Robert T. London, MD

Recently, I conducted a rather unscientific survey. I asked a few psychotherapists how they would treat a patient with whom I had worked successfully in the past.

The patient is a 39-year-old single woman who is a successful attorney. Despite her career success, the patient’s personal and social life had been replete with conflicts, especially surrounding her relationships with men. In our work together, these issues resolved when I used a cognitive-behavioral approach with her. But just as we were wrapping things up, an unexpected issue surfaced.

She told me that at age 20, she had studied abroad for a year in Europe with her closest female friend. It seems that my patient’s friend was successfully married and the mother of four children – all under age 10. She also was an attorney but was now working part time. And now, years later, the patient reported despair and unhappiness about "not seeing her anymore."

My survey began by asking numerous therapists what their approach would be to this woman’s dilemma. All of them knew about cognitive-behavioral therapy (CBT), reported using it, and endorsed using the technique to help this patient. However, the more we talked, it became clear that they were discussing traditional psychodynamic psychotherapy rather than the type of therapy started by Albert Ellis, Ph.D., in the 1950s as rational emotive behavior therapy, and later refined and codified as CBT by Dr. Aaron T. Beck in the 1960s and 1970s. In other words, my colleagues were not viewing this patient’s fears, distress, and even anger about losing her longtime friend in "here and now" terms.

They told me that they would ask questions like "How does that make you feel?" and "What memories came to mind?" as well as the usual series of exploratory, open-ended questions and interpretations. "You need to discuss this with her and ‘get it out there,’ " one of the therapists suggested. Wrong.

Admittedly, my patient’s past was marked by perceived abandonment, including a parental divorce; the loss of an older sister; and the constant switching of schools, because her mother moved several times. I agree that a psychodynamic style in this particular case might indeed have gotten to the root of the problem – at some point. But this approach is different from CBT, which circumscribes the problem, challenges faulty beliefs, and develops avenues for change in a reasonably short period of time.

I was able to make quick progress with this patient by asking her a simple question: "When did you last see your friend?" The answer, not surprising for "all or nothing" responders, was that she had seen her the previous week – but only for a quick 45-minute lunch. And the week before that, the two had met up at the local gym and taken a class together, but "we didn’t talk much," my patient observed. My response to the patient was that she did indeed see and spend time with her friend, but not as much as she had when the friend was single and childless. Isn’t this the case? I asked. "Yes, yes that’s the case, I do see her, but, but, but ..."

As the patient and I proceeded through the thinking therapy of CBT, she was able to recognize that she did see her friend but not as much. It became easier for the patient to understand that her friend’s life had changed dramatically and that her availability was limited because her friend’s family and work responsibilities kept her busy. The patient also began to realize that her own availability also had become more limited since she was 20.

The process of working with this patient using CBT involved more than one question and answer. The approach starts out as homing in on the "all or nothing" negative-type generalized thinking, and is clearly aimed at resolving the patient’s distortions, and focusing on developing a new perspective and new way of thinking about this particular issue. Changing the thought process in this particular context is aimed at getting the patient to extrapolate to better processing in other contexts.

In addition, it is important to note that a psychodynamic approach can be incorporated into CBT as a teaching model. In this case, I found that bringing into the picture past events that had influenced the patient’s current distorted thinking helped the patient get a more honest picture of this long friendship. Her newfound perspective on that relationship spilled over into other aspects of my patient’s life in a positive way.

CBT is not only helpful for patients dealing with anxiety, depression, or lifetime personality styles and behaviors that cause them some form of distress in everyday living. A study soon to be published in the Journal of Behavior Therapy and Experimental Psychiatry suggests that CBT also might prove beneficial for negative symptoms in outpatients with disorders on the schizophrenia spectrum.

After 20 sessions of CBT over a 6-month period, the investigators found that patients reported a decrease in the number of dysfunctional beliefs about their own "cognitive abilities, performance, emotional experience, and social exclusion" (J. Behav. Ther. Exp. Psychiatry 2013;44:300-6). This was a small study (n = 21), and as the investigators noted, randomized controlled trials are needed. Still, this study is a reminder that focusing on problem resolution in a few highly focused sessions also can help patients with serious mental illness.

Those findings notwithstanding, CBT is certainly no panacea for numerous psychotic disorders. But in light of its superb track record of resolving many emotional problems, I believe that it should be used more as a mainstay of treatment and that anyone coming out of a mental health training program – whether psychiatrists, psychologists, mental health social workers, or psychiatric nurse practitioners – should be just as adept at using CBT as they are in using psychodynamic psychotherapy or medication management.

Dr. London is a psychiatrist affiliated with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

Recently, I conducted a rather unscientific survey. I asked a few psychotherapists how they would treat a patient with whom I had worked successfully in the past.

The patient is a 39-year-old single woman who is a successful attorney. Despite her career success, the patient’s personal and social life had been replete with conflicts, especially surrounding her relationships with men. In our work together, these issues resolved when I used a cognitive-behavioral approach with her. But just as we were wrapping things up, an unexpected issue surfaced.

She told me that at age 20, she had studied abroad for a year in Europe with her closest female friend. It seems that my patient’s friend was successfully married and the mother of four children – all under age 10. She also was an attorney but was now working part time. And now, years later, the patient reported despair and unhappiness about "not seeing her anymore."

My survey began by asking numerous therapists what their approach would be to this woman’s dilemma. All of them knew about cognitive-behavioral therapy (CBT), reported using it, and endorsed using the technique to help this patient. However, the more we talked, it became clear that they were discussing traditional psychodynamic psychotherapy rather than the type of therapy started by Albert Ellis, Ph.D., in the 1950s as rational emotive behavior therapy, and later refined and codified as CBT by Dr. Aaron T. Beck in the 1960s and 1970s. In other words, my colleagues were not viewing this patient’s fears, distress, and even anger about losing her longtime friend in "here and now" terms.

They told me that they would ask questions like "How does that make you feel?" and "What memories came to mind?" as well as the usual series of exploratory, open-ended questions and interpretations. "You need to discuss this with her and ‘get it out there,’ " one of the therapists suggested. Wrong.

Admittedly, my patient’s past was marked by perceived abandonment, including a parental divorce; the loss of an older sister; and the constant switching of schools, because her mother moved several times. I agree that a psychodynamic style in this particular case might indeed have gotten to the root of the problem – at some point. But this approach is different from CBT, which circumscribes the problem, challenges faulty beliefs, and develops avenues for change in a reasonably short period of time.

I was able to make quick progress with this patient by asking her a simple question: "When did you last see your friend?" The answer, not surprising for "all or nothing" responders, was that she had seen her the previous week – but only for a quick 45-minute lunch. And the week before that, the two had met up at the local gym and taken a class together, but "we didn’t talk much," my patient observed. My response to the patient was that she did indeed see and spend time with her friend, but not as much as she had when the friend was single and childless. Isn’t this the case? I asked. "Yes, yes that’s the case, I do see her, but, but, but ..."

As the patient and I proceeded through the thinking therapy of CBT, she was able to recognize that she did see her friend but not as much. It became easier for the patient to understand that her friend’s life had changed dramatically and that her availability was limited because her friend’s family and work responsibilities kept her busy. The patient also began to realize that her own availability also had become more limited since she was 20.

The process of working with this patient using CBT involved more than one question and answer. The approach starts out as homing in on the "all or nothing" negative-type generalized thinking, and is clearly aimed at resolving the patient’s distortions, and focusing on developing a new perspective and new way of thinking about this particular issue. Changing the thought process in this particular context is aimed at getting the patient to extrapolate to better processing in other contexts.

In addition, it is important to note that a psychodynamic approach can be incorporated into CBT as a teaching model. In this case, I found that bringing into the picture past events that had influenced the patient’s current distorted thinking helped the patient get a more honest picture of this long friendship. Her newfound perspective on that relationship spilled over into other aspects of my patient’s life in a positive way.

CBT is not only helpful for patients dealing with anxiety, depression, or lifetime personality styles and behaviors that cause them some form of distress in everyday living. A study soon to be published in the Journal of Behavior Therapy and Experimental Psychiatry suggests that CBT also might prove beneficial for negative symptoms in outpatients with disorders on the schizophrenia spectrum.

After 20 sessions of CBT over a 6-month period, the investigators found that patients reported a decrease in the number of dysfunctional beliefs about their own "cognitive abilities, performance, emotional experience, and social exclusion" (J. Behav. Ther. Exp. Psychiatry 2013;44:300-6). This was a small study (n = 21), and as the investigators noted, randomized controlled trials are needed. Still, this study is a reminder that focusing on problem resolution in a few highly focused sessions also can help patients with serious mental illness.

Those findings notwithstanding, CBT is certainly no panacea for numerous psychotic disorders. But in light of its superb track record of resolving many emotional problems, I believe that it should be used more as a mainstay of treatment and that anyone coming out of a mental health training program – whether psychiatrists, psychologists, mental health social workers, or psychiatric nurse practitioners – should be just as adept at using CBT as they are in using psychodynamic psychotherapy or medication management.

Dr. London is a psychiatrist affiliated with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

Recently, I conducted a rather unscientific survey. I asked a few psychotherapists how they would treat a patient with whom I had worked successfully in the past.

The patient is a 39-year-old single woman who is a successful attorney. Despite her career success, the patient’s personal and social life had been replete with conflicts, especially surrounding her relationships with men. In our work together, these issues resolved when I used a cognitive-behavioral approach with her. But just as we were wrapping things up, an unexpected issue surfaced.

She told me that at age 20, she had studied abroad for a year in Europe with her closest female friend. It seems that my patient’s friend was successfully married and the mother of four children – all under age 10. She also was an attorney but was now working part time. And now, years later, the patient reported despair and unhappiness about "not seeing her anymore."

My survey began by asking numerous therapists what their approach would be to this woman’s dilemma. All of them knew about cognitive-behavioral therapy (CBT), reported using it, and endorsed using the technique to help this patient. However, the more we talked, it became clear that they were discussing traditional psychodynamic psychotherapy rather than the type of therapy started by Albert Ellis, Ph.D., in the 1950s as rational emotive behavior therapy, and later refined and codified as CBT by Dr. Aaron T. Beck in the 1960s and 1970s. In other words, my colleagues were not viewing this patient’s fears, distress, and even anger about losing her longtime friend in "here and now" terms.

They told me that they would ask questions like "How does that make you feel?" and "What memories came to mind?" as well as the usual series of exploratory, open-ended questions and interpretations. "You need to discuss this with her and ‘get it out there,’ " one of the therapists suggested. Wrong.

Admittedly, my patient’s past was marked by perceived abandonment, including a parental divorce; the loss of an older sister; and the constant switching of schools, because her mother moved several times. I agree that a psychodynamic style in this particular case might indeed have gotten to the root of the problem – at some point. But this approach is different from CBT, which circumscribes the problem, challenges faulty beliefs, and develops avenues for change in a reasonably short period of time.

I was able to make quick progress with this patient by asking her a simple question: "When did you last see your friend?" The answer, not surprising for "all or nothing" responders, was that she had seen her the previous week – but only for a quick 45-minute lunch. And the week before that, the two had met up at the local gym and taken a class together, but "we didn’t talk much," my patient observed. My response to the patient was that she did indeed see and spend time with her friend, but not as much as she had when the friend was single and childless. Isn’t this the case? I asked. "Yes, yes that’s the case, I do see her, but, but, but ..."

As the patient and I proceeded through the thinking therapy of CBT, she was able to recognize that she did see her friend but not as much. It became easier for the patient to understand that her friend’s life had changed dramatically and that her availability was limited because her friend’s family and work responsibilities kept her busy. The patient also began to realize that her own availability also had become more limited since she was 20.

The process of working with this patient using CBT involved more than one question and answer. The approach starts out as homing in on the "all or nothing" negative-type generalized thinking, and is clearly aimed at resolving the patient’s distortions, and focusing on developing a new perspective and new way of thinking about this particular issue. Changing the thought process in this particular context is aimed at getting the patient to extrapolate to better processing in other contexts.

In addition, it is important to note that a psychodynamic approach can be incorporated into CBT as a teaching model. In this case, I found that bringing into the picture past events that had influenced the patient’s current distorted thinking helped the patient get a more honest picture of this long friendship. Her newfound perspective on that relationship spilled over into other aspects of my patient’s life in a positive way.

CBT is not only helpful for patients dealing with anxiety, depression, or lifetime personality styles and behaviors that cause them some form of distress in everyday living. A study soon to be published in the Journal of Behavior Therapy and Experimental Psychiatry suggests that CBT also might prove beneficial for negative symptoms in outpatients with disorders on the schizophrenia spectrum.

