Category: Blog

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Nicole Mori, RN, MSN, APRN-BC

Research Advanced Practice Nurse, Research Institute at Lindner Center of HOPE

Obesity, defined as a body mass index (BMI) ≥30 mg/kg, remains one of the main contributors to preventable disease and health care costs. It is also associated with increased risk for Type 2 diabetes, cardiovascular disease, and some cancers, in addition to lower quality of life and functional impairment.   Patients with psychiatric illness are 50 percent more likely to be obese than the general population.  The higher rates of obesity are contributing directly and indirectly to the marked reduction in life expectancy among those with mental illness.  In addition to being an important medical comorbidity, obesity has been associated with a more severe course of psychiatric illness, lower health-related quality of life, poor self-esteem, stigma, and discrimination.  Obesity, like mental illness, is a complex, chronic condition requiring long term management.  The treatment of overweight psychiatric patients poses unique challenges and both the psychiatric illness and the weight problem must be targets for treatment in order to achieve optimal outcomes.

The strong relationship between obesity and psychiatric illness is evidenced by the high prevalence of obesity among drug-naïve patients. Commonly-occurring symptoms such as psychomotor retardation, inactivity, hypersomnia, increased appetite, and hyperphagia are thought to contribute to weight gain.  Furthermore, binge eating behavior, eating unusually large amounts of food with a sense of loss of control over eating, is very common in people with psychiatric illness.    Binge eating behavior is a risk factor for obesity, and when present in psychiatrically ill people, is associated with greater psychiatric and medical morbidity.  Lastly, treatment with most mood stabilizers, antipsychotics, and some antidepressants is associated with significant weight gain, which renders them less acceptable to patients and leads to discontinuation.

Weight management poses unique challenges to psychiatric patients. As we have seen, both the behaviors associated with psychiatric illness and the use of certain psychotropic medications, contribute to weight gain.  In addition, the symptoms and cognitive deficits associated with mental illness are a barrier to participation in behavioral weight loss interventions.  Finally, the use of most weight control drugs is limited by their psychiatric side effects and their interactions with psychotropic medications.  Obesity and excessive weight gain place a disproportionate burden on psychiatric patients’ health, complicate adherence to treatment, and reduce quality of life.  Treatment of psychiatric illness needs to include weight management strategies and a greater integration of behavioral and medical care.

Clinicians can help improve outcomes by maintaining a focus on both the psychiatric condition and the weight problem when treating this population. First of all, regular monitoring of psychiatric symptoms should be accompanied by monitoring of weight, BMI, vital signs as well as metabolic lab parameters (e.g., lipids and glucose).  Assessing for binge eating behavior or an eating disorder is important because additional referrals and greater integration of behavioral and medical care may be indicated for patients with disordered eating.

Prescribers can mitigate weight gain associated with psychotropic medications by selecting medications with lower potential for weight and metabolic disturbances whenever possible.   Knowledge of the pharmacology of obesity and eating disorders is helpful in guiding treatment choices and avoiding adverse events.  Some FDA-approved weight-loss agents have antidepressant effects, and some off-label adjunctive medications may be beneficial to depressed patients who binge eat.  Treating mental health patients with FDA-approved weight-loss drugs requires caution due to the potential effects on psychiatric symptoms as well as drug-drug interactions.  For instance, in treating patients with bipolar disorder, medications with lower risk for mood de-stabilization should be used and most medications should be avoided in patients with hypomanic, manic or mixed symptoms.

Although new weight-loss medications have come to market in recent years, there is no research to inform their use in mental health patients.   Clinical trials typically exclude people with a psychiatric illness and those taking psychotropic medication.  Research to find effective weight-control medications that are safe for this population is greatly needed.

 

References

Allison, D. B., Newcomer, J. W., Dunn, A. L., Blumenthal, J. A., Fabricatore, A. N., Daumit, G. L., … & Alpert, J. E. (2009). Obesity among those with mental disorders: a National Institute of Mental Health meeting report.American journal of preventive medicine, 36(4), 341-350.

McElroy, S. L., Crow, S., Biernacka, J. M., Winham, S., Geske, J., Barboza, A. B. C., … & Frye, M. A. (2013). Clinical phenotype of bipolar disorder with comorbid binge eating disorder. Journal of affective disorders, 150(3), 981-986.

McElroy, S. L., Guerdjikova, A. I., Mori, N., & Keck Jr, P. E. (2016). Managing Comorbid Obesity and Depression through Clinical Pharmacotherapies. Expert Opinion on Pharmacotherapy, (just-accepted).

The Research Institute at the Lindner Center of HOPE is conducting a 40 week, placebo-controlled study of liraglutide, a novel weight loss agent, in patients with bipolar disorder with a BMI ≥30 or with a weight-related medical comorbidity and a BMI ≥27. For additional information, contact Anna Guerdjikova @ 513-536-0721. [email protected]

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

Fifty years ago, I was six years old.  My family, like many families of the day, subscribed to Life magazine.  On the cover of the magazine for the week of September 16, 1966 was a picture of Sophia Loren.  The Hollywood starlet was portrayed wearing a black see-through lacy dress that covered all the necessary parts, and covered all the necessary standards for 1966.  But the picture left an image upon my brain that I can easily recall to this day.

