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VA, Kaiser lauded for hypertension control
At a time when the Department of Veterans Affairs is criticized for the care it delivers, and when some also see it threatened by privatization, it was refreshing to hear the VA praised for the quality of its hypertension care, a model for success in a new era of reduced blood pressure treatment targets and revised hypertension guidelines that classify millions more Americans as having hypertension.
“In systems of care, like the VA and Kaiser Permanente Northern California, we are doing much better with hypertension control, reaching control rates greater than 90%,” Paul Whelton, MD, said in November during a talk at the American Heart Association scientific sessions in Anaheim, Calif. In a separate report at the same meeting, Dr. Whelton, a professor of public health at Tulane University in New Orleans, first presented the new hypertension diagnosis and management guidelines, produced by the American College of Cardiology/American Heart Association panel that he chaired (J Am Coll Cardiol. 2017 Nov 13. doi: 10.1016/j.jacc.2017.11.006).
He again stressed that the VA and Kaiser are doing “remarkably well” when it came to controlling hypertension in the vast majority of their patients.
That assessment seems especially appropriate for Kaiser Permanente Northern California, Oakland, Calif. Data from an audit of Kaiser’s hypertension registry showed that during 2000-2013 the percentage of patients with hypertension at their goal blood pressure rose from 44% in 2000 to 90% in 2013 (J Clin Hypertension. 2016 April;18[4]:260-1). The two Kaiser researchers who reported these findings attributed the rise in control rates to a hypertension treatment program that Kaiser Permanente Northern California put into practice starting in 2000.
Current success in the VA Health System is harder to pin down and put in the Kaiser ballpark. The most up-to-date audit I could find was a 2012 report from a team of VA researchers who reviewed control rates of more than half a million hypertensive veterans at 15 VA medical centers during 2000-2010. They found that, during that 11-year period, the percentage of hypertensive patients with their blood pressure controlled to their target level had risen from 46% in 2000 to 76% in 2010 (Circulation. 2012 May 22;125[20]:2462-68).
While this 76% rate of control in 2010 is short of the 90% rate in Kaiser in 2013, it’s still not shabby. To put the 76% control rate in perspective, consider data reported at the AHA meeting from TargetBP, a national program begun in late 2015 to aid all U.S. health care programs in improving their hypertension control rates: This data showed that, among 310 participating programs that filed 2016 control-rate data with TargetBP, the average control rate was 66%. Specifically, of those 310 reporting programs, 191 (62%) had control rates that exceeded 70%, with an average control rate among these more successful programs of 76%.
As-yet-unpublished data collected by the VA show that other centers in the system beyond those 15 included in the study discussed above have also recently reached a similar control level of about 75%, said Vasilios Papademetriou, MD, a professor of medicine at Georgetown University and the director of the Interventional Hypertension and Vascular Medicine Program at the VA Medical Center in Washington. Plus, certain VA centers are now up to an 85% control rate, he added in an interview. “Blood pressure control rates have been exceptionally good in the VA medical system,” he declared. Dr. Papademetriou attributed the rising control rates to a concerted hypertension program the VA instituted starting in the early 2000s.
“The VA has had some physicians who have championed this issue, and they have built computer-based systems to identify patients with uncontrolled hypertension, and then they plug these patients into their care algorithms,” commented Donald M. Lloyd-Jones, MD, a professor and chairman of preventive medicine at Northwestern University in Chicago. “Often, when there are champions, things change,” he noted.
William C. Cushman, MD, a hypertension specialist who is chief of preventive medicine for the VA Medical Center in Memphis and professor of preventive medicine at the University of Tennessee, also in Memphis, highlighted several steps the VA took that have helped fuel the program’s success in controlling blood pressure.
Dr. Cushman couldn’t resist adding that this successful approach to hypertension management is now threatened by potential changes to the VA system that could take some patients out of the existing program and move them to privatized medical care. “If that happens, patients will not get the same comprehensive care” that until now has produced such high rates of hypertension control, he warned.
[email protected]
On Twitter @mitchelzoler
At a time when the Department of Veterans Affairs is criticized for the care it delivers, and when some also see it threatened by privatization, it was refreshing to hear the VA praised for the quality of its hypertension care, a model for success in a new era of reduced blood pressure treatment targets and revised hypertension guidelines that classify millions more Americans as having hypertension.
“In systems of care, like the VA and Kaiser Permanente Northern California, we are doing much better with hypertension control, reaching control rates greater than 90%,” Paul Whelton, MD, said in November during a talk at the American Heart Association scientific sessions in Anaheim, Calif. In a separate report at the same meeting, Dr. Whelton, a professor of public health at Tulane University in New Orleans, first presented the new hypertension diagnosis and management guidelines, produced by the American College of Cardiology/American Heart Association panel that he chaired (J Am Coll Cardiol. 2017 Nov 13. doi: 10.1016/j.jacc.2017.11.006).