After 20 sessions of CBT over a 6-month period, the investigators found that patients reported a decrease in the number of dysfunctional beliefs about their own "cognitive abilities, performance, emotional experience, and social exclusion" (J. Behav. Ther. Exp. Psychiatry 2013;44:300-6). This was a small study (n = 21), and as the investigators noted, randomized controlled trials are needed. Still, this study is a reminder that focusing on problem resolution in a few highly focused sessions also can help patients with serious mental illness.

Those findings notwithstanding, CBT is certainly no panacea for numerous psychotic disorders. But in light of its superb track record of resolving many emotional problems, I believe that it should be used more as a mainstay of treatment and that anyone coming out of a mental health training program – whether psychiatrists, psychologists, mental health social workers, or psychiatric nurse practitioners – should be just as adept at using CBT as they are in using psychodynamic psychotherapy or medication management.

Dr. London is a psychiatrist affiliated with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

When a working woman becomes pregnant, one of her main questions is: What will I do about maternity leave?

When a working woman suffers from anxiety because she becomes pregnant, she might ask: Which will I choose – the baby or the job?

All too often, women I’ve talked to and treated discover that they have no maternity leave and that the only way to take time off is to do so under the Family Medical Leave Act. This law, which allows certain employees to take up to 12 unpaid weeks of leave, might be great for some women (and men). However, taking time off without pay is not an option for many women.

In fact, a recent study by the Pew Research Center showed that a record 40% of all U.S. households with children under 18 have mothers who are either the only source of income for the family or the primary source. In other words, a large percentage of households depend on the mother’s income.

The angst caused by these income pressures brings unnecessary stress to our pregnant patients, which in turn can lead to adverse effects for the fetus as well as the mother. One review of 13 studies published from 1966 to 2006 found that in 8 of the studies, anxiety during pregnancy was tied to prematurity and low birthweight (Cad. Saude Publica. 2007;23:747-56).

Psychiatrists and mental health professionals who treat pregnant women with anxiety issues would do best using cognitive-behavioral therapy and relaxation techniques coupled with guided imagery, thus avoiding medications. From a philosophical point of view, we need to be active in advocating on behalf of public policies that support paid maternity leave for mothers of newborns and allow the United States to join the ranks of other industrialized nations.

For example, Canada provides its citizens with paid maternity benefits for up to a maximum of 15 weeks, in addition to parental benefits for up to a maximum of 35 weeks. The parental leave benefit can be divided between partners in any way a couple so chooses. In addition, Canada does the right thing by extending eligibility for maternity benefits to surrogate mothers and parental benefits to adoptive parents, according to Service Canada.

Training self-help strategies

The potential risk of psychotropic medications to both the mother and the fetus remains controversial. I have stayed away from prescribing medications for pregnant patients suffering from anxiety, and I have had positive results. My approach has been to treat these disorders using cognitive-behavioral therapy (CBT) and relaxation/hypnosis, coupled with guided imagery.

Pregnant women with anxiety tend to ruminate about the future and "what will be" on a number of issues. These concerns become more excessive and intense in their minds when the baby is born into an economically challenging financial situation to a mother with limited or no maternity leave. Using the CBT approach for such patients offers a new and lasting perspective on thoughts driving the anxiety, giving a wider berth for negative thoughts to be challenged, changed, and channeled into the more here-and-now thinking with an emphasis on focusing the patient on taking the best care of herself each day.

Anxiety and future worries can play tricks on the person’s thinking. The key is to get the patient to live "where her feet are" and avoid the frightening thoughts of "what ifs" tied to the future. This allows the patient to shift away from negative "all or nothing" or "this or that" thinking. The clinician allows the person to stay more in the moment with a new and broader perspective on the issues facing her and to think about the beauty of childbirth. This shift in thinking that occurs with CBT, which reduces anxiety, will allow the patient to tap into clearer thinking and into her strength, to develop a better idea about the future, including how much time she will be able to free up for child care. She also will be better able to determine what types of plans, including financial planning, can be developed after childbirth.

In some cases, relaxation/hypnotic techniques coupled with guided imagery is most helpful in lowering anxiety levels on a daily basis. I give the patient instruction in these techniques and teach her how to do the techniques on her own on a daily basis. It’s extremely helpful for the patient to practice the relaxation and guided imagery techniques on her own for a few moments many times a day to increase proficiency.

Policy changes are needed

When did the thinking change on how much time a woman should take off with her baby? Back when my father graduated from medical school in the 1930s, the universal thinking among his medical and surgical peers (who often did prenatal and delivery care) was that it took at least a year or more before the mother was back physically and mentally. But these days, that age-old clinical concept is not really accepted, and women are given clearance to return to work within 6 weeks after a vaginal birth. From a psychological perspective, that’s just not enough time.

Canada is certainly not the only industrialized country with maternity leave policies that are more reasonable. A recent report by Institute for Women’s Policy Research says that the United States is the only high-income country that does not mandate paid maternity leave for employees. The Family and Medical Leave Act 2012 survey estimates that about 35% of employees work for companies that provide paid maternity leave, and about 20% provide paid paternity leave. Of course, lower-paid employees are least likely to have paid leave.

Interestingly, Marissa Mayer, chief executive officer of Yahoo, has recently started offering new mothers and fathers 8 weeks of paid parental leave, and mothers have the option of taking an additional 8 weeks. This is not as generous as the family policies of Google, Mayer’s former employer, which offers 7 weeks of paid leave for parents who did not give birth and up to 22 weeks for new mothers. Facebook reportedly gives mothers and fathers 4 months of paid leave as well as $4,000 in "baby cash." The model set by Silicon Valley companies does a great job of addressing the needs of new mothers.

We regularly speak of the importance of mental health. However, when it comes to the mental health of expectant mothers (and fathers), we have failed to provide what most industrialized countries accept as normal: a financially secure year to heal from giving birth, and to nourish and nurture the newborn child.

We must encourage mental health advocacy organizations and politicians to put more emphasis on addressing this important issue.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He has no conflicts of interest to disclose.

When a working woman becomes pregnant, one of her main questions is: What will I do about maternity leave?

When a working woman suffers from anxiety because she becomes pregnant, she might ask: Which will I choose – the baby or the job?

All too often, women I’ve talked to and treated discover that they have no maternity leave and that the only way to take time off is to do so under the Family Medical Leave Act. This law, which allows certain employees to take up to 12 unpaid weeks of leave, might be great for some women (and men). However, taking time off without pay is not an option for many women.

In fact, a recent study by the Pew Research Center showed that a record 40% of all U.S. households with children under 18 have mothers who are either the only source of income for the family or the primary source. In other words, a large percentage of households depend on the mother’s income.

The angst caused by these income pressures brings unnecessary stress to our pregnant patients, which in turn can lead to adverse effects for the fetus as well as the mother. One review of 13 studies published from 1966 to 2006 found that in 8 of the studies, anxiety during pregnancy was tied to prematurity and low birthweight (Cad. Saude Publica. 2007;23:747-56).

Psychiatrists and mental health professionals who treat pregnant women with anxiety issues would do best using cognitive-behavioral therapy and relaxation techniques coupled with guided imagery, thus avoiding medications. From a philosophical point of view, we need to be active in advocating on behalf of public policies that support paid maternity leave for mothers of newborns and allow the United States to join the ranks of other industrialized nations.

For example, Canada provides its citizens with paid maternity benefits for up to a maximum of 15 weeks, in addition to parental benefits for up to a maximum of 35 weeks. The parental leave benefit can be divided between partners in any way a couple so chooses. In addition, Canada does the right thing by extending eligibility for maternity benefits to surrogate mothers and parental benefits to adoptive parents, according to Service Canada.

Training self-help strategies

The potential risk of psychotropic medications to both the mother and the fetus remains controversial. I have stayed away from prescribing medications for pregnant patients suffering from anxiety, and I have had positive results. My approach has been to treat these disorders using cognitive-behavioral therapy (CBT) and relaxation/hypnosis, coupled with guided imagery.

Pregnant women with anxiety tend to ruminate about the future and "what will be" on a number of issues. These concerns become more excessive and intense in their minds when the baby is born into an economically challenging financial situation to a mother with limited or no maternity leave. Using the CBT approach for such patients offers a new and lasting perspective on thoughts driving the anxiety, giving a wider berth for negative thoughts to be challenged, changed, and channeled into the more here-and-now thinking with an emphasis on focusing the patient on taking the best care of herself each day.

Anxiety and future worries can play tricks on the person’s thinking. The key is to get the patient to live "where her feet are" and avoid the frightening thoughts of "what ifs" tied to the future. This allows the patient to shift away from negative "all or nothing" or "this or that" thinking. The clinician allows the person to stay more in the moment with a new and broader perspective on the issues facing her and to think about the beauty of childbirth. This shift in thinking that occurs with CBT, which reduces anxiety, will allow the patient to tap into clearer thinking and into her strength, to develop a better idea about the future, including how much time she will be able to free up for child care. She also will be better able to determine what types of plans, including financial planning, can be developed after childbirth.

In some cases, relaxation/hypnotic techniques coupled with guided imagery is most helpful in lowering anxiety levels on a daily basis. I give the patient instruction in these techniques and teach her how to do the techniques on her own on a daily basis. It’s extremely helpful for the patient to practice the relaxation and guided imagery techniques on her own for a few moments many times a day to increase proficiency.

Policy changes are needed

When did the thinking change on how much time a woman should take off with her baby? Back when my father graduated from medical school in the 1930s, the universal thinking among his medical and surgical peers (who often did prenatal and delivery care) was that it took at least a year or more before the mother was back physically and mentally. But these days, that age-old clinical concept is not really accepted, and women are given clearance to return to work within 6 weeks after a vaginal birth. From a psychological perspective, that’s just not enough time.

Canada is certainly not the only industrialized country with maternity leave policies that are more reasonable. A recent report by Institute for Women’s Policy Research says that the United States is the only high-income country that does not mandate paid maternity leave for employees. The Family and Medical Leave Act 2012 survey estimates that about 35% of employees work for companies that provide paid maternity leave, and about 20% provide paid paternity leave. Of course, lower-paid employees are least likely to have paid leave.

Interestingly, Marissa Mayer, chief executive officer of Yahoo, has recently started offering new mothers and fathers 8 weeks of paid parental leave, and mothers have the option of taking an additional 8 weeks. This is not as generous as the family policies of Google, Mayer’s former employer, which offers 7 weeks of paid leave for parents who did not give birth and up to 22 weeks for new mothers. Facebook reportedly gives mothers and fathers 4 months of paid leave as well as $4,000 in "baby cash." The model set by Silicon Valley companies does a great job of addressing the needs of new mothers.

We regularly speak of the importance of mental health. However, when it comes to the mental health of expectant mothers (and fathers), we have failed to provide what most industrialized countries accept as normal: a financially secure year to heal from giving birth, and to nourish and nurture the newborn child.

We must encourage mental health advocacy organizations and politicians to put more emphasis on addressing this important issue.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He has no conflicts of interest to disclose.

When a working woman becomes pregnant, one of her main questions is: What will I do about maternity leave?

When a working woman suffers from anxiety because she becomes pregnant, she might ask: Which will I choose – the baby or the job?

All too often, women I’ve talked to and treated discover that they have no maternity leave and that the only way to take time off is to do so under the Family Medical Leave Act. This law, which allows certain employees to take up to 12 unpaid weeks of leave, might be great for some women (and men). However, taking time off without pay is not an option for many women.

In fact, a recent study by the Pew Research Center showed that a record 40% of all U.S. households with children under 18 have mothers who are either the only source of income for the family or the primary source. In other words, a large percentage of households depend on the mother’s income.

The angst caused by these income pressures brings unnecessary stress to our pregnant patients, which in turn can lead to adverse effects for the fetus as well as the mother. One review of 13 studies published from 1966 to 2006 found that in 8 of the studies, anxiety during pregnancy was tied to prematurity and low birthweight (Cad. Saude Publica. 2007;23:747-56).

Psychiatrists and mental health professionals who treat pregnant women with anxiety issues would do best using cognitive-behavioral therapy and relaxation techniques coupled with guided imagery, thus avoiding medications. From a philosophical point of view, we need to be active in advocating on behalf of public policies that support paid maternity leave for mothers of newborns and allow the United States to join the ranks of other industrialized nations.

For example, Canada provides its citizens with paid maternity benefits for up to a maximum of 15 weeks, in addition to parental benefits for up to a maximum of 35 weeks. The parental leave benefit can be divided between partners in any way a couple so chooses. In addition, Canada does the right thing by extending eligibility for maternity benefits to surrogate mothers and parental benefits to adoptive parents, according to Service Canada.

Training self-help strategies

The potential risk of psychotropic medications to both the mother and the fetus remains controversial. I have stayed away from prescribing medications for pregnant patients suffering from anxiety, and I have had positive results. My approach has been to treat these disorders using cognitive-behavioral therapy (CBT) and relaxation/hypnosis, coupled with guided imagery.

