient services for all ages, diagnostic services for all ages and short-term residential services for adults, and research. The Center is enhanced by its partnership with UC Health as its clinicians are ranked among the best providers locally, nationally and internationally. Together Lindner Center of HOPE and UC Health offer a true system of mental health care in the Greater Cincinnati area and across the country. The Center is also affiliated with the University of Cincinnati (UC) College of Medicine.

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

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

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

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

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

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

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

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

Hope on the horizon

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

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By Danielle J. Johnson, MD, FAPA

Lindner Center of HOPE, Chief Medical Officer

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

 

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

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

Resources

https://www.griefshare.org/holidays

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

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

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

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

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By Angela Couch, RN, MSN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE

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

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

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

* Feeling “paralyzed” by fear.

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

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

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

Anxiety is causing significant physical symptoms.

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

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

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

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

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

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

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

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