He again stressed that the VA and Kaiser are doing “remarkably well” when it came to controlling hypertension in the vast majority of their patients.
That assessment seems especially appropriate for Kaiser Permanente Northern California, Oakland, Calif. Data from an audit of Kaiser’s hypertension registry showed that during 2000-2013 the percentage of patients with hypertension at their goal blood pressure rose from 44% in 2000 to 90% in 2013 (J Clin Hypertension. 2016 April;18[4]:260-1). The two Kaiser researchers who reported these findings attributed the rise in control rates to a hypertension treatment program that Kaiser Permanente Northern California put into practice starting in 2000.
Current success in the VA Health System is harder to pin down and put in the Kaiser ballpark. The most up-to-date audit I could find was a 2012 report from a team of VA researchers who reviewed control rates of more than half a million hypertensive veterans at 15 VA medical centers during 2000-2010. They found that, during that 11-year period, the percentage of hypertensive patients with their blood pressure controlled to their target level had risen from 46% in 2000 to 76% in 2010 (Circulation. 2012 May 22;125[20]:2462-68).
While this 76% rate of control in 2010 is short of the 90% rate in Kaiser in 2013, it’s still not shabby. To put the 76% control rate in perspective, consider data reported at the AHA meeting from TargetBP, a national program begun in late 2015 to aid all U.S. health care programs in improving their hypertension control rates: This data showed that, among 310 participating programs that filed 2016 control-rate data with TargetBP, the average control rate was 66%. Specifically, of those 310 reporting programs, 191 (62%) had control rates that exceeded 70%, with an average control rate among these more successful programs of 76%.
As-yet-unpublished data collected by the VA show that other centers in the system beyond those 15 included in the study discussed above have also recently reached a similar control level of about 75%, said Vasilios Papademetriou, MD, a professor of medicine at Georgetown University and the director of the Interventional Hypertension and Vascular Medicine Program at the VA Medical Center in Washington. Plus, certain VA centers are now up to an 85% control rate, he added in an interview. “Blood pressure control rates have been exceptionally good in the VA medical system,” he declared. Dr. Papademetriou attributed the rising control rates to a concerted hypertension program the VA instituted starting in the early 2000s.
“The VA has had some physicians who have championed this issue, and they have built computer-based systems to identify patients with uncontrolled hypertension, and then they plug these patients into their care algorithms,” commented Donald M. Lloyd-Jones, MD, a professor and chairman of preventive medicine at Northwestern University in Chicago. “Often, when there are champions, things change,” he noted.
William C. Cushman, MD, a hypertension specialist who is chief of preventive medicine for the VA Medical Center in Memphis and professor of preventive medicine at the University of Tennessee, also in Memphis, highlighted several steps the VA took that have helped fuel the program’s success in controlling blood pressure.
Dr. Cushman couldn’t resist adding that this successful approach to hypertension management is now threatened by potential changes to the VA system that could take some patients out of the existing program and move them to privatized medical care. “If that happens, patients will not get the same comprehensive care” that until now has produced such high rates of hypertension control, he warned.
[email protected]
On Twitter @mitchelzoler
At a time when the Department of Veterans Affairs is criticized for the care it delivers, and when some also see it threatened by privatization, it was refreshing to hear the VA praised for the quality of its hypertension care, a model for success in a new era of reduced blood pressure treatment targets and revised hypertension guidelines that classify millions more Americans as having hypertension.
“In systems of care, like the VA and Kaiser Permanente Northern California, we are doing much better with hypertension control, reaching control rates greater than 90%,” Paul Whelton, MD, said in November during a talk at the American Heart Association scientific sessions in Anaheim, Calif. In a separate report at the same meeting, Dr. Whelton, a professor of public health at Tulane University in New Orleans, first presented the new hypertension diagnosis and management guidelines, produced by the American College of Cardiology/American Heart Association panel that he chaired (J Am Coll Cardiol. 2017 Nov 13. doi: 10.1016/j.jacc.2017.11.006).
He again stressed that the VA and Kaiser are doing “remarkably well” when it came to controlling hypertension in the vast majority of their patients.
That assessment seems especially appropriate for Kaiser Permanente Northern California, Oakland, Calif. Data from an audit of Kaiser’s hypertension registry showed that during 2000-2013 the percentage of patients with hypertension at their goal blood pressure rose from 44% in 2000 to 90% in 2013 (J Clin Hypertension. 2016 April;18[4]:260-1). The two Kaiser researchers who reported these findings attributed the rise in control rates to a hypertension treatment program that Kaiser Permanente Northern California put into practice starting in 2000.