Pregnant women with anxiety tend to ruminate about the future and "what will be" on a number of issues. These concerns become more excessive and intense in their minds when the baby is born into an economically challenging financial situation to a mother with limited or no maternity leave. Using the CBT approach for such patients offers a new and lasting perspective on thoughts driving the anxiety, giving a wider berth for negative thoughts to be challenged, changed, and channeled into the more here-and-now thinking with an emphasis on focusing the patient on taking the best care of herself each day.

Anxiety and future worries can play tricks on the person’s thinking. The key is to get the patient to live "where her feet are" and avoid the frightening thoughts of "what ifs" tied to the future. This allows the patient to shift away from negative "all or nothing" or "this or that" thinking. The clinician allows the person to stay more in the moment with a new and broader perspective on the issues facing her and to think about the beauty of childbirth. This shift in thinking that occurs with CBT, which reduces anxiety, will allow the patient to tap into clearer thinking and into her strength, to develop a better idea about the future, including how much time she will be able to free up for child care. She also will be better able to determine what types of plans, including financial planning, can be developed after childbirth.

In some cases, relaxation/hypnotic techniques coupled with guided imagery is most helpful in lowering anxiety levels on a daily basis. I give the patient instruction in these techniques and teach her how to do the techniques on her own on a daily basis. It’s extremely helpful for the patient to practice the relaxation and guided imagery techniques on her own for a few moments many times a day to increase proficiency.

Policy changes are needed

When did the thinking change on how much time a woman should take off with her baby? Back when my father graduated from medical school in the 1930s, the universal thinking among his medical and surgical peers (who often did prenatal and delivery care) was that it took at least a year or more before the mother was back physically and mentally. But these days, that age-old clinical concept is not really accepted, and women are given clearance to return to work within 6 weeks after a vaginal birth. From a psychological perspective, that’s just not enough time.

Canada is certainly not the only industrialized country with maternity leave policies that are more reasonable. A recent report by Institute for Women’s Policy Research says that the United States is the only high-income country that does not mandate paid maternity leave for employees. The Family and Medical Leave Act 2012 survey estimates that about 35% of employees work for companies that provide paid maternity leave, and about 20% provide paid paternity leave. Of course, lower-paid employees are least likely to have paid leave.

Interestingly, Marissa Mayer, chief executive officer of Yahoo, has recently started offering new mothers and fathers 8 weeks of paid parental leave, and mothers have the option of taking an additional 8 weeks. This is not as generous as the family policies of Google, Mayer’s former employer, which offers 7 weeks of paid leave for parents who did not give birth and up to 22 weeks for new mothers. Facebook reportedly gives mothers and fathers 4 months of paid leave as well as $4,000 in "baby cash." The model set by Silicon Valley companies does a great job of addressing the needs of new mothers.

We regularly speak of the importance of mental health. However, when it comes to the mental health of expectant mothers (and fathers), we have failed to provide what most industrialized countries accept as normal: a financially secure year to heal from giving birth, and to nourish and nurture the newborn child.

We must encourage mental health advocacy organizations and politicians to put more emphasis on addressing this important issue.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He has no conflicts of interest to disclose.

In the past, the field of psychocardiology has focused on integrating psychiatric and cardiology care for patients who are at risk for cardiovascular disease because of internal risk factors such as depression, anxiety, hostility, and the stress of decreased economic status. While running a smoking-cessation program several years ago, I was keenly aware of the importance of integrating psychiatric and cardiology care for patients at risk for heart disease. However, in light of the potential impact of psychotropic drugs on the cardiovascular system, we need to learn more and be willing to act on our knowledge.

I took a CME course recently called "Psychocardiology: Treating Mood Disorders While Minimizing Cardiovascular and Metabolic Risks" that proved to be an important review. I was reminded that certain selective serotonin reuptake inhibitors and some first- and second-generation antipsychotics can increase the risk of tachyarrhythmias as well as produce torsades de pointes and its associated increased QT interval potential, which can lead to decreased arterial blood pressure, syncope, ventricular tachycardia, and even sudden death.

In addition, H1-antihistamines, antifungal agents, diuretics, methadone, and certain cardiac medications can increase the QT intervals, thus creating an even more dangerous situation for people with multisystem medical problems who are being treated with a variety of medications. Macrolide antibiotics also fall within this category, which explains the FDA’s recent warning that azithromycin (Zithromax), also known as Z-Pak, can cause abnormal changes in the heart’s electrical activity that could lead to fatal irregular heart rhythm.

The risk further increases for more people with the wider use of some of the newer second-generation antipsychotics now used as mood stabilizers, antianxiety agents, sleep aids, antiaggression agents, and even for conditions such as attention-deficit/hyperactivity disorder. Adding to these risks is the pervasiveness of polypharmacy today, in which multiple medications with the same chemical action are prescribed to the same patient. Unfortunately, this is seen by psychiatrists who see patients in 15-minute medication management visits ("Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy," New York Times, March 5, 2011), as well as with primary care physicians, who have become an integral part in the treatment of psychiatric disorders.

In this environment, it is even more important than ever that we monitor closely the impact of our treatments on the heart. A review of three placebo-controlled trials by Dr. Raul R. Silva and his colleagues at New York University Langone Medical Center found significant increases in mean heart rate from baseline among children who had been treated with stimulants such as methylphenidate and mixed amphetamine salts. Obtaining a baseline ECG for any patient starting stimulant treatment is reasonable if access for the patient is "readily available and not too costly," they said (Clin. Pediatr. 2010;49:840-51).

SSRIs, the current mainstay medication for depression, are being used for anxiety disorders, including posttraumatic stress disorder, obsessive compulsive disorder, social anxiety, eating disorders, and even pain control. As a result, a larger population is at risk for serious side effects, especially cardiovascular disease, and particularly torsades de pointes. The biggest culprit among SSRIs is citalopram, which explains why the Food and Drug Administration has offered detailed recommendations about the risks of QT prolongation among patients taking that antidepressant.

QT prolongation can develop suddenly and prove life threatening – unlike other complications of past and present psychiatric medications.

Given this increased risk of cardiovascular disease, the best care for patients would be medical/cardiac assessments before they started any psychiatric medications that might lead to prolongation of the QT interval, including ongoing assessments of cardiovascular status as psychiatric medications are continued.

Our role as physicians with expertise in treating mental illness places us in a unique position to read and interpret electrocardiograms and QT intervals for our patients if we are prepared to learn and relearn the skills needed. If cardiologic consultations are not readily available, it would seem that psychiatrists could refer their patients for an ECG, just as we do for routine blood testing, CT scans, or MRIs when appropriate. Unfortunately, we have been reluctant to do so.

In a small study of 64 consultants and trainees in psychiatry asked to complete a questionnaire testing their knowledge, only 62% were able to calculate the heart rate correctly and only 5% calculated the QT intervals correctly using Bazett’s formula, which is still considered to be the most popular correction formula. "We expected that the increased awareness of the cardiotoxicity of psychotropics and interaction between medications would have made psychiatrists more adept at QT interval and ECG abnormality interpretation, but this study indicates that the problem remains," the investigators wrote in the Psychiatrist (2008;32:291-4).

The American Psychiatric Association has issued guidance on prescribing psychotropics and the risks of cardiac sudden death: "An absolute QTc interval of >500 msec or an increase of 60 msec from baseline may be associated with an increased risk of [torsades de pointes] and should prompt reduction or discontinuation of the offending agent." The guidance also encourages use of the lowest effective dose "for any given patient ... to minimize dose-dependent adverse effect risks."

Many of the drugs we prescribe have the ability to prolong our patients’ QT, although we must keep in mind that case reports of torsades de pointes in association with most psychotropics are rare (Dtsch. Arztebl. Int. 2011;41:687-93). Nevertheless, it’s important to understand that the medications used today in treating psychiatric disorders are not without side effects or risks.

As today’s psychiatrists become medication managers, it would seem only reasonable and logical for us to be doing the appropriate medical follow-up with a cardiologist on the medications used or routinely sending our patients for testing with improved knowledge of testing results. In addition, patient education regarding other drug classes capable of producing a similar cardiac effect needs to be integrated into our treatment plans.

Dr. London, a psychiatrist with NYU Langone Medical Center, New York, has no conflicts of interest to disclose. He can be reached at [email protected].

In the past, the field of psychocardiology has focused on integrating psychiatric and cardiology care for patients who are at risk for cardiovascular disease because of internal risk factors such as depression, anxiety, hostility, and the stress of decreased economic status. While running a smoking-cessation program several years ago, I was keenly aware of the importance of integrating psychiatric and cardiology care for patients at risk for heart disease. However, in light of the potential impact of psychotropic drugs on the cardiovascular system, we need to learn more and be willing to act on our knowledge.

I took a CME course recently called "Psychocardiology: Treating Mood Disorders While Minimizing Cardiovascular and Metabolic Risks" that proved to be an important review. I was reminded that certain selective serotonin reuptake inhibitors and some first- and second-generation antipsychotics can increase the risk of tachyarrhythmias as well as produce torsades de pointes and its associated increased QT interval potential, which can lead to decreased arterial blood pressure, syncope, ventricular tachycardia, and even sudden death.

In addition, H1-antihistamines, antifungal agents, diuretics, methadone, and certain cardiac medications can increase the QT intervals, thus creating an even more dangerous situation for people with multisystem medical problems who are being treated with a variety of medications. Macrolide antibiotics also fall within this category, which explains the FDA’s recent warning that azithromycin (Zithromax), also known as Z-Pak, can cause abnormal changes in the heart’s electrical activity that could lead to fatal irregular heart rhythm.

The risk further increases for more people with the wider use of some of the newer second-generation antipsychotics now used as mood stabilizers, antianxiety agents, sleep aids, antiaggression agents, and even for conditions such as attention-deficit/hyperactivity disorder. Adding to these risks is the pervasiveness of polypharmacy today, in which multiple medications with the same chemical action are prescribed to the same patient. Unfortunately, this is seen by psychiatrists who see patients in 15-minute medication management visits ("Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy," New York Times, March 5, 2011), as well as with primary care physicians, who have become an integral part in the treatment of psychiatric disorders.

In this environment, it is even more important than ever that we monitor closely the impact of our treatments on the heart. A review of three placebo-controlled trials by Dr. Raul R. Silva and his colleagues at New York University Langone Medical Center found significant increases in mean heart rate from baseline among children who had been treated with stimulants such as methylphenidate and mixed amphetamine salts. Obtaining a baseline ECG for any patient starting stimulant treatment is reasonable if access for the patient is "readily available and not too costly," they said (Clin. Pediatr. 2010;49:840-51).

SSRIs, the current mainstay medication for depression, are being used for anxiety disorders, including posttraumatic stress disorder, obsessive compulsive disorder, social anxiety, eating disorders, and even pain control. As a result, a larger population is at risk for serious side effects, especially cardiovascular disease, and particularly torsades de pointes. The biggest culprit among SSRIs is citalopram, which explains why the Food and Drug Administration has offered detailed recommendations about the risks of QT prolongation among patients taking that antidepressant.

QT prolongation can develop suddenly and prove life threatening – unlike other complications of past and present psychiatric medications.

Given this increased risk of cardiovascular disease, the best care for patients would be medical/cardiac assessments before they started any psychiatric medications that might lead to prolongation of the QT interval, including ongoing assessments of cardiovascular status as psychiatric medications are continued.

Our role as physicians with expertise in treating mental illness places us in a unique position to read and interpret electrocardiograms and QT intervals for our patients if we are prepared to learn and relearn the skills needed. If cardiologic consultations are not readily available, it would seem that psychiatrists could refer their patients for an ECG, just as we do for routine blood testing, CT scans, or MRIs when appropriate. Unfortunately, we have been reluctant to do so.

In a small study of 64 consultants and trainees in psychiatry asked to complete a questionnaire testing their knowledge, only 62% were able to calculate the heart rate correctly and only 5% calculated the QT intervals correctly using Bazett’s formula, which is still considered to be the most popular correction formula. "We expected that the increased awareness of the cardiotoxicity of psychotropics and interaction between medications would have made psychiatrists more adept at QT interval and ECG abnormality interpretation, but this study indicates that the problem remains," the investigators wrote in the Psychiatrist (2008;32:291-4).

The American Psychiatric Association has issued guidance on prescribing psychotropics and the risks of cardiac sudden death: "An absolute QTc interval of >500 msec or an increase of 60 msec from baseline may be associated with an increased risk of [torsades de pointes] and should prompt reduction or discontinuation of the offending agent." The guidance also encourages use of the lowest effective dose "for any given patient ... to minimize dose-dependent adverse effect risks."

Many of the drugs we prescribe have the ability to prolong our patients’ QT, although we must keep in mind that case reports of torsades de pointes in association with most psychotropics are rare (Dtsch. Arztebl. Int. 2011;41:687-93). Nevertheless, it’s important to understand that the medications used today in treating psychiatric disorders are not without side effects or risks.

