Latest Information on the E&M Commercial Reimbursement Policy

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Latest Information on the E&M Commercial Reimbursement Policy

BCBS of NC recently published an update explaining the E&M commercial reimbursement policy related to the reduction in payment of Problem Oriented Evaluation and Management Related Services when submitted on the same date as a Preventive Medicine or Annual Wellness encounter.  The new policy will be effective as of September 8, 2022. 

Due to technical issues claims submitted for dates of service between June 1, 2021 and September 7, 2022 will not be subject to the updated E&M commercial reimbursement policy. Claims submitted for dates of service September 8, 2022 and beyond will process in alignment with the updated policy.

If you have received a request for recoupment, please disregard at this time. If you have submitted a refund in response to a request from BCBS, more details will be shared soon on the process for reversing your payment. 

Click here for more information.

Gratitude

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Gratitude

By MICHAEL SHAPIRO, PhD

September 2022

A casual look at the blog section of our SR-AHEC website recently led me to realize that I haven’t made a “Piece of Mind” contribution in almost two years! Ironically, the last one–written towards the end of the first year of the global COVID pandemic–was on “resilience.” Although I’ve been neglectful of my blog, I’m going to take it as a testimony to our collective resilience that despite the tumult of the intervening two years, I’m still here writing, you’re still here reading, and the world is still roughly round in shape and has not yet gone completely off the rails (although the day is young).

Which brings me to a topic that is completely entwined with resilience: gratitude. Yes, it is likely that tragedy has touched you, your family, and your loved ones in some way or at some point since COVID made its debut in late 2019. In fact, “touched” may be way too delicate a word…you may have been assailed, assaulted, or sucker punched. Yet, once again, here we are. If you’ve managed to survive, regardless of your circumstances, you can ind something for which you can be grateful.

Gratitude is defined as “…the quality of being thankful; readiness to show appreciation for and to return kindness.” It’s not an emotional reaction. It’s not personality characteristic. It’s not a “gift” or ability that is given to some but not to others. It’s a decision: one that has to be made every day. In fact, it’s the first decision you should make every day: to be grateful for waking up alive (not quite sure how you’d wake up dead, but you get the idea); for that first cup of coffee (which is unavailable to many people); and for someone—somewhere—who loves you, be it a spouse, family member, or friend.

According to a 2012 study published in Personality and Individual Differences, gratitude actually improves physical health. Grateful people exercise more regularly and have fewer aches and pains. They actually sleep better and are more resilient in the face of stress and tragedy. There are psychological benefits as well, including less depression, less aggressive behavior, and improved self-esteem in those who make it a point to take time during the day to have grateful thoughts. Gratitude may even be protective against post-traumatic stress: a 2006 study published in Behavior Research and Therapy found that Vietnam War veterans with higher levels of gratitude experienced lower rates of PTSD.

At this point, you might argue that the relationship between gratitude and overall wellbeing is a classic chicken or egg phenomenon: does gratitude make people healthy, or are healthy people more grateful because they’re not sick or depressed? The answer is…who cares? Depending on your circumstances, it may take some work to be grateful, but gratitude is never bad, it won’t kill you, and your health insurance company will never argue with you about having it.

So, let’s be real (as a psychologist, I’m nothing if not realistic). I totally understand that some people’s circumstances are so relentlessly depressing that they find it difficult to do anything but ruminate about the unfairness of life (often justifiably) or seethe with anger about how they can never catch a break. In such circumstances, platitudes like “Well, at least you’re alive,” or “It could be worse” or “There are other people who are less well-off than you are” may feel unhelpful at best, and downright insulting at worst. Gratitude can’t just be made to “appear” at the request or insistence of others. Instead, like a plant that grows slowly, it has to be cultivated, and it takes some time and effort.

Actually, there are many simple things that you can do to plant the seed and start the process of being more grateful. Starting the day by simply writing down three things (or people) that you’re grateful for will set the emotional tone for the rest of the day. Then, if there is a person on that list who is readily available and accessible, take a moment to express that gratitude to that person, be it by text, email, or carrier pigeon. Even though some of us find it difficult to express “mushy” emotions in this way, research suggests that doing so actually gives us a jolt of serotonin and dopamine, which are the neurochemicals that work in the “pleasure and reward” system of the brain. Later, just before you go to bed, think about the events of the day and reflect on the ones that you can be grateful for (even if it’s as simple as, “I sure am glad that I didn’t run off the road when that guy cut me off in traffic”). After all, even if you perceive your life as miserable and unyielding, no one’s day can possibly be 100% bad. There must be at least one thing for which you can be thankful. In doing so, you will “pre-program” yourself to have a more positive attitude tomorrow.

However, unlike these simple “starter” steps, my last suggestion may seem counter-intuitive or completely illogical. Rather than trying to forget a stressful event from your immediate or distant past, I urge you to think about it…not by just re-living the moment in your mind or stewing in resentment, which is just painful and unproductive. Instead, as you reflect on a certain experience, you’ll remember that, at least at the time, you felt that this was the worst thing that had ever happened to you, and you didn’t think you could possibly endure. Yet somehow, you survived. Going through that struggle made you a better or stronger person in some way. Changing your attitude about a terrible event in this way is known as “re-framing.” In his book, Gratitude Works!, Robert Emmons reminds us to re-frame tragic experiences by asking ourselves the following questions:

  • What lessons did the experience teach me?
  • Can I find ways to be thankful for what happened to me now even though I was not at the time it happened?
  • What ability did the experience draw out of me that surprised me?
  • How am I now more the person I want to be because of it? Have my negative feelings about the experience limited or prevented my ability to feel gratitude in the time since it occurred?
  • Has the experience removed a personal obstacle that previously prevented me from feeling grateful?

While dwelling meaninglessly on a tragic experience can be harmful, using that event to prove to yourself that you are resilient can be liberating and strengthening. Then, you can steep yourself in gratitude for the lessons it taught you and the people who helped you get through it.

In a world full of tragedy in which people seem determined to marinate themselves in anger and indignation, it may be difficult to feel grateful. But, once again, “feeling” is just that: an emotional reaction. Gratitude is a decision, and a mindset that needs to be cultivated. Once gratitude becomes a habit, you’ll realize that there were many things to be grateful for all along. Personally, I’m grateful that you took the time to read this, and I hope that the events of today will give you plenty of opportunities to be thankful.

Illness Anxiety in the Pandemic Era

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Illness Anxiety in the Pandemic Era

By MICHAEL SHAPIRO, PhD

I’ve never been a Harry Potter fan. In fact, I’m not even exactly sure what the Harry Potter series is about. My understanding is that it revolves around a bunch of kids who ride broomsticks and play some kind of anti-gravity version of basketball at a private school in some place that looks kind of like the Rocky Mountains, but with fewer Starbucks. Oh, and one of the kids has a scar on his head.

I also know that an important component of the storyline involves a “Book of Spells” or some such thing. Evidently, this book has all the rules or spells (or whatever) that adolescent magicians need to do their job or learn their craft (or whatever).

So, here in the equally magical world of Behavioral Health, we have also have mysterious book known as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (known to you Muggles as “the DSM 5”). This single volume contains a detailed description of every mental disorder anyone has ever had, or could possibly have. These disorders span from the easily recognizable (like depression) to the obscure (like trichotillomania, or compulsive hair-pulling). I’ve often told people that if you look through the DSM 5 long enough, you’ll find some disorder that fits you, no matter how mentally healthy you may feel at the moment.

Anyway, in the DSM 5, there’s a diagnosis called Illness Anxiety Disorder. To qualify for that diagnosis, you have to be obsessively worried about the possibility of acquiring a serious illness. You have to be constantly anxious about your own health, and in an attempt to relieve that anxiety, you have to either engage in excessive health-related behaviors (for example, repeatedly checking your body for signs of illness) or totally avoid healthcare (e.g., staying away from hospitals and doctors’ offices). 

