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COVID-19 crisis: We must care for ourselves as we care for others
“I do not shrink from this responsibility – I welcome it.” – John F. Kennedy, inaugural address
COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto.
In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said: “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”
And, of course, it is primary care providers – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses – who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.
The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call – and take care of ourselves – in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So too must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.
With this in mind, we would be wise to consider developing plans in three domains: physical, mental, and social.
With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.
To take care of our mental health, we need to have the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.
From a social standpoint, we must be proactive about preventing emotional isolation. Technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: family, coworkers, and patients.
Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.1
Life carries on amidst the pandemic. Even though the current focus is on the COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant and someone else will be diagnosed with cancer, plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.
We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946 after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”2
A version of this commentary originally appeared in the Journal of Family Practice (J Fam Pract. 2020 April;69[3]:119,153).
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.
References
1. Brockell G. “During a pandemic, Isaac Newton had to work from home, too. He used the time wisely.” The Washington Post. 2020 Mar 12.
2. Frankl VE. “Man’s Search for Meaning.” Boston: Beacon Press, 2006.
“I do not shrink from this responsibility – I welcome it.” – John F. Kennedy, inaugural address
COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto.
In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said: “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”
And, of course, it is primary care providers – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses – who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.
The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call – and take care of ourselves – in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So too must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.
With this in mind, we would be wise to consider developing plans in three domains: physical, mental, and social.
With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.
To take care of our mental health, we need to have the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.
From a social standpoint, we must be proactive about preventing emotional isolation. Technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: family, coworkers, and patients.
Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.1
Life carries on amidst the pandemic. Even though the current focus is on the COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant and someone else will be diagnosed with cancer, plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.
We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946 after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”2
A version of this commentary originally appeared in the Journal of Family Practice (J Fam Pract. 2020 April;69[3]:119,153).
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.
References
1. Brockell G. “During a pandemic, Isaac Newton had to work from home, too. He used the time wisely.” The Washington Post. 2020 Mar 12.
2. Frankl VE. “Man’s Search for Meaning.” Boston: Beacon Press, 2006.
“I do not shrink from this responsibility – I welcome it.” – John F. Kennedy, inaugural address
COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto.
In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said: “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”
And, of course, it is primary care providers – family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses – who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.
The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call – and take care of ourselves – in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So too must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.
With this in mind, we would be wise to consider developing plans in three domains: physical, mental, and social.
With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.
To take care of our mental health, we need to have the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.
From a social standpoint, we must be proactive about preventing emotional isolation. Technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: family, coworkers, and patients.
Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.1
Life carries on amidst the pandemic. Even though the current focus is on the COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant and someone else will be diagnosed with cancer, plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.
We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946 after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”2
A version of this commentary originally appeared in the Journal of Family Practice (J Fam Pract. 2020 April;69[3]:119,153).
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.
References
1. Brockell G. “During a pandemic, Isaac Newton had to work from home, too. He used the time wisely.” The Washington Post. 2020 Mar 12.
2. Frankl VE. “Man’s Search for Meaning.” Boston: Beacon Press, 2006.
Treatment of depression – nonpharmacologic vs. pharmacologic
Major depressive disorder (MDD) affects 16% of adults in the United States at some point in their lives. It is one of the most important causes of disability, time off from work, and personal distress, accounting for more than 8 million office visits per year.
Recent information shows that while 8% of the population screens positive for depression, only a quarter of those with depression receive treatment. Most patients with depression are cared for by primary care physicians, not psychiatrists.1 It is important that primary care physicians are familiar with the range of evidence-based treatments for depression and their relative efficacy. Most patients with depression receive antidepressant medication and less than one-third of patients receive some form of psychotherapy.1 The American College of Physicians guideline reviews the evidence regarding the relative efficacy and safety of second-generation antidepressants and nonpharmacologic treatment of depression.2
Outcomes evaluated in this guideline include response, remission, functional capacity, quality of life, reduction of suicidality or hospitalizations, and harms.
The pharmacotherapy treatment of depression, as assessed in this guideline, are second-generation antidepressants (SGAs), which include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and selective serotonin norepinephrine reuptake inhibitors. Previous reviews have shown that the SGAs have similar efficacy and safety with the side effects varying among the different medications; common side effects include constipation, diarrhea, nausea, decreased sexual ability, dizziness, headache, insomnia, and fatigue.