Current success in the VA Health System is harder to pin down and put in the Kaiser ballpark. The most up-to-date audit I could find was a 2012 report from a team of VA researchers who reviewed control rates of more than half a million hypertensive veterans at 15 VA medical centers during 2000-2010. They found that, during that 11-year period, the percentage of hypertensive patients with their blood pressure controlled to their target level had risen from 46% in 2000 to 76% in 2010 (Circulation. 2012 May 22;125[20]:2462-68).
While this 76% rate of control in 2010 is short of the 90% rate in Kaiser in 2013, it’s still not shabby. To put the 76% control rate in perspective, consider data reported at the AHA meeting from TargetBP, a national program begun in late 2015 to aid all U.S. health care programs in improving their hypertension control rates: This data showed that, among 310 participating programs that filed 2016 control-rate data with TargetBP, the average control rate was 66%. Specifically, of those 310 reporting programs, 191 (62%) had control rates that exceeded 70%, with an average control rate among these more successful programs of 76%.
As-yet-unpublished data collected by the VA show that other centers in the system beyond those 15 included in the study discussed above have also recently reached a similar control level of about 75%, said Vasilios Papademetriou, MD, a professor of medicine at Georgetown University and the director of the Interventional Hypertension and Vascular Medicine Program at the VA Medical Center in Washington. Plus, certain VA centers are now up to an 85% control rate, he added in an interview. “Blood pressure control rates have been exceptionally good in the VA medical system,” he declared. Dr. Papademetriou attributed the rising control rates to a concerted hypertension program the VA instituted starting in the early 2000s.
“The VA has had some physicians who have championed this issue, and they have built computer-based systems to identify patients with uncontrolled hypertension, and then they plug these patients into their care algorithms,” commented Donald M. Lloyd-Jones, MD, a professor and chairman of preventive medicine at Northwestern University in Chicago. “Often, when there are champions, things change,” he noted.
William C. Cushman, MD, a hypertension specialist who is chief of preventive medicine for the VA Medical Center in Memphis and professor of preventive medicine at the University of Tennessee, also in Memphis, highlighted several steps the VA took that have helped fuel the program’s success in controlling blood pressure.
Dr. Cushman couldn’t resist adding that this successful approach to hypertension management is now threatened by potential changes to the VA system that could take some patients out of the existing program and move them to privatized medical care. “If that happens, patients will not get the same comprehensive care” that until now has produced such high rates of hypertension control, he warned.
[email protected]
On Twitter @mitchelzoler
Eating disorders over the holidays
For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.
Below are some tips from the National Eating Disorder Association that may be helpful for youth struggling with an eating disorder over the holiday season:
• Eat regularly and in a consistent pattern. Avoid skipping meals or restricting intake in preparation for a holiday meal.
• Discuss any anticipated struggles around food or family with your parents, therapist, health care provider, dietitian, or other members of your support group. This can allow you to plan ahead for any challenges that may arise, and could prevent potential negative or harmful coping behaviors
• Consider choosing a loved one to be your “reality check” with food, to either help fix a plate for you or to give you sound feedback on the food portion sizes you make for yourself.
• Have a game plan before you go to a holiday event. Know who your support people are and how you’ll recognize when it may be time to make a quick exit and get connected with needed support.
• Avoid overextending yourself. A lower stress level can decrease the need to turn to eating-disordered behaviors or other unhelpful coping strategies.
• Work on being flexible in your thoughts. Learn to be flexible when setting guidelines for yourself and expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self-imposed criticism, rigidity, and perfectionism.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
National Eating Disorders Association: www.nationaleatingdisorders.org
“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.
References
1. Prev Chronic Dis. 2008 Oct;5(4):A114.
2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.
3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.
4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.
5. J Adolesc Health. 2015 Aug;57(2):144-9.
6. Am J Public Health. 2013 Feb;103(2):e16-22.
7. J Adolesc Health. 2009 Sep;45(3):238-45.
For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.
Below are some tips from the National Eating Disorder Association that may be helpful for youth struggling with an eating disorder over the holiday season:
• Eat regularly and in a consistent pattern. Avoid skipping meals or restricting intake in preparation for a holiday meal.
• Discuss any anticipated struggles around food or family with your parents, therapist, health care provider, dietitian, or other members of your support group. This can allow you to plan ahead for any challenges that may arise, and could prevent potential negative or harmful coping behaviors
• Consider choosing a loved one to be your “reality check” with food, to either help fix a plate for you or to give you sound feedback on the food portion sizes you make for yourself.
• Have a game plan before you go to a holiday event. Know who your support people are and how you’ll recognize when it may be time to make a quick exit and get connected with needed support.
• Avoid overextending yourself. A lower stress level can decrease the need to turn to eating-disordered behaviors or other unhelpful coping strategies.