Fifty years later, digital pornographic images are now easily accessible.  The Internet has made it possible for thousands of images and videos to be accessed within seconds.  The Internet has made it available for instant digital infidelity to occur.  Such images and encounters can easily be accessed on any smartphone, tablet, and computer.

So how concerned should we be as a society?  Do we accept this dark digital domain as a part of our technological culture?  How harmful can pornography and digital infidelity be?  Is it possible that sexual images and/or compulsive sexual behaviors reside within the same realm as problematic alcohol and drug use?  The answer is plain and simple.  It does.  Pornography and cybersex can become addictive.  In the long run, this behavior rewires the brain, and can lead to abusive and destroyed relationships for men and women.

Sixty-eight percent of young men and 18% of young women view pornography at least once a week, and those numbers are growing. A sexual addictive epidemic is on the rise, not only because of easier access, but also the lack of information people have had on the negative and harmful effects associated with this addictive behavior.

Many researchers and clinicians in the field of mental health no longer discriminate between behavioral addictions (i.e., pornography, sex, gambling) and chemical addictions (i.e., alcohol, drugs).  Simply stated: The brain doesn’t care.  The brain doesn’t care whether you pour it down your throat, place it in your nose, see it with your eyes, or do it with your hands.  Pornography and sex, along with other addictions, flood the brain with dopamine and make the recipient feel good.   They help you to escape, as you seek the behavior over and over again.  Over time, as more dopamine is released, the individual will begin to feel the effects of this neurochemical less and less. This leads one to search for more graphic images, increase high-risk sexual behaviors, escalating the addictive behavior in order to obtain the desired effect.

Researchers indicate that nearly 80% of individuals who have an alcohol or drug issue will also have a mental illness issue as well.  This is the rule rather than the exception.  So what is the relationship that pornography, cybersex, and other addictive behaviors have with mental illnesses like depression and anxiety?  This could be better understood by the CUBIS model, an acronym that represents five areas that I believe demonstrates this relationship between addiction and mental illness.

Chemical Imbalance 

Within the field of psychiatry a basic premise is that some individuals may have issues of mental illness as a result of a chemical imbalance. When an individual experiences challenges of depression and/or anxiety, for example, particular neurochemicals within the brain may not be producing at desired levels, resulting in symptoms of mental illness (e.g., depression, fear, anxiety, paranoia).  This is where medications can be helpful.  However, addictive behaviors like sex and pornography, as well as alcohol, drugs and gambling, can also serve to temporarily regulate this imbalance, resulting in the individual feeling better and distracting his or herself with undesirable and destructive behaviors.

Unresolved Issues

For many, issues of trauma, abuse, grief, loss and/or abandonment, can lead some individuals to seek out ways to escape and numb one’s self from the aforementioned mental health challenges.  Whenever these problems bubble up to the top, the individual doesn’t want to think about or feel the emotions associated with these particular issues.  Cybersex and pornography, like other addictive behaviors, serve a purpose in suppressing these thoughts or feelings and help the individual to escape, distract, or forget about mental health concerns.

Beliefs (that are distorted)

We all grow up with a belief system.  This system consists of the messages we receive from our parents, relatives, neighbors, and society in general.  It’s how we see the world, and how we see ourselves.  But what if some of these beliefs are untrue, irrational, or distorted?  What if one had the belief that the only way to be social is to have a drink, or the only way to relax is to smoke a joint?  These beliefs, of course, are untrue.  Anyone is able to relax and become social without substances.  But how do these distorted beliefs materialize with sexual acting-out behaviors?  Typically within healthy relationships, the initial element is one of friendship.  This is usually followed by trust, increased commitment, and closeness through intimacy (love), and then sex.  But for some, the way one develops friendship, establishes trust, makes commitment, is by being sexual.  Sex provides a way to meet his or her unmet needs.  One’s distorted and irrational beliefs may perpetuate this unhealthy cycle of addiction.

Inability to Cope

Think for a moment of someone who has been a best friend. A best friend is someone that you can always count on, and is always reliable, 24/7.  This is the same relationship that the addict has with pornography, sex, and other addictive behaviors.  Our digital world has made cybersex and pornography readily available 24/7.  It is accessible during good times and bad.  It always delivers what it promises to do when reality can be so unpredictable.  In addition, the area of the brain affected by addiction is the same area where meaningful relationships are developed.  One’s addiction becomes on par with his or her spouse, children, parents, and friends. Sometimes, unfortunately, it becomes number one.  For the addict with mental illness issues, in order to get well, I have to give up my best friend.

