When To Seek Treatment For Anxiety
By Angela Couch, RN, MSN, PMHNP-BC
Psychiatric Nurse Practitioner, Lindner Center of HOPE
Anxiety is a common symptom. Anxiety is a part of everyone’s lives, we have all experienced it to one degree or another. Believe it not, anxiety serves some useful purposes. Anxiety can help give you the drive to make a change, or complete task on time.Anxiety can activate the fight or flight instinct, in a “potentially” dangerous situation, giving you the drive to get out of there, or do something to prevent harm. Anxiety can occur when you are enduring multiple stressors, or there is uncertainty, and it’s not entirely unexpected.
For instance, say you hear layoffs are coming in the company, and you’re not sure if your department will be affected. You may experience physical symptoms of anxiety (which could include racing heart, nervous stomach, sweating, tremor, nausea, shortness of breath, and more), and you might also experience worry. COVID-19…yup, that can cause some anxiety, or worry, too! Situational anxiety is a part of life, and often can be managed by rational self-talk, problem-solving, and various positive self-care strategies. (For more on that, see some of our other recent blog articles, for lots of helpful ideas!) So how do we know when the anxiety is more than just “normal” or to be expected, and when to seek help?
According to the National Comorbidity Study Replication, about 19.1% of U.S. adults will have had an anxiety disorder in the past year, and 31.1% experience an anxiety disorder in their lifetime. In other words, it’s pretty common! There are various types of anxiety disorders, and most have an underlying common thread– difficulty in accepting uncertainty in some form. So how do you know if you may need to seek further assessment or help for anxiety, if it’s really so common? If everyone gets it, is it really a problem that requires treatment? The answer is yes, it might. Some symptoms that may indicate problematic anxiety include:
* Feeling “paralyzed” by fear.
* Anxiety is causing you to avoid things you used to be able to do without anxiety, or things that are important to you (this could include social activities, leaving your house, going to your job, driving, engaging in spiritual activities, etc.).
* You have difficulty staying present “in the moment”, which may repeatedly distract you from attending to conversations, being able to complete work or school tasks because of lack of focus.
* You are having difficulty with sleep or eating due to excessive worry or anxiety.
Anxiety is causing significant physical symptoms.
* You cannot determine a cause for the anxiety and the symptoms are persistent or very bothersome.
* You worry about “everything” or “all the time”.
* The anxiety/worry you are experiencing about situations seem excessive.
* You need to engage in compulsive or repetitive behaviors, or do things in a certain way, in order to avoid significant anxiety/worry.
* Anxiety is causing you to turn to self-medication with alcohol or substances.
So you’ve determined you should seek help, now what? Psychotherapy can be helpful for anxiety, and is a very important component of treatment. Psychotherapy may include several modalities such as cognitive behavioral therapy, addressing faulty beliefs contributing to anxiety, psychoeducation about anxiety and worry, problem-solving, exercise and wellness activities/lifestyle changes, addressing sleep hygiene, skills for time management and stress reduction, or exposure therapy, just to name a few.
How do you know if psychotherapy is enough to manage the symptoms? Medication can be a helpful component in treatment of anxiety, particularly if symptoms are not improving with other psychotherapeutic interventions mentioned above. Medications alone are rarely enough to treat anxiety disorders adequately. Medication can often make it easier to engage in meaningful psychotherapy, to make those helpful lifestyle changes, or try new ways of coping with the anxiety/worry. If you are experiencing suicidal thinking or significant depression, medication should be a consideration. If the anxiety symptoms are preventing you from being able to work or do other essential tasks, medication may be indicated. If your therapist suggests a medication consultation, you should consider it.
The important things to remember are, everyone has some anxiety, not all anxiety is bad, and when anxiety does become problematic or excessive, there are evidence-based treatments to help, so don’t be afraid to reach out for help!
Isolation and Loneliness During Social Distancing
Quarantine.Isolation . Lockdown.
Who could have ever predicted that these words – so often associated with scary movies or rare, brief safety emergencies – would become so commonplace in our social language? The terms, themselves, being so casually thrown around that we’ve nearly become numb to their actual magnitude? The concept of loneliness is a broad one: certainly, this can describe distance or literal, geographical separation from others; however, it is also quite possible to experience loneliness while physically surrounded by people. This often arises in response to feeling misunderstood or “different” from those around us, or through a belief that we are truly alone in our struggles and suffering.