• Work on being flexible in your thoughts. Learn to be flexible when setting guidelines for yourself and expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self-imposed criticism, rigidity, and perfectionism.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
National Eating Disorders Association: www.nationaleatingdisorders.org
“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.
References
1. Prev Chronic Dis. 2008 Oct;5(4):A114.
2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.
3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.
4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.
5. J Adolesc Health. 2015 Aug;57(2):144-9.
6. Am J Public Health. 2013 Feb;103(2):e16-22.
7. J Adolesc Health. 2009 Sep;45(3):238-45.
For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.
Below are some tips from the National Eating Disorder Association that may be helpful for youth struggling with an eating disorder over the holiday season:
• Eat regularly and in a consistent pattern. Avoid skipping meals or restricting intake in preparation for a holiday meal.
• Discuss any anticipated struggles around food or family with your parents, therapist, health care provider, dietitian, or other members of your support group. This can allow you to plan ahead for any challenges that may arise, and could prevent potential negative or harmful coping behaviors
• Consider choosing a loved one to be your “reality check” with food, to either help fix a plate for you or to give you sound feedback on the food portion sizes you make for yourself.
• Have a game plan before you go to a holiday event. Know who your support people are and how you’ll recognize when it may be time to make a quick exit and get connected with needed support.
• Avoid overextending yourself. A lower stress level can decrease the need to turn to eating-disordered behaviors or other unhelpful coping strategies.
• Work on being flexible in your thoughts. Learn to be flexible when setting guidelines for yourself and expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self-imposed criticism, rigidity, and perfectionism.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
National Eating Disorders Association: www.nationaleatingdisorders.org
“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.
References
1. Prev Chronic Dis. 2008 Oct;5(4):A114.
2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.
3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.
4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.
5. J Adolesc Health. 2015 Aug;57(2):144-9.
6. Am J Public Health. 2013 Feb;103(2):e16-22.
7. J Adolesc Health. 2009 Sep;45(3):238-45.
‘Tea with Freud’: Engaging, authentic, but nonanalytic
If I traveled back in time to meet with a 60-year-old Sigmund Freud, the first thing I would say to him is: “Stop smoking, and get out of Austria!”
That was my thought as I read “Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works” (Dog Ear Publishing, 2016), in which the author, psychiatrist Steven B. Sandler, MD, holds a series of imaginary meetings with Freud to discuss the evolution of psychoanalysis into Sandler’s preferred mode of short-term dynamic psychotherapy (STDP) and to present case material for Freud’s supervision.
The chapters in “Tea with Freud” alternate between the imagined meetings with Freud and Sandler’s clinical work, presented from what I assume are transcripts of videotaped sessions with some disguises and composites to protect patients’ privacy. These clinical vignettes bring the reader into the nitty-gritty of the treatment room, which may be highly instructive for a lay person – particularly one who has never been in therapy.
At the same time, the book has the potential to be quite misleading. This would not be the case if Sandler were simply trying to introduce the reader to STDP. Instead, he attempts to convince the reader, and apparently himself, that the therapy he practices is a modern rendition of psychoanalysis because it tries to access the patient’s unacceptable, unconscious feelings; encourages her to “remember with emotion” or “experience” her feelings; and leads to some sort of cathartic resolution and improvement in symptoms and outlook.
While, “Aha!” moments and cathartic abreaction were characteristic of very early analyses, modern psychoanalysis is about slow but permanent change in character structure. The unwritten message in the book is that Freud’s true heirs practice psychotherapy as Sandler does. He does not seem to consider the significance of the many psychoanalysts, myself included, practicing psychoanalysis today.
Sandler uses a (mercifully) attenuated Davanloo technique to provoke patients into dramatic enactments. He is highly directive, with statements like, “We don’t solve any particular problem if we jump around all over.” I wonder how he can possibly learn about his patients when he begins with a foregone conclusion about where they should be headed.
His treatments are very brief. During his first session with a patient named Carla, he deduces that she is suffering from unresolved anger related to childhood trauma and manifesting it in chronic anxiety with angry outbursts. He then proceeds to “cure” her in five sessions.
Sandler wonders why some of his patients relapse and decides it is because they have not explored their “positive memories” in treatment, as though memories were univalent.
And he talks way too much.
All of this is decidedly un-analytic, which, again, would not matter if he were only trying to demonstrate STDP in action. Nonanalytic psychotherapies are entitled to be nonanalytic. Sandler has Freud point out precisely these analytic errors, so he must be aware that he is making them. And, yet, he stubbornly maintains his position that his work is analytic. What a waste of time travel it would be to meet with Freud only to reinforce one’s own opinions.