The strongest evidence, rated as moderate quality, comes from trials comparing SGAs to a form of psychotherapy called cognitive-behavioral therapy (CBT). CBT uses the technique of “collaborative empiricism” to question patients maladaptive beliefs, and by examining those beliefs, help patients to take on interpretations of reality that are less biased by their initial negative thoughts. Through these “cognitive” exercises, patients begin to take on healthier, more-adaptive approaches to the social, physical, and emotional challenges in their lives. These interpretations are then “tested” in the real world, the behavioral aspect of CBT. Studies that ranged in time from 8 to 52 weeks in patients with MDD showed SGAs and CBT to have equal efficacy with regard to response and remission of depression to therapy. Combining SGA and CBT, compared with SGA alone, did not show a difference in outcomes of response to therapy or remission of depression, though patients who received both therapies had some improved efficacy in work function.
When SGAs were compared with interpersonal therapy, psychodynamic therapy, St. John’s wort, acupuncture, and exercise, there was low-quality evidence that these interventions performed with equal efficacy to SGAs. Two trials of exercise, compared with sertraline, had moderate-quality evidence showing similar efficacy between the two treatments.
When patients have an incomplete response to initial treatment with an SGA, there was no difference in response or remission when using a strategy of switching from one SGA to another versus switching to cognitive therapy. Similarly, with regard to augmentation, CBT appears to work equally to augmenting initial SGA therapy with bupropion or buspirone.
The guidelines discuss that, with regard to adverse effects, while the discontinuation rates of SGAs and CBT are similar, CBT likely has fewer side effects. In addition, it is important to recognize that CBT has lower relapse rate associated with its use than do SGAs. This is presumably because once a skill set is developed when learning CBT, those skills can continue to be used long term.
The bottom line
Most patients who experience depression are cared for by their primary care physician. Treatments for depression include psychotherapy, complementary and alternative medicine (CAM), exercise, and pharmacotherapy. After discussion with the patient, the American College of Physicians recommends choosing either cognitive-behavioral therapy or second-generation antidepressants when treating depression.
References
1. Olfson M, Blanco C, Marcus SC. Treatment of Adult Depression in the United States. JAMA Intern Med. 2016 Oct;176(10):1482-91.
2. Qaseem A, et al. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Mar 1;164:350-59.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Aaron Sutton is a behavioral therapy consultant in the family medicine residency program at Abington Memorial Hospital.
Major depressive disorder (MDD) affects 16% of adults in the United States at some point in their lives. It is one of the most important causes of disability, time off from work, and personal distress, accounting for more than 8 million office visits per year.
Recent information shows that while 8% of the population screens positive for depression, only a quarter of those with depression receive treatment. Most patients with depression are cared for by primary care physicians, not psychiatrists.1 It is important that primary care physicians are familiar with the range of evidence-based treatments for depression and their relative efficacy. Most patients with depression receive antidepressant medication and less than one-third of patients receive some form of psychotherapy.1 The American College of Physicians guideline reviews the evidence regarding the relative efficacy and safety of second-generation antidepressants and nonpharmacologic treatment of depression.2
Outcomes evaluated in this guideline include response, remission, functional capacity, quality of life, reduction of suicidality or hospitalizations, and harms.
The pharmacotherapy treatment of depression, as assessed in this guideline, are second-generation antidepressants (SGAs), which include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and selective serotonin norepinephrine reuptake inhibitors. Previous reviews have shown that the SGAs have similar efficacy and safety with the side effects varying among the different medications; common side effects include constipation, diarrhea, nausea, decreased sexual ability, dizziness, headache, insomnia, and fatigue.
The strongest evidence, rated as moderate quality, comes from trials comparing SGAs to a form of psychotherapy called cognitive-behavioral therapy (CBT). CBT uses the technique of “collaborative empiricism” to question patients maladaptive beliefs, and by examining those beliefs, help patients to take on interpretations of reality that are less biased by their initial negative thoughts. Through these “cognitive” exercises, patients begin to take on healthier, more-adaptive approaches to the social, physical, and emotional challenges in their lives. These interpretations are then “tested” in the real world, the behavioral aspect of CBT. Studies that ranged in time from 8 to 52 weeks in patients with MDD showed SGAs and CBT to have equal efficacy with regard to response and remission of depression to therapy. Combining SGA and CBT, compared with SGA alone, did not show a difference in outcomes of response to therapy or remission of depression, though patients who received both therapies had some improved efficacy in work function.
When SGAs were compared with interpersonal therapy, psychodynamic therapy, St. John’s wort, acupuncture, and exercise, there was low-quality evidence that these interventions performed with equal efficacy to SGAs. Two trials of exercise, compared with sertraline, had moderate-quality evidence showing similar efficacy between the two treatments.
When patients have an incomplete response to initial treatment with an SGA, there was no difference in response or remission when using a strategy of switching from one SGA to another versus switching to cognitive therapy. Similarly, with regard to augmentation, CBT appears to work equally to augmenting initial SGA therapy with bupropion or buspirone.