When in this state of mind, it’s easy to inadvertently fall into self-destructive patterns and habits that further worsen the depth of isolation we experience. This tends to be easier to “catch” in the “normal” world – someone is missing days at work or school, not showing up to family events, skipping appointments. However, in the midst of the COVID19 pandemic, this has become more difficult to identify, both in ourselves and in family members or friends. In this strange new reality, maladaptive coping might present through symptoms of depression:
– Withdrawing from others by declining phone calls or choosing not to respond to text messages
– Staying in bed during times when you’re not sleeping or physically in need of rest
– Deferring school assignments or work deadlines in favor of binging on Netflix series for extended periods of time
– Not leaving the house for fresh air when weather permits
– Declining hygiene practices and decreased attention to nutritional needs and physical activity
– Self-medicating through alcohol or drug use
In contrast, some individuals experience severe levels of anxiety when facing loneliness or isolation. Those with pre-existing obsessive-compulsive disorder, anxiety or impulse-control disorders, eating disorders, or traits of perfectionism may attempt to cope with isolation by trying to gain a sense of control over specific aspects of their lives. This could present as:
– Excessive cleaning, organizing, list-making in the home without clear need to do so
– Catastrophic thought processes with over-indulgence in news reports and social media
– Difficulty sleeping or resting due to racing thoughts
– Flare-ups of previous OCD rituals or disordered eating patterns
– Difficulty concentrating on school assignments or work due to preoccupation with above concerns
One of my favorite, go-to methods for combating these negative impulses is an emotion regulation technique called “opposite action,” a concept originating from the skill sets taught in dialectical behavioral therapy (DBT). This technique forces us to identify our emotion and the urges or impulses that go along with it, and to assess their degree of helpfulness or harmfulness by challenging them with facts. If found to be irrational or maladaptive, then we aim to implement the opposite of our emotion-driven impulse. We actually implement opposite action frequently through our lives without necessarily naming it as such. By identifying the technique, though, we
can consciously choose to use this skill when our level of motivation to change is low. Consider this example
(modified content courtesy of PsychPoint.com):
STEP ONE: Identify the emotion you’re looking to change. You’re really anxious about leaving home to go
STEP TWO: Identify the urges/impulses associated with the emotion. You actively avoid booking the
vacation by burying yourself in work and household tasks to subconsciously convince yourself that you simply
do not have the time to take a vacation.
STEP THREE: Assess whether the urge or behavior fits the facts of the situation. You have plenty of unused
vacation time and recognize that your year-end productivity will not be negatively impacted by taking the break.
You’ve taken vacations before and your family has benefited from the escape each time.
STEP FOUR: If the emotion and behavior does not fit the situation, then apply the opposite action.
Create a manageable schedule / timetable to take the steps necessary to search for and secure the logistics
required for booking the trip.
STEP FIVE: Experience the opposite emotion. Experience the excitement involved with planning activities
and excursions or buying a new outfit for the occasion. Go on the trip and enjoy the time with your family while
allowing others at work to keep things running smoothly until you return.
Used consistently, opposite action can help us to change our emotional response to stressors over time. It’s
important, though, to commit to the technique so that you can experience the full benefits of taking control of
your mood and behaviors rather than allowing them to be in control of you.
For a quick video explanation of opposite action, view the following:
If you’re experiencing the above symptoms associated with loneliness and have tried methods for self-help
without benefit, or if you’ve been previously diagnosed with a psychiatric illness or substance use disorder
that has begun to flare up in the midst of these extraordinary times, please know that psychiatric treatment
providers are still open, available, and ready to help you through this – at all levels of care.
Clinicians at the Lindner Center of HOPE are seeing patients every day through Telehealth, with options for
telephone or video sessions for both therapy and medication management. Additionally, our services are open
for emergency intake assessments and inpatient hospitalization, partial hospitalization, intensive outpatient,
residential, and treatment for substance use disorders.
If you or a loved one could benefit from professional help, call the Lindner Center of HOPE at 513-536-
4673 to start the conversation and take the next steps toward healing.