Stimulus-Response Relationship

When it comes to the brain and addiction, there are two main areas of the brain which play an important role with the other: the prefrontal cortex (PFC) and the midbrain.  The prefrontal cortex is the executive functioning part of the brain.  The PFC is where   decision-making, morality, and personality exist.  Everything about who one is as a person resides in the PFC.  The main role of the midbrain is to reinforce behaviors which are necessary for the organism to survive.  The midbrain does this by the release of certain neurochemicals, especially dopamine.  Dopamine provides pleasure. Behaviors that are necessary for survival are reinforced with dopamine.  If food and sex were not pleasurable, humankind would have expired thousands of years ago.

The midbrain reinforces behaviors necessary for our survival by the release of the pleasure chemical, dopamine.  But addictive behaviors also trigger dopamine.  Behaviors such as sex and pornography, as well as other addictions (drugs, alcohol, gambling) do this too.  When dopamine is released from the midbrain and begins to flood the PFC, there is a shutting down of the rational, logical, decision-making part of the brain.  The midbrain overrides the PFC which now no longer functions correctly. A hijacking of the brain’s reward system occurs.  When this happens, the memory neurochemical Glutamate is released and informs the midbrain:  “Don’t forget this!  Go out and get it!”

The brain now believes and remembers that addictive behaviors are essential for survival.  Logically, one knows that one does not need alcohol, drugs and other addictive behaviors to survive, but the brain does not realize this.  As a society, we have unfortunately responded and treated addiction as an issue of morality, a weakness, a lack of will power, a character flaw, an addictive personality, sociopathy, etc.  Our society has unfortunately responded to addiction with shame, guilt, blame, coercion, and incarceration for many years.  This old approach has and continues to be a failure.  Addiction starts earlier and deeper within the brain and hijacks its reward system by believing the addictive behavior is necessary for survival.

Treatment

What should the treatment be for these issues?  When it comes to pornography, gambling, alcohol, heroin, or in fact any addictive behavior, a strong correlation exists with mental illness.  Treatment approaches must include integration of the co-occurring disorders.  For years substance use disorders and mental illness have been treated separately from one another.  Unfortunately, this view continues in many treatment communities.  Research indicates that an effective treatment model of addiction must integrate with the individual’s mental illness issues.  If only the addiction is addressed and not the mental illness, both will get worse.  Likewise, if only mental illness is treated and not the addiction, both will get worse.

The CUBIS model provides a template for treatment:

  • Medication management:  For individuals who experience a chemical imbalance, medication management can be beneficial in assisting the individual in regulating issues of anxiety, mood, and depression.  The development of medication-assisted treatment for those in recovery has also proven to be therapeutically beneficial for individuals suffering from addiction.

 

  • Psychotherapy:  Therapy serves as a means to relieve symptoms, resolve problems in living and/or seek personal growth.  The utilization of psychotherapy can be helpful in assisting individuals with unresolved issues of trauma, abuse, grief, loss, abandonment, etc.

 

  • Cognitive-behavioral therapy:  Individuals experiencing issues of irrational, maladaptive, or distorted beliefs may benefit from cognitive-behavioral therapy.  This therapy approach focuses on issues of thoughts, perceptions, attitudes and actions in choosing healthier behaviors.

 

  • Skill development:  For individuals who need to find better ways of coping, developing skills to assist in the regulation of mood and anxiety can be helpful.  These skills may consist of various ways of coping including mindfulness, meditation, community support groups, exercise, dialectical behavior therapy, spirituality, etc.

 

  • Education:  Knowledge serves as a means of increasing understanding and awareness for individuals and family members in how addiction impacts the brain.  This level of education and awareness can hopefully reduce elements of shame, guilt and blame of the individual who suffers from addiction and mental illness.  Individuals suffering from addiction may lie, cheat and steal, but bad acts do not necessarily mean bad actors.

Final thoughts

For this clinician, a simple cover from a 1963 Life magazine has left an imprint.  It remains unclear what the long-term effect of exposure to pornography and digital images have upon the brain and especially on the developing brains of young people.  The Internet and the digital world have made many aspects of our lives more productive, informative, connected and creative.  However, in today’s world of social media, chat rooms, digital pornography, interactive webcams, instant messaging, “adult friend finder” apps and sexting, our digital world also provides more destructive means to escape from life stressors, depression, anxiety and all other forms of mental illness.  Individuals suffering from mental illness may be easily drawn into other means of regulating mood, thoughts, and behaviors by high-tech addictive behaviors.  No longer can humanity afford to turn a blind eye as men, women, and children are pulled into the seductive charms of the dark side of the digital world. There is nothing romantic about pornography. Instead, it promotes an unrealistic and unhealthy view of relationships and true intimacy.

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summerBy: Jennifer Farley Psy.D.

If you’re on social media, you may have chuckled at recent posts depicting the difference between teachers and students at the beginning versus the end of the school year – with all of them involving anticipation for summer’s reign to begin. Summer is The Quintessential Break for our kids and their educators, and it should be – it’s good for kids to have a nice break from the structure of school to be able to enjoy the opportunities that a no-school summer offers.