The guidelines discuss that, with regard to adverse effects, while the discontinuation rates of SGAs and CBT are similar, CBT likely has fewer side effects. In addition, it is important to recognize that CBT has lower relapse rate associated with its use than do SGAs. This is presumably because once a skill set is developed when learning CBT, those skills can continue to be used long term.
The bottom line
Most patients who experience depression are cared for by their primary care physician. Treatments for depression include psychotherapy, complementary and alternative medicine (CAM), exercise, and pharmacotherapy. After discussion with the patient, the American College of Physicians recommends choosing either cognitive-behavioral therapy or second-generation antidepressants when treating depression.
References
1. Olfson M, Blanco C, Marcus SC. Treatment of Adult Depression in the United States. JAMA Intern Med. 2016 Oct;176(10):1482-91.
2. Qaseem A, et al. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Mar 1;164:350-59.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Aaron Sutton is a behavioral therapy consultant in the family medicine residency program at Abington Memorial Hospital.
Major depressive disorder (MDD) affects 16% of adults in the United States at some point in their lives. It is one of the most important causes of disability, time off from work, and personal distress, accounting for more than 8 million office visits per year.
Recent information shows that while 8% of the population screens positive for depression, only a quarter of those with depression receive treatment. Most patients with depression are cared for by primary care physicians, not psychiatrists.1 It is important that primary care physicians are familiar with the range of evidence-based treatments for depression and their relative efficacy. Most patients with depression receive antidepressant medication and less than one-third of patients receive some form of psychotherapy.1 The American College of Physicians guideline reviews the evidence regarding the relative efficacy and safety of second-generation antidepressants and nonpharmacologic treatment of depression.2
Outcomes evaluated in this guideline include response, remission, functional capacity, quality of life, reduction of suicidality or hospitalizations, and harms.
The pharmacotherapy treatment of depression, as assessed in this guideline, are second-generation antidepressants (SGAs), which include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and selective serotonin norepinephrine reuptake inhibitors. Previous reviews have shown that the SGAs have similar efficacy and safety with the side effects varying among the different medications; common side effects include constipation, diarrhea, nausea, decreased sexual ability, dizziness, headache, insomnia, and fatigue.
The strongest evidence, rated as moderate quality, comes from trials comparing SGAs to a form of psychotherapy called cognitive-behavioral therapy (CBT). CBT uses the technique of “collaborative empiricism” to question patients maladaptive beliefs, and by examining those beliefs, help patients to take on interpretations of reality that are less biased by their initial negative thoughts. Through these “cognitive” exercises, patients begin to take on healthier, more-adaptive approaches to the social, physical, and emotional challenges in their lives. These interpretations are then “tested” in the real world, the behavioral aspect of CBT. Studies that ranged in time from 8 to 52 weeks in patients with MDD showed SGAs and CBT to have equal efficacy with regard to response and remission of depression to therapy. Combining SGA and CBT, compared with SGA alone, did not show a difference in outcomes of response to therapy or remission of depression, though patients who received both therapies had some improved efficacy in work function.
When SGAs were compared with interpersonal therapy, psychodynamic therapy, St. John’s wort, acupuncture, and exercise, there was low-quality evidence that these interventions performed with equal efficacy to SGAs. Two trials of exercise, compared with sertraline, had moderate-quality evidence showing similar efficacy between the two treatments.
When patients have an incomplete response to initial treatment with an SGA, there was no difference in response or remission when using a strategy of switching from one SGA to another versus switching to cognitive therapy. Similarly, with regard to augmentation, CBT appears to work equally to augmenting initial SGA therapy with bupropion or buspirone.
The guidelines discuss that, with regard to adverse effects, while the discontinuation rates of SGAs and CBT are similar, CBT likely has fewer side effects. In addition, it is important to recognize that CBT has lower relapse rate associated with its use than do SGAs. This is presumably because once a skill set is developed when learning CBT, those skills can continue to be used long term.
The bottom line
Most patients who experience depression are cared for by their primary care physician. Treatments for depression include psychotherapy, complementary and alternative medicine (CAM), exercise, and pharmacotherapy. After discussion with the patient, the American College of Physicians recommends choosing either cognitive-behavioral therapy or second-generation antidepressants when treating depression.
References
1. Olfson M, Blanco C, Marcus SC. Treatment of Adult Depression in the United States. JAMA Intern Med. 2016 Oct;176(10):1482-91.
2. Qaseem A, et al. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Mar 1;164:350-59.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Aaron Sutton is a behavioral therapy consultant in the family medicine residency program at Abington Memorial Hospital.