Interestingly, another requirement is that this preoccupation with your own health has to be “excessive or disproportionate.” 

Ah! Therein lies the big philosophical question: in the days of the COVID-19 pandemic, aren’t we all obsessively and disproportionately preoccupied with acquiring a serious illness? Aren’t we all engaging in health-related behaviors and avoiding hospitals and doctors’ offices?  In fact, haven’t we been ordered to do these things by our local governments? If so, does this mean that we are all suffering from Illness Anxiety Disorder?  More importantly, if we’re all doing these things, then is it really a disorder at all, or are we exhibiting completely normal behavior, just like everyone else?

I’m not exactly sure, but I think my head just imploded while trying to sort this all out. Personally, my hope is that our obsessive preoccupation with the coronavirus can still be considered a “disorder” because that’s good for my business. In fact, I’d like to take this opportunity to thank social media for contributing to my business by fanning the flames of anxiety with an inescapable, constant barrage of false, inflammatory, and often contradictory information. Thanks, Facebook!

 

But seriously, I have seen many patients over the last two months who are understandably worried and have expressed their anxiety through unanswerable questions and despairing comments like, “Am I going to catch this?”, “Will this ever end?”, “I’m afraid they’re going to lift restrictions too soon!”, and “I feel trapped!” This anxiety has been brought about by a stressful event, sort of like what happens in Posttraumatic Stress Disorder. However, with PTSD, the threat has already passed, and it was probably something very visible (like a tornado or other natural disaster). With the coronavirus, we have an invisible threat, we don’t know when it will end, and we don’t even know if it has touched our lives yet or not. In this respect, a global pandemic is unique amongst stressful events!

So, how can you calm yourself in the midst of so much uncertainty? Before answering that, let me first mention that we here at SR-AHEC are applied scientists–rigorously trained health care providers–who, I’m proud to say, do nothing that isn’t based on solid, verifiable science! We try to rely solely on treatments that have been tested and validated under the cold, dispassionate light of the scientific method! That’s why we don’t bleed patients with leeches anymore (well, except maybe that one time last year.

But come on! I couldn’t think of anything else to do, and I made sure that it was covered by insurance first).

The practice of employing only scientifically proven medical techniques is known as “Evidence-Based Medicine” (EBM). What does EBM have to say about dealing with our anxieties in this time? Well, it just so happens that the Centre for Evidence-Based Medicine (no, I didn’t misspell a word. This place is located in the UK, where they spell some things rather oddly) has analyzed many scientific articles on the topic and has come up with the following evidence-based suggestions:

  • Minimize your exposure to the news and other media (I recommend no more than an hour per day to get caught up on the day’s events).
  • Use trusted sources to access information about the pandemic (as I said in my last blog, you can pretty much trust anything that has been bears the CDC seal of approval).
  • Stay connected with family and friends, online or via telephone (just don’t lose your temper when you can’t figure out how to turn on the audio).
  • Provide help and support to other people in the community (like your elderly next-door neighbor, who could use a little help with the groceries).
  • Practice meditation and mindfulness (this can be as simple as stopping whatever you’re doing, taking a deep breath, observing your own body for signs of tension, and asking yourself what you need to do next).
  • Look after your body by maintaining a healthy diet and exercising regularly (see our earlier “Guidance to Good Health” blog about exercises you can do at home. Oh, and keep your hand out of the Cheetos).
  • Avoid unhealthy coping strategies, like drugs and alcohol (interestingly, online sales of alcohol have gone up by 243% during this pandemic!
  • Even sales of Corona beer have, ironically, increased by 50%! How weird is that?).
  • Keep doing activities you enjoy (preferably not playing video games or watching movies that involve death, destruction, or mayhem. Sesame Street is probably OK…just stay six feet away from Cookie Monster. I question his personal hygiene).

I would add to these a brief three-step cognitive behavior therapy exercise that I do with my patients:

Step 1: Ask yourself, “What is the worst possible thing that could happen to me?” Your answer may be something like, “I’m going to catch this and die.”

Step 2: Force yourself to consider the best possible scenario: for example, “I’m going to be completely OK. The statistics are on my side.”

Step 3: Consider the most likely scenario, and develop a plan for that: for instance, “I may get infected, but for most adults, the symptoms are mild. If I get sick, I’ve figured out exactly where to go for emergency care, and I might actually get caught up on all my Downton Abbey episodes while I’m recovering.”

 

These steps may all seem fairly self-evident, but once again, they are based in fact and have been verified by research, so I trust them. So, Illness Anxiety Disorder or just a “normal” reaction to a really abnormal situation?  Who cares? It’s what all the cool kids are doing. Just do what the science says. Oh, and for social distancing, just use Harry Potter’s “cloak of invisibility.” I think he has one of those.

Mental health issue? Who ya gonna call?

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Mental health issue? Who ya gonna call?

By MICHAEL SHAPIRO, PhD

So…you’ve been diagnosed with a mental, behavioral, or emotional issue that requires treatment. Or not. Maybe you’ve just hit some “bump in the road,” and you’d like a little guidance to help you navigate a work issue, career issue, or relationship issue. Or, maybe you’ve begun to suspect that something that happened to you in the past, like some trauma or stressful family event, has been interfering with your progress along the path of life (or tunnel of existence, or whatever colorful metaphor you’d like to use).  Who should you go see? To whom will you bare your soul in the interest of getting “better”?  Who will help you get all those skeletons out of your closet? Who will shrink your head? (Okay…enough is enough).

 

These days, in the context of ever-increasing awareness of mental health disorders and the need to treat them, it seems that there has been a proliferation of different kinds of mental health professionals with a multitude of degrees and qualifications.  Therapists, counselors, life coaches, psychologists, psychiatrists…so many different providers, with an alphabet soup of bewildering letters after their names. Who are these people, and how can you choose the right one to help with your particular issue?

 

First, I think that a brief history mental health treatment is in order. As you are probably aware, there was a time when only the most severe of mental problems came to the attention of a professional, and then, treatment was mostly undertaken in a hospital. In the early 1500s, Swiss physician Paracelsus was among the first to advocate for a psychotherapeutic approach for treating the insane; as opposed to some of the more “advanced” medical approaches, such as bloodletting (which, apparently, wasn’t covered by Blue Cross/Blue Shield at the time). The term “psycho-therapeia” (talking psychological therapy) was first introduced in 1853. Then, of course, came the father of my profession (and, according to some, my personal doppelganger), Sigmund Freud, who revolutionized the world by developing a technique called psychoanalysis. He used his “talking cure” to explore the minds of his patients (many of whom were middle class Viennese women) and eventually concluded that most neuroses are the result of repressed memories and impulses.  Oh, and he had a really nice couch.

 

The next 50 years or so saw the birth of a number of psychotherapeutic techniques, particularly here in America. By the 1960’s, there were over 60 different forms of psychotherapy, most of which were more efficient (and, therefore, cheaper) than traditional Freudian psychoanalysis.

 

And with each new form of therapy, there had to be an expert. And with each expert, there had to be students. And with each class of students, there had to be a certificate of training. And with each new certificate, there had to be a degree (and a bunch of initials) to testify that the practitioner had the brains to “carry the banner” responsibly. Hence, we now have a multitude of mental health providers with different degrees, different licenses, and different levels of training and experience. Interestingly, they all take cash, check, or credit card.

 

So, just as there’s always a “right tool for the right job,” how does one find the right clinician for the right problem?  Before trying to answer that question, let me first offer an observation, one that has been distilled from my 36 years of experience as a psychologist: if you and your mental health provider don’t “click;” if you don’t feel like that provider is listening to you and cares about you and takes your concerns seriously; then it doesn’t matter how experienced or well-trained he or she is: you’re not going to get the results you want. More on that in a minute.