As today’s psychiatrists become medication managers, it would seem only reasonable and logical for us to be doing the appropriate medical follow-up with a cardiologist on the medications used or routinely sending our patients for testing with improved knowledge of testing results. In addition, patient education regarding other drug classes capable of producing a similar cardiac effect needs to be integrated into our treatment plans.

Dr. London, a psychiatrist with NYU Langone Medical Center, New York, has no conflicts of interest to disclose. He can be reached at [email protected].

In the past, the field of psychocardiology has focused on integrating psychiatric and cardiology care for patients who are at risk for cardiovascular disease because of internal risk factors such as depression, anxiety, hostility, and the stress of decreased economic status. While running a smoking-cessation program several years ago, I was keenly aware of the importance of integrating psychiatric and cardiology care for patients at risk for heart disease. However, in light of the potential impact of psychotropic drugs on the cardiovascular system, we need to learn more and be willing to act on our knowledge.

I took a CME course recently called "Psychocardiology: Treating Mood Disorders While Minimizing Cardiovascular and Metabolic Risks" that proved to be an important review. I was reminded that certain selective serotonin reuptake inhibitors and some first- and second-generation antipsychotics can increase the risk of tachyarrhythmias as well as produce torsades de pointes and its associated increased QT interval potential, which can lead to decreased arterial blood pressure, syncope, ventricular tachycardia, and even sudden death.

In addition, H1-antihistamines, antifungal agents, diuretics, methadone, and certain cardiac medications can increase the QT intervals, thus creating an even more dangerous situation for people with multisystem medical problems who are being treated with a variety of medications. Macrolide antibiotics also fall within this category, which explains the FDA’s recent warning that azithromycin (Zithromax), also known as Z-Pak, can cause abnormal changes in the heart’s electrical activity that could lead to fatal irregular heart rhythm.

The risk further increases for more people with the wider use of some of the newer second-generation antipsychotics now used as mood stabilizers, antianxiety agents, sleep aids, antiaggression agents, and even for conditions such as attention-deficit/hyperactivity disorder. Adding to these risks is the pervasiveness of polypharmacy today, in which multiple medications with the same chemical action are prescribed to the same patient. Unfortunately, this is seen by psychiatrists who see patients in 15-minute medication management visits ("Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy," New York Times, March 5, 2011), as well as with primary care physicians, who have become an integral part in the treatment of psychiatric disorders.

In this environment, it is even more important than ever that we monitor closely the impact of our treatments on the heart. A review of three placebo-controlled trials by Dr. Raul R. Silva and his colleagues at New York University Langone Medical Center found significant increases in mean heart rate from baseline among children who had been treated with stimulants such as methylphenidate and mixed amphetamine salts. Obtaining a baseline ECG for any patient starting stimulant treatment is reasonable if access for the patient is "readily available and not too costly," they said (Clin. Pediatr. 2010;49:840-51).

SSRIs, the current mainstay medication for depression, are being used for anxiety disorders, including posttraumatic stress disorder, obsessive compulsive disorder, social anxiety, eating disorders, and even pain control. As a result, a larger population is at risk for serious side effects, especially cardiovascular disease, and particularly torsades de pointes. The biggest culprit among SSRIs is citalopram, which explains why the Food and Drug Administration has offered detailed recommendations about the risks of QT prolongation among patients taking that antidepressant.

QT prolongation can develop suddenly and prove life threatening – unlike other complications of past and present psychiatric medications.

Given this increased risk of cardiovascular disease, the best care for patients would be medical/cardiac assessments before they started any psychiatric medications that might lead to prolongation of the QT interval, including ongoing assessments of cardiovascular status as psychiatric medications are continued.

Our role as physicians with expertise in treating mental illness places us in a unique position to read and interpret electrocardiograms and QT intervals for our patients if we are prepared to learn and relearn the skills needed. If cardiologic consultations are not readily available, it would seem that psychiatrists could refer their patients for an ECG, just as we do for routine blood testing, CT scans, or MRIs when appropriate. Unfortunately, we have been reluctant to do so.

In a small study of 64 consultants and trainees in psychiatry asked to complete a questionnaire testing their knowledge, only 62% were able to calculate the heart rate correctly and only 5% calculated the QT intervals correctly using Bazett’s formula, which is still considered to be the most popular correction formula. "We expected that the increased awareness of the cardiotoxicity of psychotropics and interaction between medications would have made psychiatrists more adept at QT interval and ECG abnormality interpretation, but this study indicates that the problem remains," the investigators wrote in the Psychiatrist (2008;32:291-4).

The American Psychiatric Association has issued guidance on prescribing psychotropics and the risks of cardiac sudden death: "An absolute QTc interval of >500 msec or an increase of 60 msec from baseline may be associated with an increased risk of [torsades de pointes] and should prompt reduction or discontinuation of the offending agent." The guidance also encourages use of the lowest effective dose "for any given patient ... to minimize dose-dependent adverse effect risks."

Many of the drugs we prescribe have the ability to prolong our patients’ QT, although we must keep in mind that case reports of torsades de pointes in association with most psychotropics are rare (Dtsch. Arztebl. Int. 2011;41:687-93). Nevertheless, it’s important to understand that the medications used today in treating psychiatric disorders are not without side effects or risks.

As today’s psychiatrists become medication managers, it would seem only reasonable and logical for us to be doing the appropriate medical follow-up with a cardiologist on the medications used or routinely sending our patients for testing with improved knowledge of testing results. In addition, patient education regarding other drug classes capable of producing a similar cardiac effect needs to be integrated into our treatment plans.

Dr. London, a psychiatrist with NYU Langone Medical Center, New York, has no conflicts of interest to disclose. He can be reached at [email protected].

As Hurricane Sandy was predicted to hit the New York/New Jersey area, I was able to make what I believed were more than adequate preparations. I needed to stock up on food, especially the nonperishable foods and water; make sure that I had flashlights and enough batteries; keep a battery radio around; and have a bag of essentials packed – in addition to a place to retreat to if my safety was at stake.

Indeed, I prepared. This was not going to be a hurricane Andrew or Katrina for me. I would weather it with ease as I’ve done in the past. Secure in my New York City apartment, opposite the NYU Langone Medical Center, where I trained and remain on the faculty, I was secure and offered comfort to many of my neighbors as their worries increased with the impending storm.

David Shankbone/Wikimedia Commons/Creative Commons License

I watched and listened to New York City’s mayor, and the New York and New Jersey governors with their warnings and advice on storm preparations and realized I was in good shape. At around 8:30 Monday evening, the night the storm hit, my apartment lights dimmed for a brief moment. Soon after, I noticed a medical center housing complex nearby go dark. Following that, momentarily, the lights dimmed on the NYU Langone Medical and subsequently went out. I waited for the medical center’s generators to kick in as I watched from my window. It never happened.

At 8:50 p.m., my electricity went out. "Worry not," I said to myself. This is New York City, and all the power lines are underground, and there’s a deli or bodega on every corner.

I was comfortable in my darkened apartment when a friend and neighbor explained that when the lights went out, the water stopped – as the basement pumps could not work without electricity. This bothered me a bit, but I realized the power would be on soon. This was New York City.

As the hours passed, I checked the food and water, which remained cold in my refrigerator. I tuned onto an all-talk news station on my battery-operated radio, even though finding the station with one hand and the other hand holding a flashlight proved frustrating. Little did I know how my frustration would grow.

As the evening moved into night, it was reported on the news that the power from ConEdison electric station at the 14th Street was flooded, had an explosion, and that all power was out across Manhattan from 39th Street to the bottom of our crowded island. This affected a large residential and commercial part of the city.

There were no traffic lights; no food stores were open; gasoline stations were not able to pump and, in the building where I live, total darkness surrounded us, as hall and stair well emergency lighting is good for only 2 hours. Adding to this, sirens began to sound around the streets below, and ambulances were lining up in front of the NYU Langone Medical Center. As I watched, my heart sank. The hospital was being evacuated by hospital staff and EMS workers with the help of fire fighters and police officers. At the height of the storm, with the elevators not running, hundreds of patients were being carried down stairways, placed in ambulances, and sent to other hospitals.

This was the legendary NYU Medical Center where I had trained, treated patients, and supervised residents. It is where my sons were born. My father, an eye surgeon died there and recently, my four grandchildren were born there. In addition, this is an institution at which I have lifelong friendships and professional relationships. As I witnessed this evacuation, I began to feel a great loss. During that night, I slept very little and found myself watching from my window as the evacuation continued well into the next day.

On that next day, a sense of frustration and some despair began with electricity still off, no computer, the food in the refrigerator warming, the cell phone and iPad discharged, and the bathroom facilities not working because of a lack of water. This was starting to affect my emotions.

I still had a landline, and both my sons – one of whom had full power – had opened up their homes to me. But I just knew that things would get back to normal soon. This was New York City.

By Wednesday, the best information was it would be days before power would be back on. With no cell phone, computer, iPad, water, food, or electricity, I gave up and asked one of my sons to pick me up and take me to his home. During my multiple story descent in the dark, with a flashlight and a suitcase, I nearly fell – and luckily avoided a major injury.

At my son’s home, the ominous aspects of this storm became painfully clear from the TV reports: I could see people’s despair in light of destroyed homes and businesses. Some people were injured and other dying. I was lucky. Still, I felt a sense of helplessness and alienation from the two previous days and nights. Now after watching the despair that people were experiencing on TV, I felt a sense of despair as well knowing that my professional and personal routines would be changing for days and weeks to come.

I was far from having posttraumatic stress disorder or a PTSD experience, but I began to think of the PTSD patients I’ve treated using nonmedicinal approaches and the psychological toll that Sandy was bound to have on my community. Certainly Sandy, not unlike Katrina, the earthquake in Haiti, and the BP oil spill – to name a few disasters, both natural and manmade – inevitably led to numerous PTSD cases.

My concern, as always, is who will treat these PTSD patients with the most appropriate treatments, such as cognitive-behavioral therapy [CBT], behavior modification [BM], or hypnosis coupled with behavior modification and guided imagery. With so few clinicians using or knowing these techniques, it concerns me that those suffering will be treated with a variety of psychotropics, which only rarely have been successful as studies have shown.

In light of the increasing number of manmade and natural disasters as well as the many other factors that lead to PTSD, such as war experience, incarceration, torture, abuse, and near-death experiences plus the subclinical/subthreshold variations of PTSD that I’ve written about, we need to establish treatment guidelines that work best and are used first once and for all.

Mental health professionals, whether psychiatrists, psychologists, social workers, or psychiatric nurse practitioners, should be expert in the CBT, BM, and hypnotic/guided imagery techniques that have the best outcomes.

Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

As Hurricane Sandy was predicted to hit the New York/New Jersey area, I was able to make what I believed were more than adequate preparations. I needed to stock up on food, especially the nonperishable foods and water; make sure that I had flashlights and enough batteries; keep a battery radio around; and have a bag of essentials packed – in addition to a place to retreat to if my safety was at stake.

Indeed, I prepared. This was not going to be a hurricane Andrew or Katrina for me. I would weather it with ease as I’ve done in the past. Secure in my New York City apartment, opposite the NYU Langone Medical Center, where I trained and remain on the faculty, I was secure and offered comfort to many of my neighbors as their worries increased with the impending storm.

David Shankbone/Wikimedia Commons/Creative Commons License

I watched and listened to New York City’s mayor, and the New York and New Jersey governors with their warnings and advice on storm preparations and realized I was in good shape. At around 8:30 Monday evening, the night the storm hit, my apartment lights dimmed for a brief moment. Soon after, I noticed a medical center housing complex nearby go dark. Following that, momentarily, the lights dimmed on the NYU Langone Medical and subsequently went out. I waited for the medical center’s generators to kick in as I watched from my window. It never happened.

At 8:50 p.m., my electricity went out. "Worry not," I said to myself. This is New York City, and all the power lines are underground, and there’s a deli or bodega on every corner.

I was comfortable in my darkened apartment when a friend and neighbor explained that when the lights went out, the water stopped – as the basement pumps could not work without electricity. This bothered me a bit, but I realized the power would be on soon. This was New York City.

As the hours passed, I checked the food and water, which remained cold in my refrigerator. I tuned onto an all-talk news station on my battery-operated radio, even though finding the station with one hand and the other hand holding a flashlight proved frustrating. Little did I know how my frustration would grow.

As the evening moved into night, it was reported on the news that the power from ConEdison electric station at the 14th Street was flooded, had an explosion, and that all power was out across Manhattan from 39th Street to the bottom of our crowded island. This affected a large residential and commercial part of the city.