Anxiously looking for love
History: a lovelorn life
Ms. F, age 33, presents with one complaint: “I want to know how to maintain a relationship.” Problem is, social situations have made her feel anxious since childhood. She has trouble keeping a boyfriend; she left two intimate, extended relationships at different times.
She says she is too ashamed to invite people over because she cannot keep her apartment neat. She is also sick of her job as a filing clerk and wants a new career.
Ms. F reports no other anxiety symptoms or mood changes but often cannot concentrate. She denies impulsivity or poor judgment but admits that she makes decisions without getting important facts. For example, she enrolled at a community college without knowing what skills her new career would require. About 6 months ago, she left her boyfriend after realizing—18 months into the relationship—that he does not share her interests.
poll here
The authors’ observations
Information on all the above factors is crucial to diagnosing a socialization problem. Outline your differential diagnosis as the interview progresses.
Ask the patient:
How did you fare in school? A childhood history of pervasive inattention or impulsivity in at least two settings (at home and in school, for example) can signal attention-deficit/hyperactivity disorder (ADHD).fragile X syndrome). Boys with the fragile X premutation have a higher rate of ADHD symptoms and autism spectrum disorders than do boys without this premutation.3 Ms. F’s test showed two normal alleles, thus ruling out fragile X premutation.
Table 1
Mental status examination signs that suggest a PDD
| Little direct or sustained eye contact Eyes flit around the room Patient talks without looking at anyone |
| Few facial expressions Flat affect |
| Impaired speech production Although prosody (intonation) is normal, rate is rapid, with cluttered bursts followed by long pauses and occasional unusual emphasis on certain words |
| Tangential thought process Patient changes topics quickly without transition Non-sequitur responses |
| Brief responses to questions, offering little spontaneous information |
| Very detailed answers that include irrelevant information |
| Pedantic phrasing |
| Repetitive use of language |
| Does not pick up on nonquestions |
| Concrete answers to questions about emotion Patient cannot describe how emotions “feel” |
| Appears uncomfortable during conversation with examiner Rapport strained; patient does not seem to enjoy interaction |
| PDD: pervasive developmental disorder |
Treatment: medication and exploration
Ms. F agrees to an ADOS test. Her total score of 9 (7 in social, 2 in communication, and 0 in stereotyped/repetitive behavior) suggest a moderate PDD. We rule out autism based on the test score and Asperger’s syndrome because of her early language development delays (Table 2).
We start escitalopram, 10 mg/d, to address Ms. F’s anxiety. We see her weekly for medication management and start weekly psychotherapy to explore her two previous relationships and her desire to find a partner.
Ms. F, however, reacts anxiously to the therapist’s exploratory techniques. She has difficulty taking the lead and becomes extremely uncomfortable with silences in the conversation. The therapist tries cognitive-behavioral tactics to engage her, but Ms. F does not respond.
The therapist then conceptualizes her role as “coach” and tries a more-direct, problem-solving approach. She addresses specific challenges, such as an overwhelming class assignment, but Ms. F does not discuss or follow through on the problem.
After 6 months, Ms. F asks to stop psychotherapy because she has made little progress. She also asks to reduce medication checks to monthly, saying that weekly sessions interfere with her schoolwork. She says she would consider resuming psychotherapy.
At this point, Ms. F’s anxiety is significantly improved based on clinical impression. She continues to do well 6 months after stopping psychotherapy, though she is still without a boyfriend.
poll hereTable 2
Autism or Asperger’s? Watch for these distinguishing features
| Clinical feature | Autism | Asperger’s syndrome |
|---|---|---|
| Impaired nonverbal behavior | + | + |
| Language delay | + | – |
| Stereotyped behavior (routines, mannerisms) | + | + |
| Impaired social relationships | + | + |
| Cognitive delay | ± | – |
| +: Present –: absent ±: Might be present | ||
The authors’ observations
The ability to possess a theory of mind—or “mentalize”—helps us understand others’ beliefs, desires, thoughts, intentions, and knowledge. Attributing mental states to self and others helps explain and predict behavior, which is critical to social interaction.
A therapeutic relationship can help teach patients to handle social situations.4 In autism or PDD,5,6 however, theory of mind deficits typically frustrate relationship building.4 Because ability to mentalize is critical to psychodynamic psychotherapy,7 exploration does not help patients with PDD. By contrast, therapists can be more successful by being active in sessions and giving directions, suggestions, and information.
Which psychotherapy models work? Limited data address psychotherapy for adults with PDD; most studies have followed children.