Jen Milau, APRN, PMHNP-BC
Lindner Center of HOPE , Psychiatric Mental-Health Nurse Practitioner
Conversacion con la incertidumbre
En esta oportunidad quiero compartir con ustedes el articulo que escribimos en mi Grupo de estudio Psicoanalisis de Cara a lo Social integrado por Manuel Llorens, Alicia Leisse, Carmen Elena Dos Reis, Claudia Alvarez, Yone Alvarez y esta servidora. Nos reunimos de forma “virtual” cada 15 dias para discutir trabajos y temas de corte psicoanalitico y tambien social. Somos todos venezolanos conectados desde el exilio o desde la emigracion elegida. Espero que les resulte de utilidad en estos tiempos de incertidumbre…
UNA CONVERSACION CON LA INCERTIDUMBRE
Una de las anécdotas que ha circulado ampliamente en medio de la pandemia es de la antropóloga Margaret Mead cuando un estudiante le preguntó que cuál era, a su juicio, el hallazgo que evidenciaba el comienzo de la cultura. Esperando escuchar algo como potes de arcilla o cabezas de flechas, el estudiante se sorprendió al escuchar “un fémur roto que fue curado”.
La pandemia ha servido para subrayar la íntima conexión de la humanidad entera. La manera en que los hábitos alimenticios, los sistemas de gobierno, los medios cada vez más veloces de transporte, y hasta nuestra manera de saludarnos, influyen en el curso de un virus que ha detenido todo el planeta. El coronavirus ha puesto de rodillas el poderío humano: paralizó el comercio, las olimpiadas, los aeropuertos, las protestas públicas y más.
Sumado a las consecuencias de la salud de los contagiados, los sistemas sanitarios, la economía mundial y las adaptaciones a la vida cotidiana que ha exigido la pandemia, ha habido un repunte a nivel mundial de trastornos de ansiedad. Por ende se les pregunta a los profesionales de la salud mental: ¿cómo se lidia con las angustias que todo esto despierta?
Circulan muchas recomendaciones, ideas, gestos salvadores, actos creativos que dan cuenta de que, en lugares geográficos con mayor piso de respuesta social, los daños ciertamente están, pero el músculo creativo se reinventa al servicio del otro y de uno con el otro y del sí mismo. Muchas de las recomendaciones, útiles sin duda, se anclan en el terreno de las acciones concretas y conscientes que podemos incluir en nuestras rutinas para sobrellevar la angustia, el tedio, la pérdida o el conflicto que desata las medidas de protección que han alterado nuestras vidas.
Creemos, sin embargo, que puede ser útil tomar un paso al costado y escucharnos desde otro lugar. Hay por lo menos dos elementos fuera de las prescripciones más concretas que valen la pena considerar. El primero, es que la pandemia nos ha colocado de manera dramática frente a la vulnerabilidad humana. Ante esto, algunos han querido continuar como si nada, como los presidentes de Brasil y México, besucones desafiantes, que parecerían estar en negación de los riesgos que implica el COVID-19. Lo cierto, es que desde el Príncipe Carlos hasta los plebeyos estamos expuestos. La omnipotencia no está resultando buena consejera.
A la vulnerabilidad se le suma una gran cuota de incertidumbre. Nuestros parámetros de control han sido trastocados. Hay recomendaciones que nos pueden ayudar a sobrellevar el día a día, pero inevitablemente necesitamos escuchar y articular el temor que surge. El miedo, lo sabemos, pero se nos olvida, es una alerta que necesita ser atendida, para poder prepararnos para lidiar con una amenaza. Lidiar con el miedo sin negarlo, pero sin quedar sobrepasado por el desespero, es parte de la tarea.
La escucha y el esfuerzo por darle palabra a nuestro mundo interno, es parte de una solución que lidia con la incertidumbre sin pretender tener las respuestas de antemano. Una de las maneras en que la psicoterapia psicoanalítica ha sido descrita es como una “conversación con la incertidumbre”. La gran verdad, es que ni los expertos tienen la respuesta completa de las dimensiones del problema ni de su solución. Lo más probable es que tengamos que hablar y escucharnos para descifrarlo en conjunto.
Lo que estamos diciendo, y que lleva al segundo elemento, es que el problema tiene que ver con la interdependencia humana, y su solución, probablemente también. Una de las medidas preventivas curiosamente se ha llamado “distanciamiento social”, cuando lo que necesitamos es distanciamiento físico, pero no social. Tanto por el proceso de concebir soluciones a un problema de dimensión sistémica, como por el funcionamiento biológico individual: la conexión humana es esencial. Sabemos que el sistema de defensa inmunológico está íntimamente relacionado con la vinculación interpersonal, la soledad nos hace más propensos a enfermar.