“Tea with Freud” is a way for Sandler to promote STDP and his theories about “positive memories” using an established authority, Freud, to validate them. This makes the book disappointing, but fortunately, there is something more to it. I kept wondering why it was so important to the author to seek out Freud’s – that is, his father’s – approval for his work. The book never answers that question. But in his attempts to understand his motives, Sandler, who is very adept at describing his own thoughts and feelings, becomes a model for the awareness of internal states and the effects of unconscious processes. Perhaps this is the most important lesson in “Tea with Freud.”
Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York.
If I traveled back in time to meet with a 60-year-old Sigmund Freud, the first thing I would say to him is: “Stop smoking, and get out of Austria!”
That was my thought as I read “Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works” (Dog Ear Publishing, 2016), in which the author, psychiatrist Steven B. Sandler, MD, holds a series of imaginary meetings with Freud to discuss the evolution of psychoanalysis into Sandler’s preferred mode of short-term dynamic psychotherapy (STDP) and to present case material for Freud’s supervision.
The chapters in “Tea with Freud” alternate between the imagined meetings with Freud and Sandler’s clinical work, presented from what I assume are transcripts of videotaped sessions with some disguises and composites to protect patients’ privacy. These clinical vignettes bring the reader into the nitty-gritty of the treatment room, which may be highly instructive for a lay person – particularly one who has never been in therapy.
At the same time, the book has the potential to be quite misleading. This would not be the case if Sandler were simply trying to introduce the reader to STDP. Instead, he attempts to convince the reader, and apparently himself, that the therapy he practices is a modern rendition of psychoanalysis because it tries to access the patient’s unacceptable, unconscious feelings; encourages her to “remember with emotion” or “experience” her feelings; and leads to some sort of cathartic resolution and improvement in symptoms and outlook.
While, “Aha!” moments and cathartic abreaction were characteristic of very early analyses, modern psychoanalysis is about slow but permanent change in character structure. The unwritten message in the book is that Freud’s true heirs practice psychotherapy as Sandler does. He does not seem to consider the significance of the many psychoanalysts, myself included, practicing psychoanalysis today.
Sandler uses a (mercifully) attenuated Davanloo technique to provoke patients into dramatic enactments. He is highly directive, with statements like, “We don’t solve any particular problem if we jump around all over.” I wonder how he can possibly learn about his patients when he begins with a foregone conclusion about where they should be headed.
His treatments are very brief. During his first session with a patient named Carla, he deduces that she is suffering from unresolved anger related to childhood trauma and manifesting it in chronic anxiety with angry outbursts. He then proceeds to “cure” her in five sessions.
Sandler wonders why some of his patients relapse and decides it is because they have not explored their “positive memories” in treatment, as though memories were univalent.
And he talks way too much.
All of this is decidedly un-analytic, which, again, would not matter if he were only trying to demonstrate STDP in action. Nonanalytic psychotherapies are entitled to be nonanalytic. Sandler has Freud point out precisely these analytic errors, so he must be aware that he is making them. And, yet, he stubbornly maintains his position that his work is analytic. What a waste of time travel it would be to meet with Freud only to reinforce one’s own opinions.
“Tea with Freud” is a way for Sandler to promote STDP and his theories about “positive memories” using an established authority, Freud, to validate them. This makes the book disappointing, but fortunately, there is something more to it. I kept wondering why it was so important to the author to seek out Freud’s – that is, his father’s – approval for his work. The book never answers that question. But in his attempts to understand his motives, Sandler, who is very adept at describing his own thoughts and feelings, becomes a model for the awareness of internal states and the effects of unconscious processes. Perhaps this is the most important lesson in “Tea with Freud.”
Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York.
If I traveled back in time to meet with a 60-year-old Sigmund Freud, the first thing I would say to him is: “Stop smoking, and get out of Austria!”
That was my thought as I read “Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works” (Dog Ear Publishing, 2016), in which the author, psychiatrist Steven B. Sandler, MD, holds a series of imaginary meetings with Freud to discuss the evolution of psychoanalysis into Sandler’s preferred mode of short-term dynamic psychotherapy (STDP) and to present case material for Freud’s supervision.
The chapters in “Tea with Freud” alternate between the imagined meetings with Freud and Sandler’s clinical work, presented from what I assume are transcripts of videotaped sessions with some disguises and composites to protect patients’ privacy. These clinical vignettes bring the reader into the nitty-gritty of the treatment room, which may be highly instructive for a lay person – particularly one who has never been in therapy.
At the same time, the book has the potential to be quite misleading. This would not be the case if Sandler were simply trying to introduce the reader to STDP. Instead, he attempts to convince the reader, and apparently himself, that the therapy he practices is a modern rendition of psychoanalysis because it tries to access the patient’s unacceptable, unconscious feelings; encourages her to “remember with emotion” or “experience” her feelings; and leads to some sort of cathartic resolution and improvement in symptoms and outlook.