There were no traffic lights; no food stores were open; gasoline stations were not able to pump and, in the building where I live, total darkness surrounded us, as hall and stair well emergency lighting is good for only 2 hours. Adding to this, sirens began to sound around the streets below, and ambulances were lining up in front of the NYU Langone Medical Center. As I watched, my heart sank. The hospital was being evacuated by hospital staff and EMS workers with the help of fire fighters and police officers. At the height of the storm, with the elevators not running, hundreds of patients were being carried down stairways, placed in ambulances, and sent to other hospitals.

This was the legendary NYU Medical Center where I had trained, treated patients, and supervised residents. It is where my sons were born. My father, an eye surgeon died there and recently, my four grandchildren were born there. In addition, this is an institution at which I have lifelong friendships and professional relationships. As I witnessed this evacuation, I began to feel a great loss. During that night, I slept very little and found myself watching from my window as the evacuation continued well into the next day.

On that next day, a sense of frustration and some despair began with electricity still off, no computer, the food in the refrigerator warming, the cell phone and iPad discharged, and the bathroom facilities not working because of a lack of water. This was starting to affect my emotions.

I still had a landline, and both my sons – one of whom had full power – had opened up their homes to me. But I just knew that things would get back to normal soon. This was New York City.

By Wednesday, the best information was it would be days before power would be back on. With no cell phone, computer, iPad, water, food, or electricity, I gave up and asked one of my sons to pick me up and take me to his home. During my multiple story descent in the dark, with a flashlight and a suitcase, I nearly fell – and luckily avoided a major injury.

At my son’s home, the ominous aspects of this storm became painfully clear from the TV reports: I could see people’s despair in light of destroyed homes and businesses. Some people were injured and other dying. I was lucky. Still, I felt a sense of helplessness and alienation from the two previous days and nights. Now after watching the despair that people were experiencing on TV, I felt a sense of despair as well knowing that my professional and personal routines would be changing for days and weeks to come.

I was far from having posttraumatic stress disorder or a PTSD experience, but I began to think of the PTSD patients I’ve treated using nonmedicinal approaches and the psychological toll that Sandy was bound to have on my community. Certainly Sandy, not unlike Katrina, the earthquake in Haiti, and the BP oil spill – to name a few disasters, both natural and manmade – inevitably led to numerous PTSD cases.

My concern, as always, is who will treat these PTSD patients with the most appropriate treatments, such as cognitive-behavioral therapy [CBT], behavior modification [BM], or hypnosis coupled with behavior modification and guided imagery. With so few clinicians using or knowing these techniques, it concerns me that those suffering will be treated with a variety of psychotropics, which only rarely have been successful as studies have shown.

In light of the increasing number of manmade and natural disasters as well as the many other factors that lead to PTSD, such as war experience, incarceration, torture, abuse, and near-death experiences plus the subclinical/subthreshold variations of PTSD that I’ve written about, we need to establish treatment guidelines that work best and are used first once and for all.

Mental health professionals, whether psychiatrists, psychologists, social workers, or psychiatric nurse practitioners, should be expert in the CBT, BM, and hypnotic/guided imagery techniques that have the best outcomes.

Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

As Hurricane Sandy was predicted to hit the New York/New Jersey area, I was able to make what I believed were more than adequate preparations. I needed to stock up on food, especially the nonperishable foods and water; make sure that I had flashlights and enough batteries; keep a battery radio around; and have a bag of essentials packed – in addition to a place to retreat to if my safety was at stake.

Indeed, I prepared. This was not going to be a hurricane Andrew or Katrina for me. I would weather it with ease as I’ve done in the past. Secure in my New York City apartment, opposite the NYU Langone Medical Center, where I trained and remain on the faculty, I was secure and offered comfort to many of my neighbors as their worries increased with the impending storm.

David Shankbone/Wikimedia Commons/Creative Commons License

I watched and listened to New York City’s mayor, and the New York and New Jersey governors with their warnings and advice on storm preparations and realized I was in good shape. At around 8:30 Monday evening, the night the storm hit, my apartment lights dimmed for a brief moment. Soon after, I noticed a medical center housing complex nearby go dark. Following that, momentarily, the lights dimmed on the NYU Langone Medical and subsequently went out. I waited for the medical center’s generators to kick in as I watched from my window. It never happened.

At 8:50 p.m., my electricity went out. "Worry not," I said to myself. This is New York City, and all the power lines are underground, and there’s a deli or bodega on every corner.

I was comfortable in my darkened apartment when a friend and neighbor explained that when the lights went out, the water stopped – as the basement pumps could not work without electricity. This bothered me a bit, but I realized the power would be on soon. This was New York City.

As the hours passed, I checked the food and water, which remained cold in my refrigerator. I tuned onto an all-talk news station on my battery-operated radio, even though finding the station with one hand and the other hand holding a flashlight proved frustrating. Little did I know how my frustration would grow.

As the evening moved into night, it was reported on the news that the power from ConEdison electric station at the 14th Street was flooded, had an explosion, and that all power was out across Manhattan from 39th Street to the bottom of our crowded island. This affected a large residential and commercial part of the city.

There were no traffic lights; no food stores were open; gasoline stations were not able to pump and, in the building where I live, total darkness surrounded us, as hall and stair well emergency lighting is good for only 2 hours. Adding to this, sirens began to sound around the streets below, and ambulances were lining up in front of the NYU Langone Medical Center. As I watched, my heart sank. The hospital was being evacuated by hospital staff and EMS workers with the help of fire fighters and police officers. At the height of the storm, with the elevators not running, hundreds of patients were being carried down stairways, placed in ambulances, and sent to other hospitals.

This was the legendary NYU Medical Center where I had trained, treated patients, and supervised residents. It is where my sons were born. My father, an eye surgeon died there and recently, my four grandchildren were born there. In addition, this is an institution at which I have lifelong friendships and professional relationships. As I witnessed this evacuation, I began to feel a great loss. During that night, I slept very little and found myself watching from my window as the evacuation continued well into the next day.

On that next day, a sense of frustration and some despair began with electricity still off, no computer, the food in the refrigerator warming, the cell phone and iPad discharged, and the bathroom facilities not working because of a lack of water. This was starting to affect my emotions.

I still had a landline, and both my sons – one of whom had full power – had opened up their homes to me. But I just knew that things would get back to normal soon. This was New York City.

By Wednesday, the best information was it would be days before power would be back on. With no cell phone, computer, iPad, water, food, or electricity, I gave up and asked one of my sons to pick me up and take me to his home. During my multiple story descent in the dark, with a flashlight and a suitcase, I nearly fell – and luckily avoided a major injury.

At my son’s home, the ominous aspects of this storm became painfully clear from the TV reports: I could see people’s despair in light of destroyed homes and businesses. Some people were injured and other dying. I was lucky. Still, I felt a sense of helplessness and alienation from the two previous days and nights. Now after watching the despair that people were experiencing on TV, I felt a sense of despair as well knowing that my professional and personal routines would be changing for days and weeks to come.

I was far from having posttraumatic stress disorder or a PTSD experience, but I began to think of the PTSD patients I’ve treated using nonmedicinal approaches and the psychological toll that Sandy was bound to have on my community. Certainly Sandy, not unlike Katrina, the earthquake in Haiti, and the BP oil spill – to name a few disasters, both natural and manmade – inevitably led to numerous PTSD cases.

My concern, as always, is who will treat these PTSD patients with the most appropriate treatments, such as cognitive-behavioral therapy [CBT], behavior modification [BM], or hypnosis coupled with behavior modification and guided imagery. With so few clinicians using or knowing these techniques, it concerns me that those suffering will be treated with a variety of psychotropics, which only rarely have been successful as studies have shown.

In light of the increasing number of manmade and natural disasters as well as the many other factors that lead to PTSD, such as war experience, incarceration, torture, abuse, and near-death experiences plus the subclinical/subthreshold variations of PTSD that I’ve written about, we need to establish treatment guidelines that work best and are used first once and for all.

Mental health professionals, whether psychiatrists, psychologists, social workers, or psychiatric nurse practitioners, should be expert in the CBT, BM, and hypnotic/guided imagery techniques that have the best outcomes.

Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

When first I heard about the phenomenon in Le Roy, N.Y., in which several adolescent girls were mysteriously struck by symptoms reminiscent of Tourette’s, I immediately thought: I think I know how to get rid of those symptoms.

According to reports about the case in the New York Times and on NBC’s Today show, the first girl – a high school cheerleader who was a senior – woke up from a nap one day to find that her chin was jutting forward and her face was contracting into spasms. A few weeks later, her best friend and a captain of one of school’s cheerleading squads, also woke from a nap "stuttering and then later twitching, her arms flailing and head jerking," according to the Times. Two weeks later, another senior at the school experienced tics, and "arm swings and hums." The contagion continued until at least 18 girls at the school were struck by these symptoms in some way. At least one boy has been affected, according to reports.

The medical details about these cases are not known because of HIPAA rules. But media reports suggest that medical evaluations were properly done and ruled out many possible physical causes of these movement disorders from infectious to environmental, neurological, medication side effects to poisonings, or even a genetic predisposition.

After the ruling out process, the general expert consensus appears to be that the students experienced conversion disorder. Conversion disorder, which is in the DSM-IV under somatoform disorders, refers to a cluster of symptoms affecting voluntary or sensory functions that cannot be explained by a medical or neurological disorder. A DSM-5 Task Force has proposed renaming the disorder "functional neurological symptom disorder," a proposal about which I am ambivalent.

Conversion Disorder in the Literature

The term conversion disorder originates from the description made by Breuer and Freud of "pseudoneurological symptoms resulting from conversion of an unconscious psychological conflict to somatic representation" (Am. J. Psychiatry 2006;163:1510-7). Historically, words used to describe this phenomenon have included "hysterical" and "psychogenic."

Treatment of conversion disorder is not based on understanding the underlying pathophysiology. Treatment options can include psychotherapy, pharmacotherapy, transcranial magnetic stimulation, and hypnosis. The option that has worked best for patients I’ve treated with this disorder is hypnosis, which has been advocated for this condition since the time of Charcot, Janet, and Freud. A randomized, controlled trial of 45 inpatients aged 18-65 years with conversion disorder of the motor type or somatization disorder with motor conversion symptoms found that hypnosis aimed at symptom reduction brought clinically significant treatment results (Psychother. Psychosom. 2002;71:66-76).

In my work with patients, I would propose two 1.5-hour visits that family members were welcome to attend if the patient wished. After taking a history and explaining that although I may not be able to identify the cause of the movement disorder, I can offer them a treatment plan. Then I would teach them a simple hypnotic induction strategy based on my modifications to the Hypnotic Induction Profile developed by Dr. Herbert Spiegel and Dr. David Spiegel. Teaching this technique in addition to measuring hypnotizability takes no more than a half-hour.

The process also involves the patient being comfortable with the technique so she can use it on her own, once a strategy is taught and integrated into the program.

With a comfort zone being established for the patient using hypnosis, I would teach a strategy that has the patient visualize a large movie screen while in her own hypnotic state. Subsequently, she would be instructed to put a thick line down the center of the screen and focus on the left side only. When these concepts were fixed in place, the next step would be to get her to visualize herself on the screen with the movement or tic problem she was having.

During my experiences using these techniques, the movements or tics would stop or considerably slow down while in the hypnotic state. Reemergence of the movements either slowed or did not reoccur as we moved through the entire process.

Following the projection of the movements on the left side of the screen I would then have the patient focus on the blank right side of this visualized movie screen and allow her to imagine any pleasant scene she wished. During the office visit, I would have her practice this technique numerous times, allowing her to make modifications that made this approach work better for them. The whole idea leads to a self-help, empowerment approach to problem resolution.

I would encourage the patient to practice this approach 10 times a day, whether for a minute at a time or 5 minutes. I like to suggest that this problem does not magically disappear but would slowly resolve with the practice effect. It’s a good approach, which can help to save face, when treating certain psychological problems for which we do not know the cause.

The second visit, usually 2 weeks later, would be a reinforcement of the first visit and offer further discussions of the problem. The approach is clear, and after all the repetitions and suggestions are completed, so is the procedure.

A Case of Symptom Transference

One patient with conversion disorder I treated was a young woman who had moved from the Midwest to continue a business career in New York City. She developed a jerky right shoulder movement shortly after starting a new job that she wanted.

Knowing some of the work I do, her primary care physicians referred her to me purely for treatment of the symptom. After 6 months of dynamic psychotherapy, during which she discussed her separation from family and friends as well as the new job stressor – including a demanding chain of command at work and its symbolic representation to other aspects of her upbringing – she continued to have the movements.

This candidate was a good one for hypnosis but did not relate to the movie screen strategy. After discussing some of the issues that might have been at the root of the movement disorder, I tried a symptom transference approach. While she was in a hypnotic state, I encouraged her to focus on moving the middle finger of her right hand whenever the right shoulder jerked. The aim, as I clearly discussed with her, was to transfer the shoulder movement to the finger. An additional idea was that after she made this transference, she could use the finger movement to displace work stress and anxiety by moving the finger faster during stressful periods and or not at all during nonstressful periods.