CBT for persons with autism or PDD is directive, problem-focused, and targets automatic reactions.8 Social skills groups and CBT focusing on day-to-day problem solving can help older children and adolescents.9 A 20-week social skills intervention employing a CBT approach, paired with psychoeducation for parents, has helped boys ages 8 to 12 with autism, PDD, or Asperger’s syndrome.10
Other interventions use pictures, cartoons, and other visuals to help patients identify and correct misperceptions and determine how different responses might affect people’s thoughts and feelings.9,11 Role play allows the patient to practice social interaction but requires make-believe,11 so getting a PDD patient to participate can be challenging.
Medication can help manage comorbid anxiety, obsessive-compulsive, and mood symptoms in PDD. Limited data support using selective serotonin reuptake inhibitors for this purpose.12
Related resources
- Ozonoff S, Dawson G, McPartland J. A parent’s guide to Asperger syndrome & high-functioning autism: how to meet the challenges and help your child thrive. New York: Guilford Press; 2002.
- MAAP Services. A global information and support network for more advanced persons with autism and Asperger syndrome. www.asperger.org.
- Escitalopram • Lexapro
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
2. Lord C, Risi S, Lambrecht L, et al. The Autism Diagnostic Observation Schedule-Generic: A standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord 2000;30:205-23.
3. Farzin F, Perry H, Hessl D, et al. Autism spectrum disorders and attention-deficit/hyperactivity disorder in boys with the fragile X premutation. J Dev Behav Pediatr 2006;27(S2):S137-S144.
4. Ramsay JR, Brodkin ES, Cohen MR, et al. “Better strangers:” using the relationship in psychotherapy for adult patients with Asperger syndrome. Psychotherapy: Theory, Research, Practice, Training 2005;42:483-93.
5. Hill E, Frith U. Understanding autism: insights from mind and brain. Philos Trans R Soc Lond B Biol Sci 2003;358:281-9.
6. Castelli F, Frith C, Happe F, Frith U. Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes. Brain 2002;125:1839-49.
7. Gabbard GO. Psychodynamic psychiatry in clinical practice, 4th ed. Arlington, VA: American Psychiatric Publishing; 2005:60.
8. Beebe DW, Risi S. Treatment of adolescents and young adults with high-functioning autism or Asperger syndrome. In: Reinecke MA, Dattilio FM, Freeman A, eds. Cognitive therapy with children and adolescents. A casebook for clinical practice, 2nd ed. New York: Guilford Press; 2003.
9. Atwood T. Frameworks for behavioral interventions. Child Adolesc Psychiatr Clin N Am 2003;12:65-86.
10. Solomon M, Goodlin-Jones BL, Anders T. A social adjustment enhancement intervention for high functioning autism, Asperger’s syndrome, and pervasive developmental disorder NOS. J Autism Dev Disord 2004;34:649-68.
11. Rajendran G, Mitchell P, Rickards H. How do individuals with Asperger syndrome respond to nonliteral language and inappropriate requests in computer-mediated communication? J Autism Dev Disord 2005;35:429-43.
12. Namerow LB, Thomas P, Bostic JQ, et al. Use of citalopram in pervasive developmental disorders. J Dev Behav Pediatr 2003;24:104-8.
History: a lovelorn life
Ms. F, age 33, presents with one complaint: “I want to know how to maintain a relationship.” Problem is, social situations have made her feel anxious since childhood. She has trouble keeping a boyfriend; she left two intimate, extended relationships at different times.
She says she is too ashamed to invite people over because she cannot keep her apartment neat. She is also sick of her job as a filing clerk and wants a new career.
Ms. F reports no other anxiety symptoms or mood changes but often cannot concentrate. She denies impulsivity or poor judgment but admits that she makes decisions without getting important facts. For example, she enrolled at a community college without knowing what skills her new career would require. About 6 months ago, she left her boyfriend after realizing—18 months into the relationship—that he does not share her interests.
poll here
The authors’ observations
Information on all the above factors is crucial to diagnosing a socialization problem. Outline your differential diagnosis as the interview progresses.
Ask the patient:
How did you fare in school? A childhood history of pervasive inattention or impulsivity in at least two settings (at home and in school, for example) can signal attention-deficit/hyperactivity disorder (ADHD).fragile X syndrome). Boys with the fragile X premutation have a higher rate of ADHD symptoms and autism spectrum disorders than do boys without this premutation.3 Ms. F’s test showed two normal alleles, thus ruling out fragile X premutation.