While, “Aha!” moments and cathartic abreaction were characteristic of very early analyses, modern psychoanalysis is about slow but permanent change in character structure. The unwritten message in the book is that Freud’s true heirs practice psychotherapy as Sandler does. He does not seem to consider the significance of the many psychoanalysts, myself included, practicing psychoanalysis today.
Sandler uses a (mercifully) attenuated Davanloo technique to provoke patients into dramatic enactments. He is highly directive, with statements like, “We don’t solve any particular problem if we jump around all over.” I wonder how he can possibly learn about his patients when he begins with a foregone conclusion about where they should be headed.
His treatments are very brief. During his first session with a patient named Carla, he deduces that she is suffering from unresolved anger related to childhood trauma and manifesting it in chronic anxiety with angry outbursts. He then proceeds to “cure” her in five sessions.
Sandler wonders why some of his patients relapse and decides it is because they have not explored their “positive memories” in treatment, as though memories were univalent.
And he talks way too much.
All of this is decidedly un-analytic, which, again, would not matter if he were only trying to demonstrate STDP in action. Nonanalytic psychotherapies are entitled to be nonanalytic. Sandler has Freud point out precisely these analytic errors, so he must be aware that he is making them. And, yet, he stubbornly maintains his position that his work is analytic. What a waste of time travel it would be to meet with Freud only to reinforce one’s own opinions.
“Tea with Freud” is a way for Sandler to promote STDP and his theories about “positive memories” using an established authority, Freud, to validate them. This makes the book disappointing, but fortunately, there is something more to it. I kept wondering why it was so important to the author to seek out Freud’s – that is, his father’s – approval for his work. The book never answers that question. But in his attempts to understand his motives, Sandler, who is very adept at describing his own thoughts and feelings, becomes a model for the awareness of internal states and the effects of unconscious processes. Perhaps this is the most important lesson in “Tea with Freud.”
Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York.
Luxury drug treatment centers: Close scrutiny advised
About 2.5 million people received mental and/or substance use disorder treatment last year, according to the Substance Abuse and Mental Health Services Administration.1 Of those, a small but significant percentage chose support from a luxury type facility. This article intends to provide clinicians with guidance in addressing medically supervised luxury detox and/or rehabilitation programs for drug and alcohol abuse.
We recommend that individuals entering substance abuse services pursue these treatments with “eyes wide open.” A vast amount of literature indicates a rise in programs designed to attract vulnerable clients seeking treatment.2 They offer an array of luxury services such as equine, massage, and yoga therapy, as well as holistic approaches. These services are all packaged in a five-star hotel–like environment in a desirable area (by the sea, mountains, etc.).
The question is whether a $50,000-per-month treatment center is better at keeping its clients in remission than a facility that charges a fraction of the price per month. We believe that success rates may be less a function of financial cost and more a function of evidenced-based treatment strategies that are specific to recovery.
We would like to advise individuals to look for the following elements when reviewing a potential treatment center:
• Accepted by major insurance companies such as Blue Cross/Blue Shield and United Healthcare, to name a few.
• No cookie-cutter approaches: Programs allowing for inter-individual flexibility regarding length of stay (not specifically 21, 30, or 45 days), as well as flexibility of services.
• Group therapy should have no more than 15 clients. Some individuals may not be appropriate for group therapy or may have a strong aversion to this modality.
• Licensed and/or certified staff (not peer coaching and/or paraprofessionals alone).
• Minimum of 20 hours per week, per client, of clinically supervised evidence-based methods, techniques, and/or practices including individual counseling, group therapies, and family involvement.
• If the length of stay is longer, fewer staff members may be more appropriate.
• Availability of higher level of professional staff, psychologists, psychiatrists, and other physicians to address all comorbid concerns.
• Adequate aftercare treatment.
After reviewing social media that rate treatment facilities, one common thread we noticed was the total absence of aftercare services.3 Aftercare services were something that clients may not think of at the initial intake.
References
1 Substance Abuse and Mental Health Services Administration (SAMHSA). “Behavioral Health Treatments and Services.”
2 The Verge, Sept. 6, 2017
3 Rehabs.com
4. The New York Times, Sept. 14, 2017
Dr. Lesser is executive director of RANE, Medical & Mental Health, in New York City. In his recent positions as medical director for New York City and State, he was instrumental in developing and implementing nationally recognized emergency and response programs. Dr. Brenner is chief of Behavioral Health Service Line for Catholic Health Services of Long Island, in New York. He is a clinical professor of psychiatry for the State University of New York, Brooklyn, and medical director and CEO of Neurobehavioral Research Inc. Dr. Ferber is a licensed psychologist in New York and California. He has been the director of Behavioral Health Central Intake at Catholic Health Services of Long Island for the last 2 years. Dr. Ferber specializes in addiction treatment. Ms. Howard is a psychologist in training with specialization in clinical psychology. She currently treats numerous dual-diagnosed patients with comorbidities on an acute psychiatric ward.