Nos estamos quedando en casa, aunque parezca paradójico, como gesto de profundo reconocimiento del otro. Nos quedamos en casa, para cuidar a los demás tanto como a nosotros mismos. Nos quedamos en casa, porque el bienestar del otro es indispensable para el bienestar nuestro. Visto así, nuestro encierro no es aislamiento. Las redes de solidaridad, para estar atentos a las personas de nuestro vecindario que no se pueden valer por sí mismas, el comunicar nuestra preocupación por el otro, el pedir ayuda, la música en los balcones o los aplausos a los operarios de salud, son gestos indispensables de conexión humana, necesarios para mantenernos sanos y cuerdos.
No olvidemos finalmente que los riesgos y las desventajas tienden a multiplicarse, por lo que, aquellos que vienen arrastrando desventajas, están ahora en una situación multiplicada de riesgo. Los que tienen alguna situación previa de vulnerabilidad, por edad, por salud, por pobreza, por red de apoyo limitada, están mucho más expuestos y haremos bien en pensar en el problema priorizando las necesidades de aquéllos que la van a sufrir más.
La cuarentena es un alto obligatorio que puede ayudar a hacer un parado en una vida que no deja de exigir apresuramiento, un llamado a abrir espacios para la reflexión, para recalibrar nuestras prioridades y para hacernos más conscientes de nuestra interdependencia, nuestra necesidad del otro, fomentar nuestra capacidad de construir la cultura en los términos que propuso Margaret Mead.
Margot Brandi, MD,
Sibcy House, Medical Director
Mental Health Remains Critical During Pandemic
Lindner Center of HOPE, Chief Clinical and Operating Officer, Psychiatrist
4075 Old Western Row Rd.
Mason, OH 45040
Most of us are weeks into the significant life changes caused by the novel coronavirus. Even as we work to adjust to our new normal, there continues to be changing instructions and sometimes confusing and frightening information to process. Daily, we are being asked to make sacrifices and critically important decisions for the safety and welfare of our family and our communities. It is important during this crisis to remember to monitor and maintain our own mental wellness.
Some tips to manage the stress of today’s circumstances include avoiding excess exposure to media, including social media, taking care of yourself through exercise, eating healthy foods, getting enough sleep, and talking to friends and family. Cultivating a practice of mindfulness and gratitude is another evidence-based way of improving wellness and alleviating stress-related mental health symptoms. For people new to the idea of meditation and to those with more experience, there are many apps, such as Headspace www.headspace.com, to guide the process. Also, even though social distancing is necessary during these times, seek out safe ways to stay connected with others. The American Psychological Association, The National Alliance on Mental Illness, and Mental Health America are advocacy organizations that have a wealth of information about supporting your mental wellbeing during this crisis. www.apa.org www.nami.org www.mhanational.org
With most students out of school and engaged in some combination of home-based and online learning, the situation is understandably stressful for both children and parents. It can be hard to know where to start; but, try and establish a regular routine. Children (and most adults) are reassured by structure and predictability. Try to keep in mind that children learn from watching and listening to the adults around them. They will be very interested in how you respond to news about the coronavirus outbreak. Let children know that there are lots of people helping the people affected by the coronavirus outbreak. This is a good opportunity to show children that when something scary or bad happens, there are people to help. Try to create an open and supportive environment where children know they can ask questions. It is also important to remember that most children may be more interested in playing games, reading books, and other physical and recreational activities than discussing current events or following the news about what is happening across the country or elsewhere in the world. The American Academy of Child and Adolescent Psychiatry’s website is an excellent resource with advice to help families help the children in their lives through the pandemic. www.aacap.org
When there are many changes and uncertainties that are beyond our control, heightened stress and anxiety are normal feelings. A time of crisis can also be a trigger for the onset or reoccurrence of mental health symptoms. If anxiety and/or stress related feelings are causing you significant discomfort or are interfering with relationships, work, or other areas of your life, it may be time to seek help from a mental health professional. Other symptoms to look for include:
- Behaving, thinking, or feeling in ways that are out of character
- Withdrawing from social contacts
- Lack of interest in things that would normally bring joy
- Becoming consistently irritable
- A change in sleep patterns
- Changes in eating habits and/or weight
- Increased use of intoxicating substances
It is essential to remember that mental health services are still available during the COVID-19 crisis. For individuals already receiving mental health and/or substance use disorder treatment services, it is important to continue with these services during this difficult time. To follow social distancing guidelines, outpatient services for mental health assessment and treatment are being offered virtually via a simple phone call or one of several easy-to-use, secure video conferencing apps. When needed, in-person services are still being offered with added health and safety measures to keep patients and staff safe throughout their treatment.