 

So let’s talk about levels of training, beginning with the doctors. Psychiatrists and psychologists both have terminal degrees and are typically referred to as “doctor.” What’s the difference between the two? About $30 an hour! (Yeah, I never get tired of that joke). 

 

But seriously, psychiatrists are physicians (MDs or DOs) who have gone to medical school and are, therefore, allowed to prescribe medications. They are experts in psychoactive medications; and they are well-versed in understanding how medications interact with each other, and how certain physical illnesses (like thyroid disease) may cause psychiatric symptoms. These days, most psychiatrists use medication as their main form of treatment. Despite Freud’s best efforts, few psychiatrists do psychotherapy (fun fact: Freud was actually a neurologist, not a psychiatrist!). Therefore, they may work in tandem with psychologists.

 

Psychologists are doctoral-level clinicians (PhD, PsyD, EdD) who are involved in research, teaching, clinical practice, or a combination of all three. In addition to doing psychotherapy of one sort or another, most of them are also trained to perform psychological evaluations, which involves the use of psychological tests to measure things like intelligence, personality, and emotional functioning. Although they cannot prescribe medications, many (including Yours Truly) specialize in understanding the biological and neurological components of mental health problems.

 

Lastly, there are clinicians with Master’s degrees who provide counseling and psychotherapy in a number of contexts. These include LCSWs (Licensed Clinical Social Workers), LMFTs (Licensed Marriage and Family Therapists), Certified Addiction Counselors (CACs), and Licensed Professional Counselors (LPCs). Most of these clinicians pursued their specific degrees because they were interested in doing a specific kind of treatment (for example, marriage therapy, family therapy, stress management, or substance abuse treatment) or working with a specific population (like families, children, or military veterans). They are highly trained in one or more specific kinds of treatment, to which they dedicate their careers.

 

In a perfect world (such as the one we have here at SR-AHEC), a patient with a mental health issue would be able to get help through an “integrated” model, wherein he or she might have access to all of these clinicians. A psychiatrist might manage a patient’s medication, for example, while a counselor or psychologist provides ongoing therapy. Unfortunately, this is rarely the case. More often, a patient is referred to one of these mental health professionals by a primary care provider, such as a Family Physician. Therefore, if you are struggling with a mental health issue and don’t know where to turn, the best place to start is your good old family doc. Since most insurance companies require them to make referrals to specialists, most family docs know who know who is good, reputable, competent, and qualified.  Also, your family doc is most likely to know if medication will be involved (in which case, you may be referred to a psychiatrist), or if this is more of a “phase of life” problem (in which case, you may be sent to a counselor or therapist).

 

But here’s the thing: once a referral has been made, it is up to you—the consumer—to thoroughly vet the professional to whom you have been referred.  I advise people not to be intimidated by all those degrees and diplomas!  Call the psychiatrist, psychologist, or counselor.  Ask if they have the training to deal with your particular problem. Ask about their education and licensure. Ask other important questions, like, “How often will I be seen?”, “How long will I be in therapy?”, “What kind of therapy do you use?”, and (most importantly) “Exactly how much will I have to pay?” In fact, ask whatever you need to ask to feel comfortable about the person treating you! As I mentioned earlier, your relationship with a mental health professional is a little like a marriage…if there isn’t some “chemistry” in the relationship, it may not work out! If the clinician is resistant to being “interrogated” or questioned about his or her training, then (to my mind) this is a sign of arrogance, and you should go elsewhere! As a clinician myself, I have always welcomed the opportunity to answer any question from a prospective patient.

Oh…and one more important thing. Everyone who seeks psychiatric or psychological treatment should be assured that nothing…NOTHING that they say during therapy will be divulged to anyone else. Confidentiality is one of the highest-held principles of mental health care, and in most mental health professions, the penalty for violating a patient’s confidentiality is usually akin to being made to walk the gangplank on a pirate ship.  Being assured of confidentiality will help you feel more relaxed about exposing those skeletons in the closet. However, please keep in mind that there are circumstances in which confidentiality can be legally broken, as when the patient threatens harm to self or someone else. In such cases, the clinician may have a duty to warn an intended victim,

although these “duty to warn” statutes vary slightly from state to state.

Once again, it’s a good thing that our current culture has promoted increasing awareness of mental health issues, and it’s a wonderful thing that there are so many dedicated clinicians who have been thoroughly trained to help people who are facing mental or emotional challenges. I hope that the information in this month’s blog will help you be an informed consumer. Meanwhile, I’m going to put on my tweed jacket, light a cigar, trim my beard, and head back to that big couch in my office.

Sleep: just 5 minutes more, please!

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Sleep: just 5 minutes more, please!

By MICHAEL SHAPIRO, PhD

I once heard sleep compared to a fickle girlfriend: when you want her and need her, she’s nowhere to be found. When you don’t want her around, there she is (before you ladies get indignant…this is just a metaphor. The same could certainly be said of a boyfriend!).  Very few biological activities (other than sex, perhaps) have been sought after so rigorously or been the subject of so much attention. Sometimes we yearn for it deeply. Sometimes we resent it and fight it with all we’ve got. In the end, however, it always wins.

Most people spend about a third of their life asleep.  That means that if you live to be, say, 75 years old and are lucky enough to sleep 8 hours per night, you will have been unconscious for about 25 of those years, or 9125 days.

Have you ever wondered why so much of our time on this earth has to be devoted to sleep? Doesn’t it strike you as a huge waste of time? The fact is, while you’re asleep, your body is very busy doing lots of restorative work. Sleep is sort of the custodian on the night shift at the museum, charged with repairing and maintaining the facility while no one is using it.  This takes time: during deep sleep, your body works to repair cells in your muscles and organs. Chemicals that strengthen your immune system start to circulate in your blood. In addition, hormones that regulate appetite (ghrelin and leptin) are balanced. Consequently, when we’re sleep deprived, we feel the need to eat more, which leads to weight gain.

Not only does your body stay busy during sleep, but your brain is (as always) hard at work: sleep consolidates and strengthens memories that you’ve formed throughout the day, and newer memories are linked to older ones during sleep. Of course, your brain is also busy dreaming! No matter what you may have heard, and despite the many advances in the psychological and biological sciences that have occurred since Freud theorized that dreams are a manifestation of subconscious fears and desires, no one is absolutely sure why people dream. However, we do know that while you dream, your arm and leg muscles become temporarily paralyzed, thereby preventing you from acting out your dreams (thank goodness)!

So, while much about sleep remains a mystery, we do know that it’s critically important to life. Although we actually need less sleep as we age, the research suggests that adults should get no less than 7 hours of sleep per night to maintain optimal health. Unfortunately, the invention of the electric light bulb in 1879 forever changed the course of sleep history. Ever since then, humans have been able to cheat sleep by staying awake and staying active well past sunset, which is nature’s cue for the body to begin to settle down. Now, in the 21st century, this situation is made even worse by television, computers, smart phones, and other distractions that prolong the “day” and keep our brains busy, well past the time we should be resting.

In fact, research indicates that anywhere from 35% to 50% of adults get less than the recommended 7 hours of sleep per night. In addition to contributing to obesity, this “insomnia epidemic” increases the risk of many other health problems such as hypertension, stroke, and psychiatric disorders (like depression and dementia). One study has even suggested that sleeplessness results in the loss of certain brain cells in the part of your brain that regulates stress and panic! There is also an increased risk of death by accident: if you haven’t been getting enough sleep, your brain will go into “microsleep,” which is an uncontrollable, brief episode of sleep that can last anywhere from a fraction of a second to a full 10 seconds. Of course, the results can be fatal if a microsleep occurs while you’re behind the wheel or operating machinery!