Table 1
Mental status examination signs that suggest a PDD
| Little direct or sustained eye contact Eyes flit around the room Patient talks without looking at anyone |
| Few facial expressions Flat affect |
| Impaired speech production Although prosody (intonation) is normal, rate is rapid, with cluttered bursts followed by long pauses and occasional unusual emphasis on certain words |
| Tangential thought process Patient changes topics quickly without transition Non-sequitur responses |
| Brief responses to questions, offering little spontaneous information |
| Very detailed answers that include irrelevant information |
| Pedantic phrasing |
| Repetitive use of language |
| Does not pick up on nonquestions |
| Concrete answers to questions about emotion Patient cannot describe how emotions “feel” |
| Appears uncomfortable during conversation with examiner Rapport strained; patient does not seem to enjoy interaction |
| PDD: pervasive developmental disorder |
Treatment: medication and exploration
Ms. F agrees to an ADOS test. Her total score of 9 (7 in social, 2 in communication, and 0 in stereotyped/repetitive behavior) suggest a moderate PDD. We rule out autism based on the test score and Asperger’s syndrome because of her early language development delays (Table 2).
We start escitalopram, 10 mg/d, to address Ms. F’s anxiety. We see her weekly for medication management and start weekly psychotherapy to explore her two previous relationships and her desire to find a partner.
Ms. F, however, reacts anxiously to the therapist’s exploratory techniques. She has difficulty taking the lead and becomes extremely uncomfortable with silences in the conversation. The therapist tries cognitive-behavioral tactics to engage her, but Ms. F does not respond.
The therapist then conceptualizes her role as “coach” and tries a more-direct, problem-solving approach. She addresses specific challenges, such as an overwhelming class assignment, but Ms. F does not discuss or follow through on the problem.
After 6 months, Ms. F asks to stop psychotherapy because she has made little progress. She also asks to reduce medication checks to monthly, saying that weekly sessions interfere with her schoolwork. She says she would consider resuming psychotherapy.
At this point, Ms. F’s anxiety is significantly improved based on clinical impression. She continues to do well 6 months after stopping psychotherapy, though she is still without a boyfriend.
poll hereTable 2
Autism or Asperger’s? Watch for these distinguishing features
| Clinical feature | Autism | Asperger’s syndrome |
|---|---|---|
| Impaired nonverbal behavior | + | + |
| Language delay | + | – |
| Stereotyped behavior (routines, mannerisms) | + | + |
| Impaired social relationships | + | + |
| Cognitive delay | ± | – |
| +: Present –: absent ±: Might be present | ||
The authors’ observations
The ability to possess a theory of mind—or “mentalize”—helps us understand others’ beliefs, desires, thoughts, intentions, and knowledge. Attributing mental states to self and others helps explain and predict behavior, which is critical to social interaction.
A therapeutic relationship can help teach patients to handle social situations.4 In autism or PDD,5,6 however, theory of mind deficits typically frustrate relationship building.4 Because ability to mentalize is critical to psychodynamic psychotherapy,7 exploration does not help patients with PDD. By contrast, therapists can be more successful by being active in sessions and giving directions, suggestions, and information.
Which psychotherapy models work? Limited data address psychotherapy for adults with PDD; most studies have followed children.
CBT for persons with autism or PDD is directive, problem-focused, and targets automatic reactions.8 Social skills groups and CBT focusing on day-to-day problem solving can help older children and adolescents.9 A 20-week social skills intervention employing a CBT approach, paired with psychoeducation for parents, has helped boys ages 8 to 12 with autism, PDD, or Asperger’s syndrome.10
Other interventions use pictures, cartoons, and other visuals to help patients identify and correct misperceptions and determine how different responses might affect people’s thoughts and feelings.9,11 Role play allows the patient to practice social interaction but requires make-believe,11 so getting a PDD patient to participate can be challenging.
Medication can help manage comorbid anxiety, obsessive-compulsive, and mood symptoms in PDD. Limited data support using selective serotonin reuptake inhibitors for this purpose.12
Related resources
- Ozonoff S, Dawson G, McPartland J. A parent’s guide to Asperger syndrome & high-functioning autism: how to meet the challenges and help your child thrive. New York: Guilford Press; 2002.
- MAAP Services. A global information and support network for more advanced persons with autism and Asperger syndrome. www.asperger.org.
- Escitalopram • Lexapro
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
History: a lovelorn life
Ms. F, age 33, presents with one complaint: “I want to know how to maintain a relationship.” Problem is, social situations have made her feel anxious since childhood. She has trouble keeping a boyfriend; she left two intimate, extended relationships at different times.
She says she is too ashamed to invite people over because she cannot keep her apartment neat. She is also sick of her job as a filing clerk and wants a new career.