It is also fairly true that a newly acquired movement is easier for a person to extinguish than a consolidated one and that, over time, the patient would gain greater control over her right middle finger than the uncontrolled shoulder movements.

The approach worked, and the shoulder movements stopped. As I understood it, she was able to keep the finger movements under good voluntary control.

Time and again the notion of symptom substitution arises. My experience and that of others who use hypnosis in symptom removal is that symptom substitution might occur in a few cases. As a general rule, however, those people who are motivated for the symptoms to be removed are successful and do not seem to show any further problems.

Helping the Patients in Le Roy

The National Institutes of Health is the process of recruiting participants for a prospective study that includes healthy volunteers and people with psychogenic movement disorders or nonepileptic seizures. Participants aged 18 years and older might be eligible for the study, which is being conducted at NIH and at Brown University Rhode Island Hospital in Providence.

The agency extended an invitation to the young people in Le Roy, but only one of those patients has been seen, according to Dr. Mark Hallett, a neurologist who serves as chief of the NIH’s Human Motor Control Section. He is also on the Editorial Advisory Board for Clinical Neurology News, a sister publication.

Nevertheless, Dr. Hallett said in an interview, many of the patients seem to be improving. "This is certainly good, and one of the factors might be the reduction in media interest," he said.

As research continues into the causes of conversion disorder, we psychiatrists must be prepared to help patients get rid of these symptoms. Not every movement disorder deemed psychological in origin can be treated successfully with hypnosis, guided imagery, and behavioral modification. But these approaches are certainly worth a try.

Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

When first I heard about the phenomenon in Le Roy, N.Y., in which several adolescent girls were mysteriously struck by symptoms reminiscent of Tourette’s, I immediately thought: I think I know how to get rid of those symptoms.

According to reports about the case in the New York Times and on NBC’s Today show, the first girl – a high school cheerleader who was a senior – woke up from a nap one day to find that her chin was jutting forward and her face was contracting into spasms. A few weeks later, her best friend and a captain of one of school’s cheerleading squads, also woke from a nap "stuttering and then later twitching, her arms flailing and head jerking," according to the Times. Two weeks later, another senior at the school experienced tics, and "arm swings and hums." The contagion continued until at least 18 girls at the school were struck by these symptoms in some way. At least one boy has been affected, according to reports.

The medical details about these cases are not known because of HIPAA rules. But media reports suggest that medical evaluations were properly done and ruled out many possible physical causes of these movement disorders from infectious to environmental, neurological, medication side effects to poisonings, or even a genetic predisposition.

After the ruling out process, the general expert consensus appears to be that the students experienced conversion disorder. Conversion disorder, which is in the DSM-IV under somatoform disorders, refers to a cluster of symptoms affecting voluntary or sensory functions that cannot be explained by a medical or neurological disorder. A DSM-5 Task Force has proposed renaming the disorder "functional neurological symptom disorder," a proposal about which I am ambivalent.

Conversion Disorder in the Literature

The term conversion disorder originates from the description made by Breuer and Freud of "pseudoneurological symptoms resulting from conversion of an unconscious psychological conflict to somatic representation" (Am. J. Psychiatry 2006;163:1510-7). Historically, words used to describe this phenomenon have included "hysterical" and "psychogenic."

Treatment of conversion disorder is not based on understanding the underlying pathophysiology. Treatment options can include psychotherapy, pharmacotherapy, transcranial magnetic stimulation, and hypnosis. The option that has worked best for patients I’ve treated with this disorder is hypnosis, which has been advocated for this condition since the time of Charcot, Janet, and Freud. A randomized, controlled trial of 45 inpatients aged 18-65 years with conversion disorder of the motor type or somatization disorder with motor conversion symptoms found that hypnosis aimed at symptom reduction brought clinically significant treatment results (Psychother. Psychosom. 2002;71:66-76).

In my work with patients, I would propose two 1.5-hour visits that family members were welcome to attend if the patient wished. After taking a history and explaining that although I may not be able to identify the cause of the movement disorder, I can offer them a treatment plan. Then I would teach them a simple hypnotic induction strategy based on my modifications to the Hypnotic Induction Profile developed by Dr. Herbert Spiegel and Dr. David Spiegel. Teaching this technique in addition to measuring hypnotizability takes no more than a half-hour.

The process also involves the patient being comfortable with the technique so she can use it on her own, once a strategy is taught and integrated into the program.

With a comfort zone being established for the patient using hypnosis, I would teach a strategy that has the patient visualize a large movie screen while in her own hypnotic state. Subsequently, she would be instructed to put a thick line down the center of the screen and focus on the left side only. When these concepts were fixed in place, the next step would be to get her to visualize herself on the screen with the movement or tic problem she was having.

During my experiences using these techniques, the movements or tics would stop or considerably slow down while in the hypnotic state. Reemergence of the movements either slowed or did not reoccur as we moved through the entire process.

Following the projection of the movements on the left side of the screen I would then have the patient focus on the blank right side of this visualized movie screen and allow her to imagine any pleasant scene she wished. During the office visit, I would have her practice this technique numerous times, allowing her to make modifications that made this approach work better for them. The whole idea leads to a self-help, empowerment approach to problem resolution.

I would encourage the patient to practice this approach 10 times a day, whether for a minute at a time or 5 minutes. I like to suggest that this problem does not magically disappear but would slowly resolve with the practice effect. It’s a good approach, which can help to save face, when treating certain psychological problems for which we do not know the cause.

The second visit, usually 2 weeks later, would be a reinforcement of the first visit and offer further discussions of the problem. The approach is clear, and after all the repetitions and suggestions are completed, so is the procedure.

A Case of Symptom Transference

One patient with conversion disorder I treated was a young woman who had moved from the Midwest to continue a business career in New York City. She developed a jerky right shoulder movement shortly after starting a new job that she wanted.

Knowing some of the work I do, her primary care physicians referred her to me purely for treatment of the symptom. After 6 months of dynamic psychotherapy, during which she discussed her separation from family and friends as well as the new job stressor – including a demanding chain of command at work and its symbolic representation to other aspects of her upbringing – she continued to have the movements.

This candidate was a good one for hypnosis but did not relate to the movie screen strategy. After discussing some of the issues that might have been at the root of the movement disorder, I tried a symptom transference approach. While she was in a hypnotic state, I encouraged her to focus on moving the middle finger of her right hand whenever the right shoulder jerked. The aim, as I clearly discussed with her, was to transfer the shoulder movement to the finger. An additional idea was that after she made this transference, she could use the finger movement to displace work stress and anxiety by moving the finger faster during stressful periods and or not at all during nonstressful periods.

It is also fairly true that a newly acquired movement is easier for a person to extinguish than a consolidated one and that, over time, the patient would gain greater control over her right middle finger than the uncontrolled shoulder movements.

The approach worked, and the shoulder movements stopped. As I understood it, she was able to keep the finger movements under good voluntary control.

Time and again the notion of symptom substitution arises. My experience and that of others who use hypnosis in symptom removal is that symptom substitution might occur in a few cases. As a general rule, however, those people who are motivated for the symptoms to be removed are successful and do not seem to show any further problems.

Helping the Patients in Le Roy

The National Institutes of Health is the process of recruiting participants for a prospective study that includes healthy volunteers and people with psychogenic movement disorders or nonepileptic seizures. Participants aged 18 years and older might be eligible for the study, which is being conducted at NIH and at Brown University Rhode Island Hospital in Providence.

The agency extended an invitation to the young people in Le Roy, but only one of those patients has been seen, according to Dr. Mark Hallett, a neurologist who serves as chief of the NIH’s Human Motor Control Section. He is also on the Editorial Advisory Board for Clinical Neurology News, a sister publication.

Nevertheless, Dr. Hallett said in an interview, many of the patients seem to be improving. "This is certainly good, and one of the factors might be the reduction in media interest," he said.

As research continues into the causes of conversion disorder, we psychiatrists must be prepared to help patients get rid of these symptoms. Not every movement disorder deemed psychological in origin can be treated successfully with hypnosis, guided imagery, and behavioral modification. But these approaches are certainly worth a try.

Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

When first I heard about the phenomenon in Le Roy, N.Y., in which several adolescent girls were mysteriously struck by symptoms reminiscent of Tourette’s, I immediately thought: I think I know how to get rid of those symptoms.

According to reports about the case in the New York Times and on NBC’s Today show, the first girl – a high school cheerleader who was a senior – woke up from a nap one day to find that her chin was jutting forward and her face was contracting into spasms. A few weeks later, her best friend and a captain of one of school’s cheerleading squads, also woke from a nap "stuttering and then later twitching, her arms flailing and head jerking," according to the Times. Two weeks later, another senior at the school experienced tics, and "arm swings and hums." The contagion continued until at least 18 girls at the school were struck by these symptoms in some way. At least one boy has been affected, according to reports.

The medical details about these cases are not known because of HIPAA rules. But media reports suggest that medical evaluations were properly done and ruled out many possible physical causes of these movement disorders from infectious to environmental, neurological, medication side effects to poisonings, or even a genetic predisposition.

After the ruling out process, the general expert consensus appears to be that the students experienced conversion disorder. Conversion disorder, which is in the DSM-IV under somatoform disorders, refers to a cluster of symptoms affecting voluntary or sensory functions that cannot be explained by a medical or neurological disorder. A DSM-5 Task Force has proposed renaming the disorder "functional neurological symptom disorder," a proposal about which I am ambivalent.

Conversion Disorder in the Literature

The term conversion disorder originates from the description made by Breuer and Freud of "pseudoneurological symptoms resulting from conversion of an unconscious psychological conflict to somatic representation" (Am. J. Psychiatry 2006;163:1510-7). Historically, words used to describe this phenomenon have included "hysterical" and "psychogenic."

Treatment of conversion disorder is not based on understanding the underlying pathophysiology. Treatment options can include psychotherapy, pharmacotherapy, transcranial magnetic stimulation, and hypnosis. The option that has worked best for patients I’ve treated with this disorder is hypnosis, which has been advocated for this condition since the time of Charcot, Janet, and Freud. A randomized, controlled trial of 45 inpatients aged 18-65 years with conversion disorder of the motor type or somatization disorder with motor conversion symptoms found that hypnosis aimed at symptom reduction brought clinically significant treatment results (Psychother. Psychosom. 2002;71:66-76).

In my work with patients, I would propose two 1.5-hour visits that family members were welcome to attend if the patient wished. After taking a history and explaining that although I may not be able to identify the cause of the movement disorder, I can offer them a treatment plan. Then I would teach them a simple hypnotic induction strategy based on my modifications to the Hypnotic Induction Profile developed by Dr. Herbert Spiegel and Dr. David Spiegel. Teaching this technique in addition to measuring hypnotizability takes no more than a half-hour.

The process also involves the patient being comfortable with the technique so she can use it on her own, once a strategy is taught and integrated into the program.

With a comfort zone being established for the patient using hypnosis, I would teach a strategy that has the patient visualize a large movie screen while in her own hypnotic state. Subsequently, she would be instructed to put a thick line down the center of the screen and focus on the left side only. When these concepts were fixed in place, the next step would be to get her to visualize herself on the screen with the movement or tic problem she was having.

During my experiences using these techniques, the movements or tics would stop or considerably slow down while in the hypnotic state. Reemergence of the movements either slowed or did not reoccur as we moved through the entire process.

Following the projection of the movements on the left side of the screen I would then have the patient focus on the blank right side of this visualized movie screen and allow her to imagine any pleasant scene she wished. During the office visit, I would have her practice this technique numerous times, allowing her to make modifications that made this approach work better for them. The whole idea leads to a self-help, empowerment approach to problem resolution.

I would encourage the patient to practice this approach 10 times a day, whether for a minute at a time or 5 minutes. I like to suggest that this problem does not magically disappear but would slowly resolve with the practice effect. It’s a good approach, which can help to save face, when treating certain psychological problems for which we do not know the cause.

The second visit, usually 2 weeks later, would be a reinforcement of the first visit and offer further discussions of the problem. The approach is clear, and after all the repetitions and suggestions are completed, so is the procedure.

A Case of Symptom Transference

One patient with conversion disorder I treated was a young woman who had moved from the Midwest to continue a business career in New York City. She developed a jerky right shoulder movement shortly after starting a new job that she wanted.

Knowing some of the work I do, her primary care physicians referred her to me purely for treatment of the symptom. After 6 months of dynamic psychotherapy, during which she discussed her separation from family and friends as well as the new job stressor – including a demanding chain of command at work and its symbolic representation to other aspects of her upbringing – she continued to have the movements.