Now that I’ve described the dangers of sleeplessness in gory detail, you’ll probably lie in bed tonight with eyes wide open, ruminating about why you’re not asleep…but don’t panic! Here are some hints for maintaining good “sleep hygiene,” which is the modern term for the habits and practices that are conducive to sleeping well on a regular basis:

  • No screens!  For my patients, I recommend turning off all screen devices at least 30 minutes before going to sleep, because light from those devices disrupts the body’s internal “clock.” You may have heard that only blue light is harmful to sleep, which is why some devices have a setting that allows you to filter or minimize light in the blue wavelength. However, don’t be fooled…all light stimulates the brain and disrupts circadian rhythm. Find something else to do besides looking at a screen!  You may want to try one of those old-fashioned leafy things…um, what are they called?  Oh yeah, books!  Just use a soft white light to read by until you feel sleepy.
  • No alcohol! Although a beer or a shot of your favorite spirit might help you fall asleep, alcohol disrupts normal sleep “architecture” (the phases of sleep) and blocks you from getting enough REM sleep (which is considered the most restorative phase of sleep).
  • Create a good sleep environment. For optimal sleep, the temperature of your room should be between 60 and 67 degrees. Cold? Yes, but it has been shown that the cooler environment helps stimulate sleep (much like hibernation) and allows your body to cycle naturally through the various sleep stages. It is also good to use “blackout” window coverings that keep any ambient light from messing with your sleep.
  • Adopt a schedule that is conducive to sleep. Make it a point to set your “go to bed” and “get up” times at least 7 hours apart. In other words, as far as I can tell, it takes at least 7 hours to get 7 hours-worth of sleep.
  • If you can’t sleep, get out of bed!  Much like Pavlov’s famous dogs learned to associate the sound of a bell with the coming of food, we tend to make associations (over time) between our experiences and the environment in which those experiences occur.  So, if you lie awake in bed with your eyes wide open, feeling mounting anxiety and panic as you hear (or see) the clock counting down to “wake up time,” you will eventually begin to associate your bed (and bedroom) with sleeplessness, rather than sleep. Then, the prospect of going to bed each night will become terrifying, as if you’re being sentenced to time in a torture rack! If you’re not sleeping, don’t just lie there: get out of bed, go sit in a chair and read until you feel sleepy, and then try again (as you can tell, I’m a big fan of reading to promote sleep: it focuses your mind and gets you to stop thinking about anything else. Just make sure the book is fun and entertaining…no college texts or political treatises!).

Even when you begin to use good sleep hygiene, you may still find it hard to fall into a health sleep-wake pattern (old habits die hard). Also, there are a number of medical conditions that interfere with sleep, such as chronic pain, sleep apnea, or restless leg syndrome. You should consult with your family doc or primary care provider to rule out or deal with any of these conditions. For some people, a prescription sleep aid may be appropriate just to get the sleep-wake cycle back on track: for example, medications like Ambien and Lunesta have become especially popular in recent years. However, many prescription sleep medications carry a risk of dependence, so they should be used only temporarily, and only under the guidance of a physician.  There are also “natural” sleep aids (such as melatonin, which is a hormone that’s made by the pineal gland in the brain)…but just remember this: just because a medication is “natural” doesn’t mean that it doesn’t have potential side-effects or doesn’t run the risk of interacting with some other medication that you might be taking.

 

Benjamin Franklin once said that “Fatigue is the best pillow.” Staying busy, exercising regularly, and maintaining good sleep hygiene should help you get along better with the “fickle friend.”  Meanwhile, I wish you “sweet dreams!”

The Difference Between Men and Women: Is It All in the Brain?

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The Difference Between Men and Women: Is It All in the Brain?

By MICHAEL SHAPIRO, PhD

I know this may come as a total shock, but men and women are different. This becomes readily apparent whenever the two sexes interact; be it in the bonds of marriage, a dating relationship, or long-term side-by-side service with a co-worker of the opposite sex. Although it’s almost become a worn-out, politically incorrect stereotype, doesn’t it actually appear that men are, in fact, typically more “logical,” while women are more “emotional”?  Wives and girlfriends; have you ever wondered why your male counterpart always seems to want to “fix” a problem rather than just listen to what you have to say and validate your feelings?  Husbands and boyfriends; have you ever been puzzled by that “tirade” of emotions, when it would be so easy to just get to the root of the problem and correct it?

This fundamental, seemingly universal difference may not have its roots in culture, family, upbringing, or prejudicial notions of the opposite sex. Instead, it could be a function of neurological development. It is a proven fact that there are actually differences in the structure and chemistry of male vs. female brains. These differences begin in utero, before we’re even born! In fact, a recent study using MRI scans found that female fetuses have neurological connections (“functional connectivity”) that are almost nonexistent in male brains. As such, there are hardwired differences in place before we’ve been exposed to cultural, environmental, or family influences.

During the formative period of childhood, female brains begin to process information differently than male brains. For instance, females tend to have verbal centers on both sides of the brain, while males tend to have verbal centers only in the left hemisphere.  Females often have a larger hippocampus (the “center” of human memory) with a higher density of neural connections in that area.  As a result, females take in and absorb more sensory and emotional information than their male counterparts. It has also been shown that male brains use more grey matter (information and action-centered areas of the brain) when processing information, while females use more white matter (which governs “higher order” reasoning and thinking). This is why females tend to be better at multi-tasking, are usually better at interpreting emotions, and seem to have “women’s intuition” (which I think is a term invented by men to explain why women are generally smarter!). In contrast, men actually utilize fewer brain areas and are prone to “tunnel vision” when they are actively engaged in a single activity (wives…think about trying to get your husband to listen to you while he’s watching football on TV. Yeah, I think you understand). 

It has been shown that men and women even differ in the way they use neurotransmitters (the chemicals that allow your brain cells to “talk” to each other) and hormones. Because of these differences, men are usually less able to sit still for long periods of time, and they require different strategies than women for dealing with stress.  Specifically, women do better with “face-to-face” time, during which they discuss their feelings with friends. Men, on the other hand, use “side-by-side” time to engage in a mutual activities with friends, such as playing sports or repairing a car. Of course, even though these new revelations on the differences between the male and female brain are based on solid science, NO scientific discovery is applicable to 100% of people, 100% of the time. There will always be both men and women who defy these generalizations; and there are many people of both genders who “process” information more like their traditional counterparts! Most people have both male and female aspects of their characters and personalities. However…before you get frustrated with that person (or persons) in your life, remind yourself that any differences may be innate and hard-wired. In the interest of preserving peace on Earth, take some advice: Men, turn off the TV, listen to the litany of emotions, express your sympathy and support, and don’t be in such a rush to fix things. Women, don’t expect that man to be able to sit there for hours at a time and discuss feelings over a glass of wine. That’s what your girlfriends are for.  Meanwhile, as they say in France, vive la difference!

Anxiety: Constant Companion or Mortal Enemy?

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Anxiety: Constant Companion or Mortal Enemy?

By MICHAEL SHAPIRO, PhD

Let me ask you this: have you ever been nervous, anxious, or stressed-out?  Yeah, I thought so. If you had answered “no” to that question, your response would have put you well outside the realm of “normal” humanity (or made you a complete liar).

We all worry. We all get anxious. Anxiety is actually an adaptive response to potentially threatening or dangerous situations.  The theory is that when we were Neanderthals (or cave-dwellers, or primitive men and women, or whatever you wish to call our animal-skin-wearing ancestors), our nervous systems and endocrinological systems developed a complex “circuit” to prepare our bodies for action: when the brain perceived something unusual or threatening, it would send a message (by secreting hormones, which are the chemical messengers of our bodies) to various muscles and internal organs, in order to prepare those bodily systems to either fight the threatening entity or run like heck to get away from it.  This is the legendary “flight or fight” response that you’ve undoubtedly heard about. To this very day, when our bodies secrete these “stress hormones” (particularly adrenalin and cortisol), many things happen: our heart rate and respiration increase, our blood sugar goes up (to “energize” our cells), our pupils dilate, our blood pressure escalates, and nonessential functions (like intestinal activity) are slowed down. You are now prepared for flight or fight.