That being said, if you ask most kids what they are especially excited about for summer, “Sleeping in,” tends to be a common answer, especially for teenagers. (It is also the response that elicits the most sighs and eye rolls from their parents.)  Most parents are happy to have their kids experience a more relaxed schedule in the summers.  This is especially the case for parents of children who struggle with any number of cognitive or learning challenges that make the school year much more difficult and tiresome.  Yet, as with many things in life, it’s important to maintain a healthy balance, in this case, with having enough structure without being overscheduled..  What many parents may not realize is that after the first 3 or 4 weeks of summer, kids who experience the most radical shift between the structure of their school schedule to a completely unstructured summer often complain most of boredom.  I’ve heard quite a few of these children and adolescents say that they wish they could go back to school well before the start of the next school year.

There are many families who struggle with the idea of being “too scheduled” in the summertime. Setting aside the concept of being “overscheduled” for a second, there is actually quite a bit of value to having structure and routine to our days.  Having a routine helps us plan and prepare for what comes next.  Without this, we risk not being able to have some predictability and readiness to our days. Without some predictability, we risk feeling more chaotic and disorganized.  And leading a disorganized, unplanned lifestyle brings the risk of becoming more anxious and/or depressed.  Children as young as 2 can experience comfort knowing that after a good afternoon nap they’ll be able to play again.  Four-year olds ask their parents at bedtime what they’ll be doing the next day.  Even as adults, we benefit from knowing what is coming so that we can plan ahead for it.

Have you ever noticed a difference between how you (or others) function during the week compared to the weekends? Most of us who work or send our children off to school during the week have what is called “external structure.”  We know what time we have to wake up, what sequence of tasks we need to do before we leave, and we know what time we have to leave the house to get to school and/or work on time.  When at work, we know what is expected of us and what our responsibilities are. At the end of the work day, we leave with thoughts in mind of what comes next for what is planned that evening. There is much more inherent structure built into those days.  In contrast, weekends offer the opportunity for us to guide our own tasks (providing there are no athletic games or meetings or birthday parties to take our children to).  People who struggle with initiating tasks or motivating themselves to get tasks done all too often hit Sunday evening with a somber feeling that they did not accomplish most (if any) of what they intended. It can leave adults with a sense that they wasted their time, because they have nothing to show for their weekend. This same experience can be felt among children in the summer.

Think about what “boredom” looks like for kids: they may sleep in bed late, they may sprawl on the couch with no intellectually-stimulating activity, and they look “lazy” to parents by showing no initiation for any physically-active tasks. Now, picture what “sadness” or “loneliness” or any other negative feeling “looks like” for kids.  They can be quite similar to what kids experience when they are bored. Too much boredom leads to emotional discomfort, and this can lead one to lack creativity, to feel unproductive, and to experience poor confidence. These experiences can then lead one to feel more irritable, down, restless, and even anxious.

It is healthy to have some semblance of plans and structure during the summer. A family vacation offers the excitement and anticipation of a journey to look forward to. For the day-to-day routine, many parents send their kids to day camps (especially working parents), while some send their kids to a sleep-away camp for a week or two. Some families hire a nanny or a babysitter to watch their children and to take them places.  Some families have a parent who can stay at home with their children.  In any of these instances, what is healthiest is when there is a routine by which kids wake up at a certain time and engage in a morning routine.  Structure can be in the form of whatever activity is intended that day, such as swimming in the neighborhood pool, going to a movie, or having a play date with friends.  What helps is that there is something to plan for that day. Adolescents who are taking care of themselves function even better when given structure in the form of expectations – if even to complete a designated chore first before enjoying whatever leisure activity the child hopes to do. Often times, parents get more compliance from kids who agree to complete a chore first before being allowed to engage in a fun activity, such as with their friends. Ending the day with a sense of accomplishment or satisfaction of having engaged in an activity leads one to feel more rested, physically and emotionally.

Being “overscheduled” can lead to stress on the entire family, and it does not allow for any rest time. It is good for children and adolescents to enjoy the feeling that comes with “lounging around” – especially since so many miss out on that opportunity during the school year when managing responsibilities associated with academics and extracurricular activities.   Being overscheduled also can dampen one’s creativity and ideas for how to spend down time.

The key is balance: allow for a mix of planned activities with some unscheduled leisure time by which children and adolescents can choose what they would like to do. Many children may balk at the idea of having any expectations upon them, but the structure and predictability they gain from it offers many more psychological and social benefits than having no plans at all.

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BY: Elizabeth Wassenaar, MS, MD, Lindner Center of HOPE, Staff Psychiatrist and Medical Director of Williams House

 

Life can be overwhelming and we all would like to take a day off every once in a while. Likely, as helping professionals, we don’t take mental health days as often as we could actually benefit from them.  This is one of the reasons why, when a child or adolescent refuses to go to school, we may be initially sympathetic.  Maybe a day or two off will help, we may think.  In too many cases, however, we see that a day or two off turns into something much more problematic as parents and professionals struggle to get a school avoider back to school.  Homework piles up, grades start to fall, and friends wonder what has happened to their classmate.  Parents try many different tactics to try to get their child back to school; bribing, negotiating, punishing, or even carrying a child through the school door.