This candidate was a good one for hypnosis but did not relate to the movie screen strategy. After discussing some of the issues that might have been at the root of the movement disorder, I tried a symptom transference approach. While she was in a hypnotic state, I encouraged her to focus on moving the middle finger of her right hand whenever the right shoulder jerked. The aim, as I clearly discussed with her, was to transfer the shoulder movement to the finger. An additional idea was that after she made this transference, she could use the finger movement to displace work stress and anxiety by moving the finger faster during stressful periods and or not at all during nonstressful periods.

It is also fairly true that a newly acquired movement is easier for a person to extinguish than a consolidated one and that, over time, the patient would gain greater control over her right middle finger than the uncontrolled shoulder movements.

The approach worked, and the shoulder movements stopped. As I understood it, she was able to keep the finger movements under good voluntary control.

Time and again the notion of symptom substitution arises. My experience and that of others who use hypnosis in symptom removal is that symptom substitution might occur in a few cases. As a general rule, however, those people who are motivated for the symptoms to be removed are successful and do not seem to show any further problems.

Helping the Patients in Le Roy

The National Institutes of Health is the process of recruiting participants for a prospective study that includes healthy volunteers and people with psychogenic movement disorders or nonepileptic seizures. Participants aged 18 years and older might be eligible for the study, which is being conducted at NIH and at Brown University Rhode Island Hospital in Providence.

The agency extended an invitation to the young people in Le Roy, but only one of those patients has been seen, according to Dr. Mark Hallett, a neurologist who serves as chief of the NIH’s Human Motor Control Section. He is also on the Editorial Advisory Board for Clinical Neurology News, a sister publication.

Nevertheless, Dr. Hallett said in an interview, many of the patients seem to be improving. "This is certainly good, and one of the factors might be the reduction in media interest," he said.

As research continues into the causes of conversion disorder, we psychiatrists must be prepared to help patients get rid of these symptoms. Not every movement disorder deemed psychological in origin can be treated successfully with hypnosis, guided imagery, and behavioral modification. But these approaches are certainly worth a try.

Dr. London is a psychiatrist with the New York University Langone Medical Center. He has no conflicts of interest to disclose.

When I hear or read stories about posttraumatic stress disorder, two key questions come to mind: Who is doing the treatment, and do they know how to treat this disorder?

As to the first question, it seems that "counseling" is the operative word for sufferers of PTSD. We hear and read over and over that a person suffering from PTSD is referred to a counselor, sometimes a therapist, for care.

Second, do the people doing the counseling or psychotherapy know the specific treatments for PTSD that have demonstrated the most success? I’ve spoken with numerous therapists from different disciplines, and it is clear that traditional, open-ended psychotherapy (plus medication management in the case of psychiatrists) continues to dominate treatment approaches for PTSD. This is the case even though a variety of exposure, relaxation, and behavioral techniques has shown better results, according to an overview of PTSD treatment research by the Department of Veterans Affairs’ National Center for PTSD. In fact, the VA is way ahead of more traditional clinical settings in using specialized treatments for PTSD with proven track records. For example, researchers at the agency are in the process of developing initiatives to train mental health staff in the delivery of cognitive-processing therapy and prolonged exposure therapy, two treatments for PTSD that produce positive results (J. Trauma Stress 2010;23:663-73).

First Sounds of PTSD

I remember as a teenager, while in my father’s surgical office, picking up the phone and hearing on the other end what would turn out to be my first exposure to a person with PTSD, as I look back. The patient on the line, Jim, was calling in a panic and telling me – before he knew who I was – about seeing things in his head that reminded him of things that had happened on the battlefield during World War II.

My father, an eye surgeon, was in the middle of a procedure and could not come to the phone. So I continued to listen to Jim and told him that it would be alright, not knowing what else to do. Jim had been my father’s patient for several years before my dad had become an ophthalmologist, and had continued in his care after an eye injury subsequent to a traumatic event years earlier while he was in the military during the war.

After Jim recounted his story to me, my father took the phone and appeared to calm him. Later, my father explained the entire story, and how Jim had an "anxiety neurosis" and "soldier’s heart" with vivid memories (flashbacks) of a combat experience in the war where he was injured. He once saw a psychiatrist, according to my father, and was given a sedative. But it didn’t help, and Jim did not follow up with the three- or four-times-a-week explorative talk therapy, which was the main type of outpatient care at the time.

My father was clear, as he understood psychotherapy at the time, that getting Jim to lie on a couch and relive his childhood would not stop the memories (flashbacks). Rather, Jim needed some type of "here and now" reassurance that things would be okay. My dad did tell me that "one day we’ll have a medication to treat these anxiety-ridden neurotic people." To a large extent, we do have medications that work for many depressions and anxiety disorders – but not always for PTSD.

A Long History

The history of war-related trauma in this country began to be documented around the time of Civil War. Jacob Mendes Da Costa, an internist who served as an assistant surgeon in the U.S. Army during that war, first recognized a set of anxieties centering around heart symptoms. But no cardiac illness was discovered. Over the years and well into the 20th century, many names – including Da Costa’s syndrome as well as combat neurosis, shell shock, soldier’s heart, neurocirculatory asthenia, and/or simply anxiety neurosis, as my father called it – have been applied to this syndrome.

PTSD can result from severe war-related traumas as well as from traumatic experiences caused by natural and manmade disasters, assaults, and a variety of life-threatening experiences that appear to adversely affect emotional functioning. By 1980, when the DSM-III was first published, PTSD finally had been recognized as a mental disorder and was so named. Today, we know that it is important to recognize the existence of subclinical and subthreshold PTSD, which I discussed over the years as author of "The Psychiatrist’s Toolbox" column (Clinical Psychiatry News, May 2009, p. 23). These more ambiguous cases also need to be treated in an organized and codified behavior and cognitive manner (Clinical Psychiatry News, December 2004, p. 20).

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.

When I hear or read stories about posttraumatic stress disorder, two key questions come to mind: Who is doing the treatment, and do they know how to treat this disorder?

As to the first question, it seems that "counseling" is the operative word for sufferers of PTSD. We hear and read over and over that a person suffering from PTSD is referred to a counselor, sometimes a therapist, for care.

Second, do the people doing the counseling or psychotherapy know the specific treatments for PTSD that have demonstrated the most success? I’ve spoken with numerous therapists from different disciplines, and it is clear that traditional, open-ended psychotherapy (plus medication management in the case of psychiatrists) continues to dominate treatment approaches for PTSD. This is the case even though a variety of exposure, relaxation, and behavioral techniques has shown better results, according to an overview of PTSD treatment research by the Department of Veterans Affairs’ National Center for PTSD. In fact, the VA is way ahead of more traditional clinical settings in using specialized treatments for PTSD with proven track records. For example, researchers at the agency are in the process of developing initiatives to train mental health staff in the delivery of cognitive-processing therapy and prolonged exposure therapy, two treatments for PTSD that produce positive results (J. Trauma Stress 2010;23:663-73).

First Sounds of PTSD

I remember as a teenager, while in my father’s surgical office, picking up the phone and hearing on the other end what would turn out to be my first exposure to a person with PTSD, as I look back. The patient on the line, Jim, was calling in a panic and telling me – before he knew who I was – about seeing things in his head that reminded him of things that had happened on the battlefield during World War II.

My father, an eye surgeon, was in the middle of a procedure and could not come to the phone. So I continued to listen to Jim and told him that it would be alright, not knowing what else to do. Jim had been my father’s patient for several years before my dad had become an ophthalmologist, and had continued in his care after an eye injury subsequent to a traumatic event years earlier while he was in the military during the war.

After Jim recounted his story to me, my father took the phone and appeared to calm him. Later, my father explained the entire story, and how Jim had an "anxiety neurosis" and "soldier’s heart" with vivid memories (flashbacks) of a combat experience in the war where he was injured. He once saw a psychiatrist, according to my father, and was given a sedative. But it didn’t help, and Jim did not follow up with the three- or four-times-a-week explorative talk therapy, which was the main type of outpatient care at the time.

My father was clear, as he understood psychotherapy at the time, that getting Jim to lie on a couch and relive his childhood would not stop the memories (flashbacks). Rather, Jim needed some type of "here and now" reassurance that things would be okay. My dad did tell me that "one day we’ll have a medication to treat these anxiety-ridden neurotic people." To a large extent, we do have medications that work for many depressions and anxiety disorders – but not always for PTSD.

A Long History

The history of war-related trauma in this country began to be documented around the time of Civil War. Jacob Mendes Da Costa, an internist who served as an assistant surgeon in the U.S. Army during that war, first recognized a set of anxieties centering around heart symptoms. But no cardiac illness was discovered. Over the years and well into the 20th century, many names – including Da Costa’s syndrome as well as combat neurosis, shell shock, soldier’s heart, neurocirculatory asthenia, and/or simply anxiety neurosis, as my father called it – have been applied to this syndrome.

PTSD can result from severe war-related traumas as well as from traumatic experiences caused by natural and manmade disasters, assaults, and a variety of life-threatening experiences that appear to adversely affect emotional functioning. By 1980, when the DSM-III was first published, PTSD finally had been recognized as a mental disorder and was so named. Today, we know that it is important to recognize the existence of subclinical and subthreshold PTSD, which I discussed over the years as author of "The Psychiatrist’s Toolbox" column (Clinical Psychiatry News, May 2009, p. 23). These more ambiguous cases also need to be treated in an organized and codified behavior and cognitive manner (Clinical Psychiatry News, December 2004, p. 20).

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.

When I hear or read stories about posttraumatic stress disorder, two key questions come to mind: Who is doing the treatment, and do they know how to treat this disorder?

As to the first question, it seems that "counseling" is the operative word for sufferers of PTSD. We hear and read over and over that a person suffering from PTSD is referred to a counselor, sometimes a therapist, for care.

Second, do the people doing the counseling or psychotherapy know the specific treatments for PTSD that have demonstrated the most success? I’ve spoken with numerous therapists from different disciplines, and it is clear that traditional, open-ended psychotherapy (plus medication management in the case of psychiatrists) continues to dominate treatment approaches for PTSD. This is the case even though a variety of exposure, relaxation, and behavioral techniques has shown better results, according to an overview of PTSD treatment research by the Department of Veterans Affairs’ National Center for PTSD. In fact, the VA is way ahead of more traditional clinical settings in using specialized treatments for PTSD with proven track records. For example, researchers at the agency are in the process of developing initiatives to train mental health staff in the delivery of cognitive-processing therapy and prolonged exposure therapy, two treatments for PTSD that produce positive results (J. Trauma Stress 2010;23:663-73).

First Sounds of PTSD

I remember as a teenager, while in my father’s surgical office, picking up the phone and hearing on the other end what would turn out to be my first exposure to a person with PTSD, as I look back. The patient on the line, Jim, was calling in a panic and telling me – before he knew who I was – about seeing things in his head that reminded him of things that had happened on the battlefield during World War II.

My father, an eye surgeon, was in the middle of a procedure and could not come to the phone. So I continued to listen to Jim and told him that it would be alright, not knowing what else to do. Jim had been my father’s patient for several years before my dad had become an ophthalmologist, and had continued in his care after an eye injury subsequent to a traumatic event years earlier while he was in the military during the war.

After Jim recounted his story to me, my father took the phone and appeared to calm him. Later, my father explained the entire story, and how Jim had an "anxiety neurosis" and "soldier’s heart" with vivid memories (flashbacks) of a combat experience in the war where he was injured. He once saw a psychiatrist, according to my father, and was given a sedative. But it didn’t help, and Jim did not follow up with the three- or four-times-a-week explorative talk therapy, which was the main type of outpatient care at the time.

My father was clear, as he understood psychotherapy at the time, that getting Jim to lie on a couch and relive his childhood would not stop the memories (flashbacks). Rather, Jim needed some type of "here and now" reassurance that things would be okay. My dad did tell me that "one day we’ll have a medication to treat these anxiety-ridden neurotic people." To a large extent, we do have medications that work for many depressions and anxiety disorders – but not always for PTSD.

A Long History

The history of war-related trauma in this country began to be documented around the time of Civil War. Jacob Mendes Da Costa, an internist who served as an assistant surgeon in the U.S. Army during that war, first recognized a set of anxieties centering around heart symptoms. But no cardiac illness was discovered. Over the years and well into the 20th century, many names – including Da Costa’s syndrome as well as combat neurosis, shell shock, soldier’s heart, neurocirculatory asthenia, and/or simply anxiety neurosis, as my father called it – have been applied to this syndrome.

PTSD can result from severe war-related traumas as well as from traumatic experiences caused by natural and manmade disasters, assaults, and a variety of life-threatening experiences that appear to adversely affect emotional functioning. By 1980, when the DSM-III was first published, PTSD finally had been recognized as a mental disorder and was so named. Today, we know that it is important to recognize the existence of subclinical and subthreshold PTSD, which I discussed over the years as author of "The Psychiatrist’s Toolbox" column (Clinical Psychiatry News, May 2009, p. 23). These more ambiguous cases also need to be treated in an organized and codified behavior and cognitive manner (Clinical Psychiatry News, December 2004, p. 20).