Ms. F reports no other anxiety symptoms or mood changes but often cannot concentrate. She denies impulsivity or poor judgment but admits that she makes decisions without getting important facts. For example, she enrolled at a community college without knowing what skills her new career would require. About 6 months ago, she left her boyfriend after realizing—18 months into the relationship—that he does not share her interests.
poll here
The authors’ observations
Information on all the above factors is crucial to diagnosing a socialization problem. Outline your differential diagnosis as the interview progresses.
Ask the patient:
How did you fare in school? A childhood history of pervasive inattention or impulsivity in at least two settings (at home and in school, for example) can signal attention-deficit/hyperactivity disorder (ADHD).fragile X syndrome). Boys with the fragile X premutation have a higher rate of ADHD symptoms and autism spectrum disorders than do boys without this premutation.3 Ms. F’s test showed two normal alleles, thus ruling out fragile X premutation.
Table 1
Mental status examination signs that suggest a PDD
| Little direct or sustained eye contact Eyes flit around the room Patient talks without looking at anyone |
| Few facial expressions Flat affect |
| Impaired speech production Although prosody (intonation) is normal, rate is rapid, with cluttered bursts followed by long pauses and occasional unusual emphasis on certain words |
| Tangential thought process Patient changes topics quickly without transition Non-sequitur responses |
| Brief responses to questions, offering little spontaneous information |
| Very detailed answers that include irrelevant information |
| Pedantic phrasing |
| Repetitive use of language |
| Does not pick up on nonquestions |
| Concrete answers to questions about emotion Patient cannot describe how emotions “feel” |
| Appears uncomfortable during conversation with examiner Rapport strained; patient does not seem to enjoy interaction |
| PDD: pervasive developmental disorder |
Treatment: medication and exploration
Ms. F agrees to an ADOS test. Her total score of 9 (7 in social, 2 in communication, and 0 in stereotyped/repetitive behavior) suggest a moderate PDD. We rule out autism based on the test score and Asperger’s syndrome because of her early language development delays (Table 2).
We start escitalopram, 10 mg/d, to address Ms. F’s anxiety. We see her weekly for medication management and start weekly psychotherapy to explore her two previous relationships and her desire to find a partner.
Ms. F, however, reacts anxiously to the therapist’s exploratory techniques. She has difficulty taking the lead and becomes extremely uncomfortable with silences in the conversation. The therapist tries cognitive-behavioral tactics to engage her, but Ms. F does not respond.
The therapist then conceptualizes her role as “coach” and tries a more-direct, problem-solving approach. She addresses specific challenges, such as an overwhelming class assignment, but Ms. F does not discuss or follow through on the problem.
After 6 months, Ms. F asks to stop psychotherapy because she has made little progress. She also asks to reduce medication checks to monthly, saying that weekly sessions interfere with her schoolwork. She says she would consider resuming psychotherapy.
At this point, Ms. F’s anxiety is significantly improved based on clinical impression. She continues to do well 6 months after stopping psychotherapy, though she is still without a boyfriend.
poll hereTable 2
Autism or Asperger’s? Watch for these distinguishing features
| Clinical feature | Autism | Asperger’s syndrome |
|---|---|---|
| Impaired nonverbal behavior | + | + |
| Language delay | + | – |
| Stereotyped behavior (routines, mannerisms) | + | + |
| Impaired social relationships | + | + |
| Cognitive delay | ± | – |
| +: Present –: absent ±: Might be present | ||
The authors’ observations
The ability to possess a theory of mind—or “mentalize”—helps us understand others’ beliefs, desires, thoughts, intentions, and knowledge. Attributing mental states to self and others helps explain and predict behavior, which is critical to social interaction.
A therapeutic relationship can help teach patients to handle social situations.4 In autism or PDD,5,6 however, theory of mind deficits typically frustrate relationship building.4 Because ability to mentalize is critical to psychodynamic psychotherapy,7 exploration does not help patients with PDD. By contrast, therapists can be more successful by being active in sessions and giving directions, suggestions, and information.
Which psychotherapy models work? Limited data address psychotherapy for adults with PDD; most studies have followed children.
CBT for persons with autism or PDD is directive, problem-focused, and targets automatic reactions.8 Social skills groups and CBT focusing on day-to-day problem solving can help older children and adolescents.9 A 20-week social skills intervention employing a CBT approach, paired with psychoeducation for parents, has helped boys ages 8 to 12 with autism, PDD, or Asperger’s syndrome.10
Other interventions use pictures, cartoons, and other visuals to help patients identify and correct misperceptions and determine how different responses might affect people’s thoughts and feelings.9,11 Role play allows the patient to practice social interaction but requires make-believe,11 so getting a PDD patient to participate can be challenging.