Similar to adults, children who become overly preoccupied with concerns about the coronavirus outbreak should be evaluated by a trained and qualified mental health professional. Other signs that a child is struggling and may need additional help include ongoing sleep disturbances, intrusive thoughts or worries, recurring fears about illness or death. If you notice similar symptoms or other behaviors, thoughts, or feelings that seem out of character for your child, seek a consultation with a pediatric mental health professional. For help finding such a provider, your child’s pediatrician, family physician, or school counselor are good places to seek a referral.
Unfortunately, stigma about mental illness remains the key reason that people do not access care. It is important to know that more than 50 percent of the population will suffer from a diagnosable mental illness at some point in their life and about 20 percent every year. Only a small fraction of these individuals ever seek treatment. One way to start breaking the stigma is to start talking about mental illnesses as a part of normal conversation, similar to how we may discuss illnesses like diabetes or high blood pressure. Mental illnesses are common, biological illnesses that tend to respond very well to treatments that are typically very safe. The goal of mental health treatment is to get back to feeling completely like yourself again. In most cases, treatment is highly effective and allows individuals to function to their full potential.
When it comes to mental health, we need to start treating ourselves more gently. We also need to extend that compassion to those around us. We may be social-distancing but we are all in this together. As, together, we work to fight off this pandemic and take up the challenge of recovering from it, kindness to ourselves and others has never been more important.
If you, or someone you care about, are feeling overwhelmed with emotions like sadness, depression, or anxiety, or feel like you want to harm yourself or others call:
- Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746. (TTY 1-800-846-8517)
- The National Suicide Prevention Line: 800-273-8255
Coping With Stress During This Difficult Time
by: Tracy S. Cummings, MD, Psychiatrist, Lindner Center of HOPE
The outbreak of coronavirus disease 2019 (COVID-19) may be stressful for people. Fear and anxiety about a disease can be overwhelming and cause strong emotions in adults and children. Coping with stress will make you, the people you care about, and your community stronger.
Everyone reacts differently to stressful situations. How you respond to the outbreak can depend on your background, the things that make you different from other people, and the community you live in.
People who may respond more strongly to the stress of a crisis include
- Older people and people with chronic diseases who are at higher risk for COVID-19
- Children and teens
- People who are helping with the response to COVID-19, like doctors and other health care providers, or first responders
- People who have mental health conditions including problems with substance use
If you, or someone you care about, are feeling overwhelmed with emotions like sadness, depression, or anxiety, or feel like you want to harm yourself or others call
- Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746. (TTY 1-800-846-8517)
Stress during an infectious disease outbreak can include
- Fear and worry about your own health and the health of your loved ones
- Changes in sleep or eating patterns
- Difficulty sleeping or concentrating
- Worsening of chronic health problems
- Increased use of alcohol, tobacco, or other drugs
People with preexisting mental health conditions should continue with their treatment and be aware of new or worsening symptoms.
Things you can do to support yourself
- Take breaks from watching, reading, or listening to news stories, including social media. Hearing about the pandemic repeatedly can be upsetting.
- Take care of your body. Take deep breaths, stretch, or meditate. Try to eat healthy, well-balanced meals, exercise regularly, get plenty of sleep, and avoid alcohol and drugs.
- Make time to unwind. Try to do some other activities you enjoy.
- Connect with others. Talk with people you trust about your concerns and how you are feeling.
Identifying and Treating Panic Disorder
By Nicole Bosse, PsyD
What is panic disorder? Panic disorder consists of recurrent unexpected panic attacks, specifically a spike of intense anxiety
When treating panic disorder, it is treated mostly from a cognitive behavioral approach. The cognitive piece targets the person’s misappraisals about the panic. Individuals with panic disorder tend to overestimate the likelihood of panic occurrence, underestimate one’s ability to cope with panic, and exaggerate the negative consequences of panic attacks.
By helping the individual to identify the misappraisals and working on challenging them, individuals are less fused with their thoughts and can start to think differently about things rather than buy into their thoughts as facts.