Children want to not go to school for many reasonable causes: kids can be cruel; learning can be difficult; anxiety about performance can be overwhelming; health concerns can require special privileges that feel too identifying; and getting up early in the morning is harder for some more than others. Furthermore, mental illness can make school attendance difficult for many additional reasons.  There are good reasons to keep children home from school – physical illnesses can be contagious, some stages of mental illness are better treated with mental rest, and in some cases of bullying the safest way to deal with an unsafe situation is to remove the child.

Nevertheless, school refusal is avoidance, and anxiety loves avoidance. Nothing is more reinforcing that one cannot handle something than not doing it.  So, after one has checked on physical health and for other explanations, how can professionals support parents to keep their children in school or break the cycle of school avoidance and school refusal?

  1. Help parents identify the behaviors of avoidance and link that to anxiety.

Avoidance is a coping mechanism for dealing with anxiety, which can become maladaptive when avoidance becomes the only options. Avoidance can look a lot of different ways –tantrums, tearfulness, vague physical symptoms, negotiation (more on that later), chaos, and so on.  Parents may not be able to recognize all of the forms avoidance can take. Helping them objectify avoidance will help them strategize on how to deal with it.

  1. We have to truly believe that avoiding school will not make it better.

It can be tempting to collude with anxiety that the precipitant needs to be avoided for all the reasons laid out in this article and we need to be internally convinced that anxiety is not correctly assessing the situation. As difficult as school can be, school occupies a unique place in a child’s life.  It is the place of work, play, and love.  Learning and playing are the main jobs of childhood.  Playing looks both like playing at recess and like experimenting in relationships with both friendship and love. Identity is formed and reformed through our work, play, and love.  When a child is not in school for an extended length of time, they are abrupting their opportunity for this developmental process to proceed.

  1. Negotiation is another way of avoiding and is a dangerous game.

Many of my patients have used a variety of negotiating tactics with their parent: “Let me go in later and then I’ll go, I promise” or “Let me catch up on my work today and I’ll go in tomorrow”. Small avoidances add up to large avoidance and are not moving towards your goal.  Reverse the negotiation and set up conditions that will allow an out as long one starts the day at school.  Often, once anxiety has lost its argument that one cannot handle going to school, staying in school through the day is easier to manage.

  1. Encourage parents to work with the school

Parents and school are on the same side of this concern – both parties want the child to be successful in school. For parents, this may be the first time dealing with school refusal, but it is most certainly not the first time the school has dealt with school refusal.  Most schools have a variety of plans to help keep a child in school.  Have parents reach out to the school and let them know what is going on.

  1. Set small goals that lead to the victory

The ultimate goal of full school participation is an overwhelming prospect. Depending on how severe the school refusal is, reintroducing school can be an extended process of gradually introducing larger and larger challenges.  Perhaps, on the first day, one can only walk through the school doors.  Maybe a student will be able to be in the school building, but not in classes.  Parents can engage trusted friends to provide motivation and encouragement through social interaction and distraction while at school.

  1. School has many different forms

Many families choose alternative school arrangements including home schooling, virtual schooling, and others, for a variety of reasons and this article is not meant to convict choices that do not have a child in a classroom every day. There are many viable options for school that provide an environment that promote healthy development.  When a family is making a decision to change the way school is delivered, help them examine what factors are involved in their decision.  If they are making the decision from a place of believing that the anxiety that drives school avoidance cannot be defeated then, help them with all the ways described above.

School is a venerable and sometimes dreaded rite of passage. A great deal rides on academic and social success in school which increases anxiety and can lead to school refusal.  As a team, parents, professionals, and schools can help keep children and adolescents in school and accomplishing their goals.

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The Research Institute at Lindner Center of HOPE is a site for an open label study with the primary goal of validating a signature (model) based on a panel of serum proteomic markers that discriminate Bipolar I, Bipolar II and Major Depression in people seeking treatment for a major depressive episode. The success of this study could lead to the first diagnostic test that would distinguish between the three mood disorders in a person experiencing depressive symptoms.

Lindner Center of HOPE is seeking a total of 90 study participants, between the ages of 18 and 70, with bipolar I depression, bipolar II depression, or major depression, who are currently depressed. Some exclusions apply, so participants should complete a phone screening.

The study duration is 8 weeks and includes 6 visits and 3 blood draws. Subjects will be paid per visit up to a total of $350.

Call 513-536-0707 for more information. All inquiries are kept confidential.

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On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

Click here to listen.

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By: Jennifer Bellman, Psy.D.