Medication can help manage comorbid anxiety, obsessive-compulsive, and mood symptoms in PDD. Limited data support using selective serotonin reuptake inhibitors for this purpose.12
Related resources
- Ozonoff S, Dawson G, McPartland J. A parent’s guide to Asperger syndrome & high-functioning autism: how to meet the challenges and help your child thrive. New York: Guilford Press; 2002.
- MAAP Services. A global information and support network for more advanced persons with autism and Asperger syndrome. www.asperger.org.
- Escitalopram • Lexapro
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
2. Lord C, Risi S, Lambrecht L, et al. The Autism Diagnostic Observation Schedule-Generic: A standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord 2000;30:205-23.
3. Farzin F, Perry H, Hessl D, et al. Autism spectrum disorders and attention-deficit/hyperactivity disorder in boys with the fragile X premutation. J Dev Behav Pediatr 2006;27(S2):S137-S144.
4. Ramsay JR, Brodkin ES, Cohen MR, et al. “Better strangers:” using the relationship in psychotherapy for adult patients with Asperger syndrome. Psychotherapy: Theory, Research, Practice, Training 2005;42:483-93.
5. Hill E, Frith U. Understanding autism: insights from mind and brain. Philos Trans R Soc Lond B Biol Sci 2003;358:281-9.
6. Castelli F, Frith C, Happe F, Frith U. Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes. Brain 2002;125:1839-49.
7. Gabbard GO. Psychodynamic psychiatry in clinical practice, 4th ed. Arlington, VA: American Psychiatric Publishing; 2005:60.
8. Beebe DW, Risi S. Treatment of adolescents and young adults with high-functioning autism or Asperger syndrome. In: Reinecke MA, Dattilio FM, Freeman A, eds. Cognitive therapy with children and adolescents. A casebook for clinical practice, 2nd ed. New York: Guilford Press; 2003.
9. Atwood T. Frameworks for behavioral interventions. Child Adolesc Psychiatr Clin N Am 2003;12:65-86.
10. Solomon M, Goodlin-Jones BL, Anders T. A social adjustment enhancement intervention for high functioning autism, Asperger’s syndrome, and pervasive developmental disorder NOS. J Autism Dev Disord 2004;34:649-68.
11. Rajendran G, Mitchell P, Rickards H. How do individuals with Asperger syndrome respond to nonliteral language and inappropriate requests in computer-mediated communication? J Autism Dev Disord 2005;35:429-43.
12. Namerow LB, Thomas P, Bostic JQ, et al. Use of citalopram in pervasive developmental disorders. J Dev Behav Pediatr 2003;24:104-8.
1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
2. Lord C, Risi S, Lambrecht L, et al. The Autism Diagnostic Observation Schedule-Generic: A standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord 2000;30:205-23.
3. Farzin F, Perry H, Hessl D, et al. Autism spectrum disorders and attention-deficit/hyperactivity disorder in boys with the fragile X premutation. J Dev Behav Pediatr 2006;27(S2):S137-S144.
4. Ramsay JR, Brodkin ES, Cohen MR, et al. “Better strangers:” using the relationship in psychotherapy for adult patients with Asperger syndrome. Psychotherapy: Theory, Research, Practice, Training 2005;42:483-93.
5. Hill E, Frith U. Understanding autism: insights from mind and brain. Philos Trans R Soc Lond B Biol Sci 2003;358:281-9.
6. Castelli F, Frith C, Happe F, Frith U. Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes. Brain 2002;125:1839-49.
7. Gabbard GO. Psychodynamic psychiatry in clinical practice, 4th ed. Arlington, VA: American Psychiatric Publishing; 2005:60.
8. Beebe DW, Risi S. Treatment of adolescents and young adults with high-functioning autism or Asperger syndrome. In: Reinecke MA, Dattilio FM, Freeman A, eds. Cognitive therapy with children and adolescents. A casebook for clinical practice, 2nd ed. New York: Guilford Press; 2003.
9. Atwood T. Frameworks for behavioral interventions. Child Adolesc Psychiatr Clin N Am 2003;12:65-86.
10. Solomon M, Goodlin-Jones BL, Anders T. A social adjustment enhancement intervention for high functioning autism, Asperger’s syndrome, and pervasive developmental disorder NOS. J Autism Dev Disord 2004;34:649-68.
11. Rajendran G, Mitchell P, Rickards H. How do individuals with Asperger syndrome respond to nonliteral language and inappropriate requests in computer-mediated communication? J Autism Dev Disord 2005;35:429-43.
12. Namerow LB, Thomas P, Bostic JQ, et al. Use of citalopram in pervasive developmental disorders. J Dev Behav Pediatr 2003;24:104-8.