About 2.5 million people received mental and/or substance use disorder treatment last year, according to the Substance Abuse and Mental Health Services Administration.1 Of those, a small but significant percentage chose support from a luxury type facility. This article intends to provide clinicians with guidance in addressing medically supervised luxury detox and/or rehabilitation programs for drug and alcohol abuse.
We recommend that individuals entering substance abuse services pursue these treatments with “eyes wide open.” A vast amount of literature indicates a rise in programs designed to attract vulnerable clients seeking treatment.2 They offer an array of luxury services such as equine, massage, and yoga therapy, as well as holistic approaches. These services are all packaged in a five-star hotel–like environment in a desirable area (by the sea, mountains, etc.).
The question is whether a $50,000-per-month treatment center is better at keeping its clients in remission than a facility that charges a fraction of the price per month. We believe that success rates may be less a function of financial cost and more a function of evidenced-based treatment strategies that are specific to recovery.
We would like to advise individuals to look for the following elements when reviewing a potential treatment center:
• Accepted by major insurance companies such as Blue Cross/Blue Shield and United Healthcare, to name a few.
• No cookie-cutter approaches: Programs allowing for inter-individual flexibility regarding length of stay (not specifically 21, 30, or 45 days), as well as flexibility of services.
• Group therapy should have no more than 15 clients. Some individuals may not be appropriate for group therapy or may have a strong aversion to this modality.
• Licensed and/or certified staff (not peer coaching and/or paraprofessionals alone).
• Minimum of 20 hours per week, per client, of clinically supervised evidence-based methods, techniques, and/or practices including individual counseling, group therapies, and family involvement.
• If the length of stay is longer, fewer staff members may be more appropriate.
• Availability of higher level of professional staff, psychologists, psychiatrists, and other physicians to address all comorbid concerns.
• Adequate aftercare treatment.
After reviewing social media that rate treatment facilities, one common thread we noticed was the total absence of aftercare services.3 Aftercare services were something that clients may not think of at the initial intake.
References
1 Substance Abuse and Mental Health Services Administration (SAMHSA). “Behavioral Health Treatments and Services.”
2 The Verge, Sept. 6, 2017
3 Rehabs.com
4. The New York Times, Sept. 14, 2017
Dr. Lesser is executive director of RANE, Medical & Mental Health, in New York City. In his recent positions as medical director for New York City and State, he was instrumental in developing and implementing nationally recognized emergency and response programs. Dr. Brenner is chief of Behavioral Health Service Line for Catholic Health Services of Long Island, in New York. He is a clinical professor of psychiatry for the State University of New York, Brooklyn, and medical director and CEO of Neurobehavioral Research Inc. Dr. Ferber is a licensed psychologist in New York and California. He has been the director of Behavioral Health Central Intake at Catholic Health Services of Long Island for the last 2 years. Dr. Ferber specializes in addiction treatment. Ms. Howard is a psychologist in training with specialization in clinical psychology. She currently treats numerous dual-diagnosed patients with comorbidities on an acute psychiatric ward.
About 2.5 million people received mental and/or substance use disorder treatment last year, according to the Substance Abuse and Mental Health Services Administration.1 Of those, a small but significant percentage chose support from a luxury type facility. This article intends to provide clinicians with guidance in addressing medically supervised luxury detox and/or rehabilitation programs for drug and alcohol abuse.
We recommend that individuals entering substance abuse services pursue these treatments with “eyes wide open.” A vast amount of literature indicates a rise in programs designed to attract vulnerable clients seeking treatment.2 They offer an array of luxury services such as equine, massage, and yoga therapy, as well as holistic approaches. These services are all packaged in a five-star hotel–like environment in a desirable area (by the sea, mountains, etc.).
The question is whether a $50,000-per-month treatment center is better at keeping its clients in remission than a facility that charges a fraction of the price per month. We believe that success rates may be less a function of financial cost and more a function of evidenced-based treatment strategies that are specific to recovery.
We would like to advise individuals to look for the following elements when reviewing a potential treatment center:
• Accepted by major insurance companies such as Blue Cross/Blue Shield and United Healthcare, to name a few.
• No cookie-cutter approaches: Programs allowing for inter-individual flexibility regarding length of stay (not specifically 21, 30, or 45 days), as well as flexibility of services.
• Group therapy should have no more than 15 clients. Some individuals may not be appropriate for group therapy or may have a strong aversion to this modality.
• Licensed and/or certified staff (not peer coaching and/or paraprofessionals alone).