Ah, fall. For many it means a time for apples, visiting fall farms, enjoying the cooler respite from the days of Indian summer, and purchasing any pumpkin-spice-infused food or drink or scent that hits the consumer-driven market. It’s also the time of year when parents (who might have been holding their breath for the first few weeks of school) may grow concerned about their homework-resistant child and when interim reports and/or parent-teacher conferences provide knowledge about a child’s academic progress and behaviors at school. And for some families, notices and emails of concern from teachers arrive well before the parent-teacher conferences are even scheduled.

Fall. It is when parents wonder if their child might have Attention Deficit/Hyperactivity Disorder (ADHD).

ADHD takes on different forms, depending on the age of the child. Generally speaking, the younger the child, the more behavioral problems he or she has likely exhibited in the classroom. These can include anything from talking in class, interrupting the teacher, blurting out answers, pushing others as they form a line, invading others’ personal space, and needing continual reminders to sit in one’s chair. All these are symptoms of impulsivity and hyperactivity and are the most noticeable symptoms teachers observe in class, and they are the most “disruptive” to the process of teaching and learning. It is not uncommon for these children to start exhibiting these difficulties in preschool, when they first enter into a structured group environment with expectations of age-appropriate rules and directions.

Struggles with inattentiveness (without impulsivity or hyperactivity) may start being observed in children as early as the 2nd or 3rd grades, when the fundamentals of reading and math are already expected to have been sufficiently established. Many of these children are not exhibiting outward signs of problems, nor are they causing enough of a disturbance in the class for teachers to place on their radars. Instead, these children are ones who may struggle to complete their seatwork and are required to take it home to finish, make “simple” mistakes in their work, sometimes “stare into space,” forget to turn in their homework, become distracted by other tasks, and/or “do not seem to be performing up to their academic potential.” Due to the quiet nature of inattention, it is also not uncommon for children to first become identified as having ADHD in junior high or high school, when the demands for the academic work become increasingly more difficult. Sometimes, high intelligence in a child can mask underlying inattention and distractibility; the child may still grasp the academic work without showing any difficulties. The more complex the work in school becomes, though, the more opportunities there are for a highly intelligent child with ADHD to exhibit their underlying struggles.

Many people only focus on struggles with inattentiveness, distractibility, impulsivity and/or hyperactivity when wondering if a child has ADHD. The less obvious (and yet very important) areas to consider are those of executive functioning. These are higher-order cognitive abilities “housed” within the frontal lobe of the brain, which is the last lobe of the brain to develop and is not fully formed until one’s mid-to-late 20’s. These skills involve planning, organizing, inhibiting (or, controlling) one’s impulses or behaviors, and other complex skills. We can easily observe how behavioral disinhibition (i.e., dyscontrol) is represented by impulsive acts. Two other areas of executive functioning that are especially noteworthy to consider when wondering about ADHD (and how impairments are observed) include:

Poor time management:   procrastination; conceptually minimizing the time it actually takes to complete a project or an activity; rushing; arriving late most of the time; not utilizing one’s time most effectively; taking longer to complete homework than is expected

Disorganization: having a messy backpack; keeping a messy bedroom or other areas of personal space; being unprepared; losing or misplacing belongings; difficulty knowing how to prioritize tasks in terms of importance; problems completing tasks or projects; forgetting assignments, due dates, appointments, or other tasks

Many parents question whether their child is just “not motivated enough” to complete their work. This is certainly of note to consider. It is important to understand, though, that for individuals with ADHD, it is much less about internal motivation to complete a task and much more about the desire to avoid the difficult work one faces with having to sit for a seemingly long duration, sustain one’s attention, organize one’s thoughts, and minimize distractions. We have a natural tendency to avoid what we find difficult; so, of course, individuals with ADHD try to put off tasks that require significant mental effort.

Besides medication, strategies to help improve attention, inhibitory control, organization, and time management involve implementing structure and routine. Limits and expectations, especially for house rules such as not allowing leisure or “screen” time until homework is completed, are helpful. Reminding children about the differences between tasks that are required (i.e., homework) versus optional (i.e., play time) can also be helpful. Using multiple forms of scheduling items also is recommended, such as a daily agenda, a week-in-view planner, and a month-in-view calendar help to prioritize activities and time so as to accomplish tasks.

Of course, the struggles discussed here may also represent other underlying issues beyond ADHD. For instance, problems with impulsivity, inattentiveness, behavioral disruption, and physical restlessness could be accounted for by an underlying medical condition (e.g., hyper- or hypo-thyroidism), insufficient or poor quality of sleep, adjustment to significant changes in one’s life (e.g., a move or a parents’ divorce), affective or mood states (e.g., anxiety or depression), a behavioral disorder (e.g., Oppositional-Defiant Disorder), or other possible contributions. These must always be considered when assessing whether one has ADHD. Regardless of the underlying cause of such struggles, the recommendations used for improving structure, time management, and organization are helpful for most children, anyway.

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For more than two decades, Screening for Mental Health has developed programs to educate, raise awareness, and screen individuals for common behavioral and mental health disorders and suicide.The vision is a world where mental health is viewed and treated with the same gravity as physical health, and the public’s participation in National Depression Screening Day helps make that vision a reality.