Having subsequently run from the saber-toothed tiger (or subdued it to create a lovely wall hanging for the cave), the stress hormones in the bodies of our ancestors would then return to normal, and all would be well until the arrival of the next threat…maybe a tyrannosaurus rex or something like that (just kidding…despite what you’ve seen in The Flintstones, the last of the dinosaurs was separated by the first member of homo sapiens by about 65 million years). 

Fast forward to the present. We still face threatening objects and organisms that provoke anxiety and evoke the fight or flight response. No longer a saber-tooth tiger, but maybe an irritable boss that makes too many unfair demands, or a surprise letter from the IRS, or a looming deadline, or a teenage child who is out way past curfew.  Unlike our ancestors and their tiger, we can no longer physically fight these things (at least not without getting in big trouble), nor can we run away from them (try as we might). This is the plight of modern man: the same flood of stress hormones, but no way to work it off!  The result: high levels of cortisol result in heart disease, digestive problems (like irritable bowel syndrome), and a suppressed immune system.

This is why exercise is a critically important first-line treatment for stress and anxiety. Physical exertion serves to dissipate stress hormones. How much exercise? Recent research has shown that burning as few as 350 calories three times per week can be as effective as antidepressant or anti-anxiety medication. This amounts to about 30 minutes of moderately vigorous activity during each session. By “vigorous,” I mean that you have to be exerting yourself to such a degree that you can’t carry on a conversation while you’re doing…well, whatever it is, be it walking, riding a bike, swimming, or playing pickleball. Lifting the TV remote doesn’t count; in fact, it’s been shown that complex exercise (that is, exercise that makes you use your brain, like playing a sport or doing ballroom dancing) may even ward off dementia!

 

In addition to exercise, there are a host of other activities and techniques that you can do to manage anxiety and stress. Yoga, breathing exercises, progressive muscle relaxation, making time for hobbies, and practicing “mindfulness” (taking a step back from unpleasant thoughts and feelings by focusing on being in the moment) have all been shown to mitigate stress. However, these have to become a “life or death” priority, rather than a “when I get a chance” priority! This is done by making them part of our daily routine.

So, if anxiety and stress are common to all men and women, then why don’t these fixes (exercise, hobbies, vacations, etc.) work for everyone? Sometimes, the “fight or flight” circuit is triggered for no obvious reason, when there’s really nothing to be afraid of. We call this a panic attack. Some people worry all the time, often about things that are very unlikely to happen.  We call this generalized anxiety disorder. Some people, by having bad experiences with very specific things, have learned to fear these things (like spiders or thunderstorms) to an irrational degree. We call this a specific phobia. When someone has been exposed to life-threatening stress and is constantly “on edge” and worried that the stress might re-occur, we call this posttraumatic stress. Any of these anxiety disorders can become so severe that they interfere with normal social or occupational functioning. When that happens, it’s time to seek rofessional

help.

Fortunately, most of these anxiety disorders are manageable with a combination of medication, therapy, and lifestyle changes. I usually tell my patients that medication and therapy are two wings of an airplane: they work best when used together. Certain medications (like Paxil, Prozac, and Zoloft) are particularly effective in dealing with both depression and generalized anxiety. Other medications, like Xanax, are effective for acute episodes of anxiety, but they must be used sparingly—and under the watchful eye of a physician—because of their potential for addiction. Medications help manage both the physical symptoms (sleeplessness, exhaustion, shakiness, shortness of breath) and the mental symptoms (obsessive worrisome thoughts, avoidance, and fear of “losing your mind”) of anxiety.  Then, once these symptoms have been brought under control with medication, therapy is tremendously helpful as a way of learning coping skills and stress management techniques. Some of the therapeutic techniques include Cognitive Behavior Therapy, Mindfulness Therapy, progressive relaxation, and systematic desensitization…each of which may be appropriate for certain types of anxiety disorders. Just ask your primary care provider or qualified mental health professional which of these might be best for you!

So, if you deal with stress or anxiety, welcome to the world of 7.53 humans who currently inhabit the planet. However, if you’re finding hard to manage anxiety on your own, please ask your health care provider for help. Oh…and watch out for those saber-toothed tigers!

DEPRESSION, the Black Dog (part 1)

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DEPRESSION, the Black Dog (part 1)

By MICHAEL SHAPIRO, PhD

No blog about behavioral health issues would be complete without a discussion of depression. Winston Churchill (who some think suffered from major depression or bipolar disorder) referred to his episodic dark moods as his “black dog.” He didn’t actually invent this term; in fact, it was a pejorative term used by nannies in the Victorian era to refer to unpleasant or moody children. In any event…we get the idea. Everyone on the planet who claims to be human (which, I suppose, includes pretty much everyone) has experienced low mood, despair, or sadness. If you deny it, you’re either a liar, have very poor insight, are deeply in denial, or literally live in Mr. Rogers’ Land of Make Believe (even then, the rising price of trolley tickets has got to get you down sometimes!).

Sadness is a natural, healthy reaction to loss: loss of a relationship, loss of an opportunity, even loss of physical health. It can even be evoked in response to someone else’s loss. This kind of identification with another person (in other words, feeling sad because someone else is sad) is called empathy: it ties us together as humans and motivates us to help each other. In a way, “normal” sadness gives life meaning by helping us understand our own values. It reveals what’s really important to us. Also, how can anyone appreciate joy and happiness if we’ve never known sadness?

However, there’s a difference between sadness and depression. Typically, sadness is caused by an identifiable event: your favorite team lost in the playoffs, your pet hamster died, or your child went off to college (okay…so maybe sadness and joy can sometimes co-exist). In contrast, clinical depression often appears for no reason. Indeed, people who suffer from depression often feel guilty about being depressed without any apparent cause! The job is going well, the kids are fine, the marriage is solid…what could be wrong? This conflict between a person’s mood and the reality of the situation only makes him or her feel worse.

So if clinical depression is profound sadness that often appears for no reason, what causes it? Excellent question. As with any behavioral health disorder, there is more than one answer. Specifically, depression has four facets: biological, psychological, social, and spiritual.

Let’s start with the biological facet: it is now a known fact that, as with any physical illness, depression is rooted in biology. For one thing, it appears to be hereditary. Since depression runs in families, there must be a genetic predisposition to this disorder. More often than not, someone who suffers from depression has a depressed relative (or relatives) climbing around on some branch (or branches) of the family tree.

It is also known that some kinds of depression are linked to deficiencies in neurotransmitters…the chemicals that allow brain cells to communicate with each other. That’s why treatment of depression often involves medication. Most antidepressant medications cause these neurotransmitters to be more available to the brain (more about that in our next blog!). The important take-away is this: clinical depression isn’t a weakness, a lack of character, or a moral failure! It’s a biological disorder, just like diabetes, hypertension, or the flu!

However, for someone who is biologically predisposed to depression, the first depressive episode is usually triggered by a stressful or traumatic event. Personal catastrophe (loss of a job, financial stress), family stress (divorce, frequent conflicts between family members), trauma (abuse, natural disasters), or any other stressful circumstance can precipitate a depressive episode. Whereas such circumstances would cause anyone to be depressed, the individual with clinical depression doesn’t “bounce back” and may become vegetative (loss of energy, loss of interest in things that used to be pleasurable) or suicidal.

This brings us to the social aspects of depression. This refers to the way you were raised, events of the past, and how you’ve been treated since you were a child. Did you grow up in a “negative,” unloving, or oppressive household where conflicts were the norm, or where certain emotions (like anger) were expressed while others (like love and warmth) were discouraged? If so, you may never have been able to develop the “coping skills” that are necessary to keep minor setbacks from becoming emotionally catastrophic events.