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.

People need a mental break from the anxieties and stresses inherent in daily living. In light of this, I would like to see businesses incorporate two or three "mental health days" a year into their benefits packages in addition to the usual sick days. Taking such a step would finally put us on the way toward establishing at least intellectual parity for mental health problems. This, in turn, would lessen the stigma associated with emotional disorders.

Americans are clearly suffering. According to the National Comorbidity Survey Replication, about 26% of American adults aged 18 and older suffer from a diagnosable mental disorder in any given year.

Not only is feeling "down" or "anxious" cause for a mental health break. But often, emotional problems are a result of physical pain from problems such as headache and backache. That also is the case when it comes to gastrointestinal, cardiac, and skin problems. In medicine, we know that the sympathetic and parasympathetic innervations control GI disorders; cardiovascular problems; and skin disorders.

Over and over, we psychiatrists, psychologists and other mental health professionals hear people say "I can’t take another day of work," or "I’ll go crazy if I have to return to work tomorrow." The list of remarks illustrating the sense of dread that many people feel about their workplaces could go on and on. People certainly don’t want to quit their jobs – especially in these uncertain economic times. But some people do opt to use sick days when they need a break from the stress. Why not formalize such an action? After all, the ability to take a sick day because of extreme anxiety or stress is just as important as being able to do so because of a severe upper respiratory infection.

Speaking of physical ailments, I was pleased to see Dr. Amin A. Gadit’s commentary about the World Health Organization’s focus on the need for psychiatrists and primary care physicians to work together in its World Mental Health Day observance this year ("A Call for More Collaboration," Clinical Psychiatry News, October 2010, p. 8). The WHO estimates that 450 million people worldwide suffer mental health problems either directly or through physical illness that lead to mental disorders or mental disorders that lead to physical illnesses. Again, according to a WHO Health and Work Performance Questionnaire that assesses sick days, depression was cited as the No. 1 reason for absenteeism. According to the February 2010 issue of the Harvard Mental Health Letter, the top five reasons for absenteeism included depression, anxiety as well as back and neck pain. And because of the huge demands on the time of most nonpsychiatric physicians, coupled with the lack of depth they often bring to treating psychiatric illnesses, the mental health needs of patients they see often go unmet.

Perhaps our health care system would do a better job of meeting those needs if primary care physicians referred to us and our colleagues in mental health more often. Just as primary care physicians routinely recommend certain labs, EKGs, radiographic studies, or stress tests, they must make it routine to refer whenever they recognize an anxiety- or stress-related problem – including depression. One person I spoke with recently who is a chronic migraineur and subsequently misses days of work, told me that her primary care physician prescribes two medications for the migraines. In addition, he encourages the patient to eliminate the cause of her stress. And there it stops.

Therefore, I would propose an alternative system for handling the many mental health problems that the primary care physicians advise and treat. That would be a system in which mental health referrals would be routine – or even standard of care – for a suspected psychological problem or when psychotropic medications are prescribed. This approach would improve the quality of care for mental health problems.

Moving forward, one approach toward our larger goal might be to have primary care physicians hold a mental health day once a week or perhaps biweekly in their offices or clinics. On those days, patients with mental health problems could see a mental health expert – a psychiatrist, psychologist, psychiatric nurse practitioner, or mental health social worker. The point would be to have the mental health problem, whether one of the anxiety disorders, stress-related issues, depression, or the myriad of psychiatric disorders that are first seen by primary care physicians addressed by those experts trained to do this kind of intervention and care, as part of the general health care routine. In these sessions, a strategy would be put into place – whether short-term interventions, a cognitive-behavioral program, or a more dynamic approach.

Psychiatric and psychological associations need to be more in the forefront of these kinds of changes. To date, we see more awareness about mental health problems from big pharma (not that there’s anything wrong with that) for commercial reasons than from mental health organizations. This needs to change.

Imagine an employee requesting a mental health day as a matter of course. As acceptability grew, we would become a nation that not only is more aware of mental disorders in and out of the workplace, but we also would begin to put the embarrassment and shame that so many people feel about mental health care, or as some say "going to the shrink," to rest. This would lead to looking at emotional problems in the same light as physical problems, be they big or little.

Dr. London, a psychiatrist with the New York University Langone Medical Center, has no disclosures. He can be reached at [email protected].

People need a mental break from the anxieties and stresses inherent in daily living. In light of this, I would like to see businesses incorporate two or three "mental health days" a year into their benefits packages in addition to the usual sick days. Taking such a step would finally put us on the way toward establishing at least intellectual parity for mental health problems. This, in turn, would lessen the stigma associated with emotional disorders.

Americans are clearly suffering. According to the National Comorbidity Survey Replication, about 26% of American adults aged 18 and older suffer from a diagnosable mental disorder in any given year.

Not only is feeling "down" or "anxious" cause for a mental health break. But often, emotional problems are a result of physical pain from problems such as headache and backache. That also is the case when it comes to gastrointestinal, cardiac, and skin problems. In medicine, we know that the sympathetic and parasympathetic innervations control GI disorders; cardiovascular problems; and skin disorders.

Over and over, we psychiatrists, psychologists and other mental health professionals hear people say "I can’t take another day of work," or "I’ll go crazy if I have to return to work tomorrow." The list of remarks illustrating the sense of dread that many people feel about their workplaces could go on and on. People certainly don’t want to quit their jobs – especially in these uncertain economic times. But some people do opt to use sick days when they need a break from the stress. Why not formalize such an action? After all, the ability to take a sick day because of extreme anxiety or stress is just as important as being able to do so because of a severe upper respiratory infection.

Speaking of physical ailments, I was pleased to see Dr. Amin A. Gadit’s commentary about the World Health Organization’s focus on the need for psychiatrists and primary care physicians to work together in its World Mental Health Day observance this year ("A Call for More Collaboration," Clinical Psychiatry News, October 2010, p. 8). The WHO estimates that 450 million people worldwide suffer mental health problems either directly or through physical illness that lead to mental disorders or mental disorders that lead to physical illnesses. Again, according to a WHO Health and Work Performance Questionnaire that assesses sick days, depression was cited as the No. 1 reason for absenteeism. According to the February 2010 issue of the Harvard Mental Health Letter, the top five reasons for absenteeism included depression, anxiety as well as back and neck pain. And because of the huge demands on the time of most nonpsychiatric physicians, coupled with the lack of depth they often bring to treating psychiatric illnesses, the mental health needs of patients they see often go unmet.

Perhaps our health care system would do a better job of meeting those needs if primary care physicians referred to us and our colleagues in mental health more often. Just as primary care physicians routinely recommend certain labs, EKGs, radiographic studies, or stress tests, they must make it routine to refer whenever they recognize an anxiety- or stress-related problem – including depression. One person I spoke with recently who is a chronic migraineur and subsequently misses days of work, told me that her primary care physician prescribes two medications for the migraines. In addition, he encourages the patient to eliminate the cause of her stress. And there it stops.

Therefore, I would propose an alternative system for handling the many mental health problems that the primary care physicians advise and treat. That would be a system in which mental health referrals would be routine – or even standard of care – for a suspected psychological problem or when psychotropic medications are prescribed. This approach would improve the quality of care for mental health problems.

Moving forward, one approach toward our larger goal might be to have primary care physicians hold a mental health day once a week or perhaps biweekly in their offices or clinics. On those days, patients with mental health problems could see a mental health expert – a psychiatrist, psychologist, psychiatric nurse practitioner, or mental health social worker. The point would be to have the mental health problem, whether one of the anxiety disorders, stress-related issues, depression, or the myriad of psychiatric disorders that are first seen by primary care physicians addressed by those experts trained to do this kind of intervention and care, as part of the general health care routine. In these sessions, a strategy would be put into place – whether short-term interventions, a cognitive-behavioral program, or a more dynamic approach.

Psychiatric and psychological associations need to be more in the forefront of these kinds of changes. To date, we see more awareness about mental health problems from big pharma (not that there’s anything wrong with that) for commercial reasons than from mental health organizations. This needs to change.

Imagine an employee requesting a mental health day as a matter of course. As acceptability grew, we would become a nation that not only is more aware of mental disorders in and out of the workplace, but we also would begin to put the embarrassment and shame that so many people feel about mental health care, or as some say "going to the shrink," to rest. This would lead to looking at emotional problems in the same light as physical problems, be they big or little.

Dr. London, a psychiatrist with the New York University Langone Medical Center, has no disclosures. He can be reached at [email protected].

People need a mental break from the anxieties and stresses inherent in daily living. In light of this, I would like to see businesses incorporate two or three "mental health days" a year into their benefits packages in addition to the usual sick days. Taking such a step would finally put us on the way toward establishing at least intellectual parity for mental health problems. This, in turn, would lessen the stigma associated with emotional disorders.

Americans are clearly suffering. According to the National Comorbidity Survey Replication, about 26% of American adults aged 18 and older suffer from a diagnosable mental disorder in any given year.

Not only is feeling "down" or "anxious" cause for a mental health break. But often, emotional problems are a result of physical pain from problems such as headache and backache. That also is the case when it comes to gastrointestinal, cardiac, and skin problems. In medicine, we know that the sympathetic and parasympathetic innervations control GI disorders; cardiovascular problems; and skin disorders.

Over and over, we psychiatrists, psychologists and other mental health professionals hear people say "I can’t take another day of work," or "I’ll go crazy if I have to return to work tomorrow." The list of remarks illustrating the sense of dread that many people feel about their workplaces could go on and on. People certainly don’t want to quit their jobs – especially in these uncertain economic times. But some people do opt to use sick days when they need a break from the stress. Why not formalize such an action? After all, the ability to take a sick day because of extreme anxiety or stress is just as important as being able to do so because of a severe upper respiratory infection.

Speaking of physical ailments, I was pleased to see Dr. Amin A. Gadit’s commentary about the World Health Organization’s focus on the need for psychiatrists and primary care physicians to work together in its World Mental Health Day observance this year ("A Call for More Collaboration," Clinical Psychiatry News, October 2010, p. 8). The WHO estimates that 450 million people worldwide suffer mental health problems either directly or through physical illness that lead to mental disorders or mental disorders that lead to physical illnesses. Again, according to a WHO Health and Work Performance Questionnaire that assesses sick days, depression was cited as the No. 1 reason for absenteeism. According to the February 2010 issue of the Harvard Mental Health Letter, the top five reasons for absenteeism included depression, anxiety as well as back and neck pain. And because of the huge demands on the time of most nonpsychiatric physicians, coupled with the lack of depth they often bring to treating psychiatric illnesses, the mental health needs of patients they see often go unmet.

Perhaps our health care system would do a better job of meeting those needs if primary care physicians referred to us and our colleagues in mental health more often. Just as primary care physicians routinely recommend certain labs, EKGs, radiographic studies, or stress tests, they must make it routine to refer whenever they recognize an anxiety- or stress-related problem – including depression. One person I spoke with recently who is a chronic migraineur and subsequently misses days of work, told me that her primary care physician prescribes two medications for the migraines. In addition, he encourages the patient to eliminate the cause of her stress. And there it stops.

Therefore, I would propose an alternative system for handling the many mental health problems that the primary care physicians advise and treat. That would be a system in which mental health referrals would be routine – or even standard of care – for a suspected psychological problem or when psychotropic medications are prescribed. This approach would improve the quality of care for mental health problems.

Moving forward, one approach toward our larger goal might be to have primary care physicians hold a mental health day once a week or perhaps biweekly in their offices or clinics. On those days, patients with mental health problems could see a mental health expert – a psychiatrist, psychologist, psychiatric nurse practitioner, or mental health social worker. The point would be to have the mental health problem, whether one of the anxiety disorders, stress-related issues, depression, or the myriad of psychiatric disorders that are first seen by primary care physicians addressed by those experts trained to do this kind of intervention and care, as part of the general health care routine. In these sessions, a strategy would be put into place – whether short-term interventions, a cognitive-behavioral program, or a more dynamic approach.

Psychiatric and psychological associations need to be more in the forefront of these kinds of changes. To date, we see more awareness about mental health problems from big pharma (not that there’s anything wrong with that) for commercial reasons than from mental health organizations. This needs to change.

Imagine an employee requesting a mental health day as a matter of course. As acceptability grew, we would become a nation that not only is more aware of mental disorders in and out of the workplace, but we also would begin to put the embarrassment and shame that so many people feel about mental health care, or as some say "going to the shrink," to rest. This would lead to looking at emotional problems in the same light as physical problems, be they big or little.

Dr. London, a psychiatrist with the New York University Langone Medical Center, has no disclosures. He can be reached at [email protected].