National Depression Screening Day, held annually on the Thursday of the first full week in October, is an education and screening event conducted by hospitals, clinics, colleges, and community groups nationwide. Much like the medical community screens for diabetes and high blood pressure, the goal is to offer large-scale mood disorder screenings for the public. The program provides free, anonymous screenings for depression, generalized anxiety disorder, bipolar disorder and posttraumatic stress disorder, as well as referral to treatment resources if warranted.

This year, October 8th, will mark 25 years of this revolutionary event.

Please participate in this milestone National Depression Screening Day and help spread the word to increase awareness of mental health. Take a screening now at http://screening.mentalhealthscreening.org/#/lindner-center-of-hope and encourage your family, friends and colleagues to do the same.

Facts About Depression

General

  • Up to 80 percent of those treated for depression show an improvement in their symptoms generally within four to six weeks of beginning treatment. (NIH)

Global

  • According to the World Health Organization, depression is projected to become the second leading contributor to the global burden of disease by 2020
  • Depression is a common mental disorder. Globally, more than 350 million people of all ages suffer from depression. (WHO)

United States

  • One in five 18 to 25 year olds experienced a mental illness in the past year
  • An Estimated 1 in 10 U.S. Adults Report Depression (CDC)
  • Major depressive disorder is the leading cause of disability in the U.S. for ages 15-44. (World Health Organization, 2004)

Physical & Mental Health Connection

  • One-third of individuals with a chronic illness experience symptoms of depression
  • People with depression are 4 times as likely to develop a heart attack than those without the illness.
  • Many conditions may coexist with depression. Depression may increase the risk for another illness, and dealing with an illness may lead to depression. In fact, according to the NIMH, depression affects:
  • More than 40 percent of those with post-traumatic stress disorder
    • 25 percent of those who have cancer
    • 27 percent of those with substance abuse problems
    • 50 percent of those with Parkinson’s disease
    • 50 to 75 percent of those who have an eating disorder
    • 33 percent of those who’ve had a heart attack
  • Depression is a prevalent and increasingly recognized risk factor for both the development of and the outcome from coronary artery disease (CAD). (National Institute of Health)

Signs and Symptoms

Depression is a treatable mental health disorder that causes persistent sadness and loss of interest. Some of the most common signs and symptoms include:

  • Changes in sleep and appetite
  • Poor Concentration
  • Loss of energy
  • Loss of interest in usual activities
  • Low self-esteem
  • Hopelessness or guilt
  • Recurring thoughts of death or suicide

For a complete list visit: NAMI.org

Bipolar disorder, also known as manic depression, is a treatable illness defined by extreme changes in mood, thought, energy and behavior. These changes are categorized into manic (high) and depressive (low) episodes, ranging from bursts of energy to deep despair. Some of the most common symptoms include:

Mania Symptoms

  • Heightened mood, exaggerated optimism and self-confidence
  • Excessive irritability, aggressive behavior
  • Decreased need for sleep without experiencing fatigue
  • Racing speech, racing thoughts, flight of ideas
  • Impulsiveness, poor judgment, easily distracted
  • Reckless behavior

Depressive Symptoms

  • Changes in sleep and appetite
  • Poor Concentration
  • Loss of energy
  • Loss of interest in usual activities
  • Low self-esteem
  • Hopelessness or guilt
  • Recurring thoughts of death or suicide

For a complete list visit: dbsalliance.org

Generalized anxiety disorder (GAD) is an anxiety disorder that involves chronic worrying, nervousness, and tension. Some of the most common symptoms include:

  • Feeling like your anxiety is uncontrollable; there is nothing you can do to stop the worrying
  • A pervasive feeling of apprehension or dread
  • Inability to relax, enjoy quiet time, or be by yourself
  • Difficulty concentrating or focusing on things
  • Avoiding situations that make you anxious
  • Feeling tense; having muscle tightness or body aches
  • Having trouble falling asleep or staying asleep because your mind won’t quit
  • Feeling edgy, restless, or jumpy

For a complete list visit: helpguide.org

Posttraumatic Stress Disorder (PTSD) is a mental health condition that’s triggered by witnessing or experiencing a traumatic event. Some common symptoms include:

  • Intrusive, upsetting memories of the event
  • Flashbacks (acting or feeling like the event is happening again)
  • Nightmares (either of the event or of other frightening things)
  • Avoiding activities, places, thoughts, or feelings that remind you of the trauma
  • Feeling detached from others and emotionally numb
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Hypervigilance (on constant “red alert”)

For a complete list visit: helpguide.org

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Susan L. McElroy, MD

Lindner Center of HOPE, Chief Research OfficerUniversity of Cincinnati College of Medicine, Professor of Psychiatry and Neuroscience

Intermittent Explosive Disorder (IED) is a common and serious disorder that is often unrecognized and untreated. People with IED are periodically unable to restrain impulses that result in verbal and physical aggression. The aggressive behaviors are unplanned, out of proportion to provocation, and cause distress and psychosocial impairment, including interpersonal difficulties, divorce, school suspension, job loss, and financial and legal problems.