It’s worth mentioning that these social factors appear to have become more prevalent in modern times, such that depression has almost become an epidemic. In fact, it has been shown that at least one out of every five people in the US will experience an episode of major depression at some point in their lives. At least some of this increase in depression can be attributed to the fact that mental health professionals are getting better at describing and identifying this disorder. Also, depression carries less of a stigma than it used to, so people are more likely to admit that they have a problem and seek treatment. However, let’s be realistic: there have been numerous social changes that have contributed to the rise in depression, such as rising divorce rates and the slow erosion of family structure since the 1940s and 50s. Of course, there’s also the impact of social media, which has given millions of people a stage on which to share their sorrow or exploit the sorrow of others. There are even websites and Facebook pages that instruct depressed people on the best ways to commit suicide!

In view of these social aspects of depression, another component of treatment involves individual counseling or psychotherapy. It is the task of the mental health professional (counselor, therapist, psychiatrist, or psychologist) to help the individual come to grips with the social components of depression and untangle the complexities of things like past trauma, abuse, or a fragmented family.

In addition, therapists can be very helpful with the psychological component of depression. This refers to aspects of your own personality…the way you think, the way you view the world, and how you naturally react to circumstances. Have you ever known someone who is a “natural worrier,” or someone who always sees the glass as half empty? These

tendencies are part of your inborn personality and temperament, but they can be changed. Therapists use techniques like Cognitive Behavior Therapy to help the depressed person learn how to change those depressive or negative thoughts that lead to depressed mood.

Lastly, although some people embrace it and other people ignore it, I can tell you that there is always a spiritual component to depression. When someone is depressed, their thoughts invariably turn to some of the “big picture” questions that reveal their spiritual convictions (or lack thereof): “Why am I here?” “Would the world be better off without me?” “Why is God letting me go through this?” Several studies have suggested that religious and spiritual beliefs are protective against depression. Also, although there are certainly some people who are “spiritual” but do not participate in an organized religion, the prognosis is better for people who are involved in a faith community like a church, temple, or mosque. As such, a component of treatment should involve either spiritual guidance from a leader in the faith (pastor, minister, rabbi, priest, imam, or monk, to name a few), or cultivation of a more introspective type of spiritual exercise (meditation, yoga, etc.).

So, it is hoped that you now view depression as an actual disorder that is very common but is more complex than you originally thought. If so, good…because we’re about to make it even more interesting by discussing different types of depression and how to recognize them according to their specific symptoms. However, that will have to wait until next month. See you then!

DEPRESSION, the Black Dog (part 2)

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DEPRESSION, the Black Dog (part 2)

By MICHAEL SHAPIRO, PhD

In my previous blog, I introduced the notion of clinical depression and (hopefully) differentiated this from “normal” sadness due to grief or loss. We then discussed the four-part nature of clinical depression (well, okay, there wasn’t actually much discussion. I did all the talking). Now, did you know that there are several kinds of clinical depression? As with other disorders, you can view depression as being on a spectrum, from mild to severe. The different types of depression can also be distinguished by other factors, such as the underlying cause, or the length of each depressive episode. For this blog, I’d like to confine my observations to the two most “popular” forms of depression; Major Depressive Disorder and Persistent Depressive Disorder.

 

Major Depressive Disorder (aka major depression) tends to receive the most attention in the popular media, at least partly because it has become less stigmatized and has claimed so many lives. It often comes from out of the blue (no pun intended), with no obvious reason or precipitant. It hits like a truck, overwhelming the person with feelings of sadness, hopelessness, and despair. Necessary for this diagnosis are what are known as “vegetative” symptoms, such as anergia (loss of energy and motivation) and anhedonia (loss of interest in things that used to be fun or pleasurable). Sleep is usually disrupted, such that the person sleeps too little (insomnia) or too much (hypersomnia). Also, there is typically weight gain (as a result of “eating for comfort”) or weight loss (from decreased appetite). In major depression, these symptoms become so severe that they ultimately interfere with one’s ability to take care of the normal day-to-day demands of life, such as going to work and keeping up with family responsibilities.

 

During a major depressive episode, a person will often feel useless and non-productive. This begins a domino effect of guilt, feelings of worthlessness, declining self-esteem… often culminating in the question, “If the rest of my life is going to be like this, why should I go on living?” Mental health professionals refer to this as a passive suicidal thought. If left unchecked, it may escalate to active suicidal intent, wherein the individual forms an actual plan as to how to take his or her own life. Whether suicidal thoughts are passive or active, they must never be ignored, underestimated, or written off as someone just trying to get attention. Emergency treatment should be sought for anyone who entertains thoughts of suicide, or shows any signs of self-harmful behavior.

 

A diagnosis of major depression is applicable when someone’s mood and demeanor is distinctly different from the way he or she was before the depressive episode. In contrast, Persistent Depressive Disorder (which is also known by the more intimidating name, dysthymia) is more chronic, less extreme, and often more difficult to recognize. This type of depression is less episodic than major depression. In fact, to have this diagnosis, the individual must have experienced depressed mood (more days than not) for at least two years!

 

Whereas dysthymia has been shown to be more prevalent in women than in men, my experience tells me that men with this disorder are much more likely to go undetected. Why? At the risk of over-generalizing, men tend to be less sensitive to their…um…what are those uncomfortable things called again? Oh, yeah. “Feelings.” As a species, they seem to be more apt to put their heads down, charge forward, and “soldier on,” even when they are sad and joyless.

 

Many of my older male patients with dysthymia apparently decided early on that it was just their lot in life to be unhappy. Interestingly, most of them did not show up in my office on their own accord; they were “urged” to seek help by their wives or other close family members, who had gotten tired of being married to Eeyore (don’t get that reference?Google it). 

 

Interestingly, because dysthymia in an adult is more chronic than acute, it used to be thought of as a “personality problem” and actually went by the (now archaic) name, Depressive Personality. However, in children and teenagers, dysthymia usually appears in the form of irritability rather than outright depression. Has your child ever been irritable? Yeah, I thought so. If he or she has been that way (more days than not) for at least a year, you might think about dysthymia. You might also think about getting help for yourself…because, you know, you’ve been living with a grouchy child for a long time.

 

Regardless of whether someone is suffering from major depression or dysthymia, the good news is that both conditions are very treatable. As I tell all my patients, treatment of depression usually entails two things: medication and psychotherapy. Although each of these works well, neither alone works as well they do together…rather like the two wings of an airplane. Whereas medicine addresses the biological component of depression, therapy helps address some of the psychological and social issues that we talked about last time.

 

Antidepressant medications relieve the vegetative symptoms of depression. The most popular antidepressants, called SSRIs (Selective Serotonin Reuptake Inhibitors), have relatively few side-effects and also have anti-anxiety properties. As such, they help to break the cycle of anxious, unwanted, ruminative thoughts that seem so hard to ignore (“Why am I so unhappy?” “Will I always be this way?” “What should I be doing about this?”). Once those symptoms have been relieved and the “dark cloud” has lifted somewhat (or, using our metaphor from the last blog, the “black dog” has been put back on the chain), the patient can apply his or her mind to therapy. 

 

There are many types of therapy, and each type focuses on a different aspect of depression. For example, Cognitive Behavior Therapy (CBT) is a very popular and particularly effective form of therapy that is based on the theory is that your thoughts lead to your depressed feelings, not the other way around. Clinicians who use CBT train patients to recognize and change irrational or unrealistic thoughts that lead to depressed mood. Interpersonal Therapy (IT) focuses on helping a patient navigate and untangle the complicated family and social relationships (got any of those?) that might be contributing to depression. Mindfulness Therapy is a meditation-like technique wherein you learn to calm your mind by being “in the moment,” not thinking about the past (which you can do nothing about) or the future (which isn’t here yet).