The behavioral piece of the approach involves exposure therapy, specifically exposure to what situations they avoid, but also interoceptive exposures. Interoceptive exposures involve gradually exposing oneself to the physical sensations of the panic attack that are feared. Working with a therapist to identify the exposures that rank from low to high is important. Once this is identified, the patient and therapist work from the least distressing to the most distressing. The following are some examples of possible interoceptive exposures:
* Running in Place
* Holding breath
* Head shaking (side to side)
* Spinning in a chair
* Mirror staring
* All over muscle tensing
* Straw breathing
* Over breathing
* Head between legs
The therapist and the individual work to complete just one of these exposures, five times during the day for about 30-60 seconds. This is done repeatedly every day until the person habituates to that sensation before moving on to the next exercise.
Another exposure idea that is sometimes used is pretending to actually have a panic attack in a public area. This strategy is brought in when the person’s fear centers around the social consequences of having a panic attack, such as not wanting others to crowd around them or being embarrassed. For example, I have suggested that individual’s go to a store and practice sitting down somewhere to pretend they are dizzy or cannot catch their breath. This is a great strategy for teaching the person that what they typically fear in that situation is not as bad as they make it out in their mind. It actually usually ends up being pretty uneventful.
Exposures for the avoidance of situations is a little more specific for the person and their unique avoidances. Some common examples of avoidance that I have come across are the following: avoiding caffeine, avoiding intense exercise that increases their heart rate, avoiding being in a car, avoiding driving, avoiding going into stores, avoiding traveling far distances from one’s house, avoiding going places alone, avoiding going places without safety items (i.e., water, benzodiazepine, food, etc.), and avoiding places where the amount of time being there is uncertain (i.e., waiting in lines, sitting down at a restaurant, etc.)
Once the individual’s unique avoidances are identified, the therapist and individual work to create another hierarchy, ranking from low to high distress. For example, if someone avoids going certain distances from their house, some exposures could consist of walking down the street and gradually increasing the distance. A similar strategy could also be used for driving, gradually increasing the distance of driving from a person’s house. Similarly, for line waiting, the individual could practice waiting in lines and gradually increase the amount of time they wait in line, working up to actually waiting in the entire line and being uncertain of when it when it will end.
As you can see by the above described therapy, the main component is facing what the individual fears and letting the body learn that their anxiety will decrease without having to escape the situation. Panic disorder is a very treatable disorder, especially when engaging the correct therapy for it and when combined with the appropriate medication.
“In the News” – Dr. Cummings and patient discuss youth mental illness warning signs with Local 12’s Liz Bonis.
Trevor Steinhauser’s struggle with mental illness began at an early age, but thanks to receiving early help and support for his symptoms, Trevor is feeling better and is now four years sober.
Trevor and Tracy Cummings, MD, Medical Director of Inpatient and Partial Hospital Program Services at Lindner Center of HOPE, spoke with Local 12’s Liz Bonis about mental illness warning signs to watch for in children, such as anxiety and panic attacks.
Trevor credits the Lindner Center of HOPE for helping him overcome his own issues with mental illness and substance abuse. By employing a team approach and giving him a voice in his own treatment, Trevor says the Center was the first to help him learn coping skills for lifelong problems, such as depression and anxiety.
According to Dr. Cummings, behaviors that lead to addiction often present in a person’s youth.
“The reality is that, in any given year, one in five of us are experiencing mental illness. About half of those cases started before age 14, so a lot of people have been having symptoms for a long time. They’ve just figured out ways to either adapt to those or not talk about those,” Dr. Cummings said.
Lindner Center of HOPE has a comprehensive program that treats both substance abuse and co-occurring mental health disorders. Learn more about our Intensive Outpatient program here.
Watch the full story from Trevor and Dr. Cummings’ sit down with Liz Bonis interview on local12.com
An Overview of Maternal Mental Health Issues
By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry
May is Maternal Mental Health Awareness Month. One in five women will develop a maternal mental health disorder. They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth. Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood. Awareness and education are important to reduce stigma so mothers and babies get the help they need.
PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers. Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety. These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.
About 10% of women experience depression during pregnancy and about 15% during the first year postpartum. Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression. Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.
Anxiety can occur alone, or with depression, in 10% of new mothers. Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea. Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling. Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.
Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth. Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery. Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD. Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.
Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers. Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis. Compulsions are repetitive acts performed to reduce obsessions. Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby. Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.
Postpartum psychosis is the most severe of the PMADs. It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women. The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment. Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.) If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder. Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.
PMADs are the most common complication of pregnancy and childbirth. They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.
How to manage school avoidance
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?
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
The Benefits of Residential Assessment.
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.