The violent behaviors of IED, often called explosive outbursts or rage attacks, are often preceded by aggressive or violent impulses, described as “the need to attack,” ‘the need to defend oneself,” “the need to strike out,” “seeing red,” or “an adrenaline rush.” These impulses are associated with tension, anger, increased physiological arousal, and increased energy. The explosive outbursts are brief, lasting 10 to 30 minutes, and usually followed by feelings of depression, remorse, guilt, and fatigue.

Once thought to be rare, we now know that IED is very common. Research has shown that the lifetime prevalence of IED in the general population is 1 to 7 percent. The average age of onset is 14 to 18 years among adults, and 13 among adolescents. IED is most common males and younger people. Of note, people with IED often have other psychiatric disorders, like depression, bipolar disorder, alcohol or drug abuse, and anxiety.

The cause of IED is unknown but biological, psychological, and social factor are thought to be involved. Importantly, IED runs in families suggesting that genetic factor are involved. Research also suggests that abnormalities in serotonin function in the central nervous system plays a role in IED.

IED is usually treated with medications and/or cognitive behavioral therapy (CBT). Medications that may be helpful include serotonin reuptake inhibitor s (like fluoxetine), anti-epilepsy medications (like carbamazepine ), or mood-stabilizers like lithium. When treating IED, it is crucial that other psychiatric conditions are identified and properly managed.

No medication, however, is approved by the United States Food and Drug Administration for the treatment of IED.   Hence, Azevan Pharmaceuticals is sponsoring a study to see if a novel medication is efficacious for IED in adults. This medication affects vasopressin, a hormone in the brain thought to play an important role in regulating aggressive behavior. This medication has been shown to reduce aggressive behavior in animals. The Research Institute at the Lindner Center of HOPE will be participating in this study which is scheduled to begin in late August. The Research Institute will be recruiting volunteers with IED to participate at that time. If an individual has questions about the study and might be interested in participating, they can call 513-536-0710 for further information.

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By Scott Bullock, MSW, LISW-S

Lindner Center of HOPE, Clinical Director and Family Therapist Child/Adolescent Services, Harold C. Schott Foundation Eating Disorders Program Clinical Consultant, Cincinnati Children’s Hospital and Medical Center at The Lindner Center of HOPE University of Cincinnati, Department of Psychiatry and Behavioral Neuroscience, Adjunct Instructor

Despite numerous recent advances in the field of brain research, our understanding of the principles that guide the development and operation of the brain and its complex functioning remains elusive. This is particularly true when attempting to understand a multi-faceted illness as anorexia nervosa (AN), however having a comprehensive grasp on the neurobiology on AN brain is mandatory for successful treatment. Thus, with the narrative below, we will be providing some fundamental assumptions about the neurobiology of AN brain, as researched extensively by Dr.W.Kaye.

In AN all body organs, including the brain suffer from malnutrition. Malnutrition affects all parts of the brain and especially the anterior insula. This region acts as the “brain switchboard” assuring that all parts of the brain adequately communicate with each other. The anterior insula plays a key role in the brain’s ability to recognize and process the connection between emotions and cognition and when affected in AN patient, presents with typical symptoms of altered taste, abnormal response to pleasurable foods and body distortions. The neurotransmitters dysregulations in AN are very complex and involve many systems, circuits and brain regions. To date, most research has focused on serotonin function and dopamine/reward systems function that are found to be compromised in AN as briefly outlined below.

Serotonin

Brain imaging studies suggest alterations of 5-HT1A and 5-HT2A receptors and the 5-HT transporterin AN. Dysfunctions of these circuits may affect mood and impulse control as well as the motivating and pleasurable aspects of food consumption leading to a dysphoric mood. In an attempt to reduce their dysphoric mood, the patients engage in dieting and exercise which results in malnourishment of the brain leading to the lowering of tryptophan and steroid hormone metabolism. This then reduces serotonin levels at these critical sites, further increasing dysphoric mood thus perpetuating starvation.This becomes a cyclical action as the patient tries to control their dysphoric mood while driving themselves deeper into the illness.

Dopamine and Reward System

Dopamine system dysfunction might contribute to altered reward and affect, decision-making and executive control, and decreased food ingestion in patients with AN. Dysregulation in this circuit might contribute to patients with AN not being able to correctly act on immediately important tasks but rather focusing on planning and remote consequences.

In conclusion, this is just a glimpse of the complex function of the Anorexic brain. Genetics, puberty, stress, trauma, cultural and social expectations as well as the temperament of the individual also play important roles in the development of AN in adolescents.

 

Ref: Kaye, Walter H., Fudge, Julie L., and Paulus, Martin. New Insights into symptoms and neurocircuit function of Anorexia Nervosa. Nature Reviews/ Neuroscience. 10, 573-587 (2009)