 

Once again, the research robustly suggests that medication and therapy work best as a team. Whenever I propose this two-pronged plan of treatment, the first question the patient usually asks is, “How long?” Let’s face it: almost no one likes to take medication. So, please keep in mind that medication is never intended to be a life-long treatment! However, I usually ask my patients to commit to an antidepressant medication for at least 9 months to a year. That prevents them from giving up too early if they don’t feel better immediately (“See? I knew this wasn’t going

to work!”) or if they do feel better immediately (“Yay! I feel better! Now I

don’t have to take medication anymore!”).

 

It’s important to understand that antidepressant medications don’t (usually) work overnight. It takes time, sometimes weeks, for them to take effect. Even then, the patient doesn’t just magically wake up “happy” one day. Instead, the changes are subtle: the depressed person slowly discovers that minor things aren’t quite as irritating or bothersome as they used to be. As I tell my patients, medicine will help “increase your ability to tolerate frustration” (sounds wise and scientific, doesn’t it?). If, after about a year, the patient has shown sustained improvement for quite a while, we can talk about slowly tapering medication. It is always a bad idea to go “cold turkey” with an antidepressant, since it takes the brain some time to establish a new neurochemical “normal.”

 

So, if you have been hounded by the black dog for at least two weeks and have experienced loss of energy, loss of interest in things, and disrupted sleep or appetite, it may be time to seek professional help. If you don’t know where to look, start with your family physician or primary care provider. First, your primary care provider will try to determine if there is some medical reason for your depression, such as hypothyroidism or some other disease. Once all possible medical factors have been ruled out, your PCP may refer you to a psychiatrist, psychologist, therapist, or counselor. Don’t know the difference between those four mental health professionals? You will in about a month…after my next blog comes out. Meanwhile, if you suffer from depression, just remember that there’s always hope: with proper treatment, the black dog can always be tamed.

ADHD and…hey, look! A squirrel!

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ADHD and…hey, look! A squirrel!

By MICHAEL SHAPIRO, PhD

In my 36 years as a psychologist who specializes in treating children, there has been no more controversial and confusing issue than the diagnosis and treatment of…um…of…now what were we talking about again?

 

But seriously, back in the Dark Ages when I started my training (and men still wore bearskins), the term Attention Deficit Disorder was not yet the buzzword it is today. However, there was growing concern about a population of children who were clearly overactive and had trouble paying attention, especially in school. Quite often, there was nothing to explain why these children were having these problems: they were usually quite intelligent, and they came from good families that enforced discipline and tried to properly balance rewards and punishments. Back in 1902, British pediatrician Sir George Still described this syndrome as an “abnormal defect of moral control in children”; but this didn’t really seem to fit, because quite often, these children were not mean-spirited or intentionally disobedient. In fact, many of this children were quite pleasant to be around…if you could only get them to sit still!

 

As is usually the case with newly emerging medical mysteries, researchers and doctors in the modern age tried to come up with a term that sounded impressive and implied that we knew exactly what we were talking about. Hence the term “Minimal Brain Dysfunction,” which was actually a junkyard term that included several disorders that were assumed to be due to abnormal neurological development, such as learning disabilities and “hyperkinesis” (hyperactivity). This term was further refined in 1968, when the Diagnostic and Statistical Manual of Mental Disorders (aka the DSM, which is the catalog of all known psychiatric diagnoses) first recognized a disorder called “hyperkinetic impulse disorder.”  The three key symptoms of this disorder were overactivity, inattention, and impulsiveness.

 

The term Attention Deficit Disorder (ADD) made its first appearance in 1980, when the DSM went through its third revision. However, by that time, there was already some debate about whether or not all kids with ADD were hyperactive: some had problems with attention and concentration, but they were not usually climbing the walls or shaving the pet cat. Therefore, the diagnosis was split in two: ADD with hyperactivity, and ADD without hyperactivity.

 

Never ones to be happy with the status quo (and always looking for ways to shake things up), psychiatrists and psychologists decided to remove this distinction when the DSM was revised (yet again) in 1987. On that go-around, the two subtypes were re-united into a new stand-alone term: Attention Deficit Hyperactivity Disorder (ADHD).  And so it was to remain for the rest of all eternity…or at least until 2000, when the DSM was revised for the fourth (but certainly not yet final) time. 

From that year until this, we have labored under the most modern terms for this disorder: ADHD, predominantly inattentive type (which refers to children who are inattentive but not particularly hyper or impulsive); ADHD, predominately hyperactive-impulsive type (for children who can’t seem to sit still and sometimes endanger themselves by being so impulsive), and ADHD, combined type (which is the most common). Oh, and I almost forgot…there’s also Unspecified ADHD, which can be used when a child (or adult, for that matter) exhibits some of the characteristics of ADHD but doesn’t seem to fit the entire clinical picture. At long last, we have all the diagnostic bases covered…at least for the next year or two.

Unless you’ve been living under a rock or are under the age of 20, you may have noticed the steep increase in this diagnosis over the last several decades, mostly since the ‘80s and ‘90s. Population surveys have found that about 5% of all children (and 2.5% of all adults) qualify for this diagnosis. Why? Is this some kind of epidemic? Is this just a function of widespread misdiagnosis? Has something changed with our children?  Are aliens commandeering the minds of our kids?  I would have say “yes” to all of the above (except maybe the last one).

Certainly, things have changed with our children since Dr. Still’s politically incorrect implication that ADHD children are “immoral.” Children now start school earlier and are expected to sit still and remain largely inactive in a highly structured environment for six to seven hours a day (depending on the state in which you live), about 180 days per year. Oh, and then they have to come home and do homework. Consider that the next time your child gets off the bus and you ask him (and I say “him” because ADHD is 75% more prevalent in boys than in girls…see my earlier blog on the differences between male and female brains) to “…get all your homework done before you can go out and play.” It would be wise to reverse that order and let your child run off all that pent-up energy before expecting him to sit down and tangle with more schoolwork!

In addition to higher expectations for concentration and achievement in school, we now throw in the modern epidemic of electronic entertainment, which satisfies the ADHD child’s need for constant stimulation but removes the beneficial effects of exercise (and actual social interaction)…more on that in a future blog. Another reason for the proliferation of ADHD has to do with making a correct diagnosis. Sure enough, more children are being diagnosed with ADHD because we have a better definition of the disorder and are getting better at recognizing it. However, what confuses the picture is the myriad of other disorders that cause the same symptoms in children—inattention, overactivity, and impulsiveness—but are not actually ADHD! Take depression, for example. We all know what that looks like in an adult. Depressed adults cry, lose interest and energy, and often want to “escape” depression by sleeping all day. In contrast, kids with depression may become irritable, inattentive, sullen, and aggressive. In fact, the same can be said of anxiety disorders and many other psychiatric problems that look one way in adults but another way in children. There are also neurodevelopmental disorders, like learning disabilities and developmental delays, which cause children to be inattentive in the classroom because the level of schoolwork is over their heads.

 

Therefore, the diagnosis of ADHD cannot be made quickly or capriciously. Making a correct diagnosis is a complex process that considers all aspects of a child’s life. There are also psychological tests that can be used to sort out how much is ADHD and how much might be something else, like a learning problem, an emotional problem, or a family problem. However, I feel my and concentration waning as I write, and there’s a shiny thing over there on my desk that I want to look at. So, you’ll have to wait until my next blog for a discussion on the cause, diagnosis, and treatment of ADHD…or whatever it is that we’ve been talking about!

ADHD, Part 2 (or was it 3? I don’t know…I wasn’t really paying attention)

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ADHD, Part 2 (or was it 3? I don’t know…I wasn’t really paying attention)

By MICHAEL SHAPIRO, PhD

As I was saying at the end of our last episode, because of the myriad of things that look like ADHD but are not, a diagnosis of ADHD should never be made casually, and should never be based solely on opinion, observation, comparison (“My other kids were never this much trouble!”), or a cursory evaluation in a doctor’s office. A proper evaluation for ADHD involves many painstaking components, beginning with a complete history. Since so many things could predispose a child to hyperactivity and attention problems, the skilled mental health professional will be careful to ask about a child’s health history (“Were there any problems with pregnancy and delivery? Does the child have any chronic health problems or take any medications?”), educational history (“Have there been any learning problems?”), family/social history (“Is this an intact family? Has there been any trauma or abuse? Is there anyone else in the family with similar problems?”), and any history of previous behavioral or mental health issues.

 

Once a thorough history has been obtained, specific tests will be administered in an attempt to verify an attention problem and rule out any other developmental, emotional, or educational issues. The first of these should be a test of intelligence, which will help the psychologist decide whether or not the child’s behaviors are consistent with his level of intellectual development. For example, children who are intellectually gifted may find it difficult to pay attention in a “normal” classroom because they’re bored. Conversely, children with a developmental delay may act impulsive or immature, but those behaviors might actually be

appropriate for their “mental age.”

 

Next, tests of academic achievement (reading, writing, and arithmetic) should be administered in order to rule out a learning disability, or to determine the degree to which a child’s inattention in the classroom has interfered with learning. Last but not least, tests of emotional functioning should be administered to assess the child’s feelings about school, himself, his family, other children, and the world in general. The clinician may ask the child to draw pictures or respond to some open-ended questions. Also, there are surveys and behavior rating scales that can be administered to parents, teachers, and the child himself for the purpose of comparison. In this way, we can get a “360 degree” picture of a child’s behavioral and emotional functioning from many viewpoints.

 

Once a history has been obtained and all the data has been collected, a proper diagnosis can be made. However, even with all this information at hand, there still may be some overlap with other diagnoses. For example, a child can suffer from both an attention deficit disorder AND a conduct disorder, an anxiety disorder, a learning disability, or a mood disorder like depression! Quite often, a good evaluation will reveal several issues that will need to be addressed at the same time! A good treatment plan will take all of these into account.

 

Speaking of treatment…let’s start with the Big Kahuna of contentious issues: medication. Typically, ADHD is treated with stimulant medication. Stimulants all work essentially the same way, by “activating” or energizing the brain. To give you a good point of reference, caffeine is a stimulant. The activating effects of caffeine are why we (or is it just me?) can’t even begin to face the day without a healthy dose of morning Joe (injected, preferably, directly into my veins).

 

Of course, when I propose stimulant medication to parents, their first reaction is something like, “A stimulant? Really? Don’t you think my kid is stimulated enough?” Although no one is entirely certain why stimulants help children with ADHD, the theory is that these medications actually stimulate the self-control centers of the brain to work more efficiently. Another theory is that the brains of ADHD children don’t receive enough stimulation from within, so they crave stimulation from without (by watching fast-changing cartoons, playing stimulating video games, or going from one thing to another). Stimulant medications satisfy the needs of these under-stimulated brains.

 

Back in the day, there were very few stimulant medications, Ritalin being the most famous and easily recognized. Nowadays, there are many stimulants on the market, as well as non-stimulant medications (which work a little differently and may be better for children with other issues, like aggression). There are also some “natural” preparations that claim to be effective, but please be aware that few of these claims are actually supported by research. In a child whose ADHD has been confirmed by an evaluation (and who has no other “complicating” issues), stimulants can be very effective, and improvement can be seen very quickly, because these medications are rapidly absorbed by the body. On the other hand, these medications don’t usually last very long, and some children may experience a “rebound” (irritability, tearfulness, or fatigue) when they wear off towards the end of the day. If this is the case, there are some long-acting stimulants that can be helpful, or the child’s doctor can make adjustments to the dosage.

I am always careful to tell the parents of children with ADHD that medication is never intended to be a “forever” thing. Because of the way the human central nervous system matures and develops, many children grow out of some of the symptoms of ADHD. After all, you don’t see many 30 year-olds running through Walmart knocking over displays and playing hide-and-seek in the clothing section (or do you?). However, they may still struggle with inattention and feelings of restlessness as an adult. For children on medication, we are careful to re-evaluate periodically, in the hopes that there will come a day when the child—usually at some point in adolescence—no longer needs medication (only 30 to 60 percent of patients diagnosed with ADHD in childhood continue to require treatment as adults).

 

How old does a child have to be to start medication? Most doctors are hesitant to medicate preschoolers. However, I usually make two exceptions: the first of these applies to children who are so impulsive that they endanger themselves or others…for example, by jumping off tall things or throwing rocks (often not out of maliciousness…just to see if the rocks can fly). The other exception involves preschoolers who are getting in so much trouble that no one likes them; not their preschool teachers, not the other children…and sometimes not their parents. With these children, if their symptoms are not managed with medication, they might develop social problems, a hatred of school, or problems with self-esteem. So, in the cost-to-benefit analysis, it may be advisable to treat these little ones now in order to prevent some more severe problems in the future.

 

Of course, medication represents only one tool in the ADHD treatment tool kit. It tends to yield the fastest improvement, which is why it’s usually the first to be recommended. Once a child’s symptoms have been brought under control with medication, individual psychotherapy can be used to help the child develop some self-control and self-regulation skills. Also, the research strongly suggests that the prognosis is best when therapy for the child is paired with training for the parent! EVERY parent can benefit from coaching on parenting skills like communication, discipline, encouragement, and the proper balancing of age-appropriate rewards and punishments. So, no therapist, counselor, or psychologist should treat only the child! The best mental health professionals are those who are skilled in both child therapy and parent training.

 

That brings us to the topic of how to choose an appropriate mental health professional, because the list of degrees, certifications, and titles can be absolutely bewildering. However, I see by the clock on the wall that it’s time for my afternoon Starbucks, without which I will lose my concentration, fall asleep, start daydreaming, or a combination of all three. So, this will have to wait until next month. See you then!

July is National Minority Mental Health Awareness Month

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July is National Minority Mental Health Awareness Month

July is National Minority Mental Health Awareness Month. It is observed to bring awareness to the unique struggles that racial and ethnic minority communities face regarding mental illness in the United States.

Specific community health awareness efforts have been centered around the COVID-19 pandemic. The US Department of Health and Human Services, Office of Minority Health (OMH), focuses on promoting tools and resources to address the stigma regarding mental health among racial and ethnic minority populations.

OMH encourages state, tribal, and local leaders, healthcare providers, community-based organizations, faith leaders, and individuals who educate their communities regarding mental health stigma.

The first week in June honored health professionals in hospital settings and professionals who work closely with communities during the Community Health Improvement week. This national event was created to raise awareness and recognize community health professionals’ dedication and passion for improving the health of the communities they serve.

Some key highlights within Community Health Improvements are:

Engaged leadership with hospitals and health systems can play vital roles internally and externally within these organizations.

Community endorsement and support can come in the form of remembering all organizations are not alike, but all organizations can be involved in partnerships within the community.

Innovative coordination and funding will help communities optimize the use of existing resources while building on existing strengths.

Provide valuable care and optimize delivery through standard processes and handoffs, connecting through common screening and assessment tools, and coordinating all levels of follow-up care.

Leveraging technology will help people in a mental health crisis and be a support line for immediate help. Leverage technology can connect an electronic referral system to efficiently triage patients and coordinate care, while telehealth offers an additional avenue to expand behavioral health services.

Measurable and Actionable can be used in Community Health Improvement to have transparency in data reporting identified outcomes to demonstrate value to community partners. These standardized screening tools and quality measures will assist in improving data integrity.

Community Health Improvement is an ongoing goal to build connections between the whole person and integrated care. This process not only highlights the medical part, but also connects the community supports of all Americans, including additional resources for racial and ethnic minority communities.