• Minimum of 20 hours per week, per client, of clinically supervised evidence-based methods, techniques, and/or practices including individual counseling, group therapies, and family involvement.
• If the length of stay is longer, fewer staff members may be more appropriate.
• Availability of higher level of professional staff, psychologists, psychiatrists, and other physicians to address all comorbid concerns.
• Adequate aftercare treatment.
After reviewing social media that rate treatment facilities, one common thread we noticed was the total absence of aftercare services.3 Aftercare services were something that clients may not think of at the initial intake.
References
1 Substance Abuse and Mental Health Services Administration (SAMHSA). “Behavioral Health Treatments and Services.”
2 The Verge, Sept. 6, 2017
3 Rehabs.com
4. The New York Times, Sept. 14, 2017
Dr. Lesser is executive director of RANE, Medical & Mental Health, in New York City. In his recent positions as medical director for New York City and State, he was instrumental in developing and implementing nationally recognized emergency and response programs. Dr. Brenner is chief of Behavioral Health Service Line for Catholic Health Services of Long Island, in New York. He is a clinical professor of psychiatry for the State University of New York, Brooklyn, and medical director and CEO of Neurobehavioral Research Inc. Dr. Ferber is a licensed psychologist in New York and California. He has been the director of Behavioral Health Central Intake at Catholic Health Services of Long Island for the last 2 years. Dr. Ferber specializes in addiction treatment. Ms. Howard is a psychologist in training with specialization in clinical psychology. She currently treats numerous dual-diagnosed patients with comorbidities on an acute psychiatric ward.
Confluent and reticulated papillomatosis
Confluent and reticulated papillomatosis of Gougerot and Carteaud, also known as Gougerot-Carteaud syndrome, is an uncommon skin disorder of young individuals characterized by hyperkeratotic or verrucous brown papules or plaques that coalesce centrally and by a reticulated pattern peripherally. It was first described by two French dermatologists, Gougerot and Carteaud, in 1927.1 Initially, the distinct entity of CARP was contested, with some dermatologists believing it to be a variant of acanthosis nigricans. However, CARP is now recognized as a distinct, though rare, dermatosis.
Histopathology reveals findings similar to those that may be found in acanthosis nigricans and epidermal nevi. Classic characteristics of CARP include hyperkeratosis, papillomatosis, increased basal melanin pigmentation, and mild acanthosis. Occasionally, there may be perivascular lymphocytic infiltrates in the superficial dermis.3,4
The etiology of CARP is unknown. CARP’s resolution in response to antibiotics and the isolation of two bacterial actinomycetes, Rhodococcus and Dietzia papillomatosis, from skin scrapings of CARP patients have led some to believe that its etiology is bacterial. However, no bacterial species have been consistently isolated from CARP patients. The prevailing theory of the past was that CARP was an abnormal host response to the fungus Malassezia furfur. Inconsistent detection of the fungus in skin scrapings, as well as persistence of the skin lesions after fungal clearance with antifungal therapy, has debunked this theory. An underlying disorder of keratinization resulting in hyperproliferation also has been suggested given reports of familial CARP and electron microscopy studies demonstrating focal-enhanced expression of keratin-16 in the stratum granulosom.5 Other theories include a cutaneous response to underlying endocrinopathies, ultraviolet light, and localized amyloidosis.1
Diagnosis and differential
CARP is poorly recognized by clinicians and frequently initially misdiagnosed due to its similar appearance to other disorders, most commonly tinea versicolor and acanthosis nigricans. Davis et al. proposed criteria for diagnosis of CARP requiring 1) presence of scaly, reticulated and papillomatous brown macules and patches; 2) distribution over the upper trunk and neck; 3) negative fungal staining of scales; 4) no improvement following antifungal treatment; and 5) improvement following minocycline.2
Tinea versicolor may appear similar to CARP, but unlike CARP, will respond to antifungal treatment and may demonstrate hyphae and yeast on KOH preparation. Acanthosis nigricans and CARP both may present with velvety, hyperpigmented plaques in individuals of obese habitus or with insulin resistance, but peripheral reticulation will be absent in acanthosis nigricans. However, acanthosis nigricans and CARP may coexist, and this coexistence is not uncommonly seen in individuals with obesity and/or insulin resistance. Darier’s disease may look similar to cases of CARP without pigmentary change, but it often will have accompanying nail changes. Macular or lichen amyloidosis may present with pruritic brown macules or papules, but skin biopsy will have positive amyloid staining. The use of 70% alcohol swabbing to diagnose terra firma-forme dermatosis, with lesions disappearing with swabbing, is classic and used to differentiate it from CARP. Other conditions to consider include seborrheic dermatitis, epidermal nevi, verruca plana, epidermodysplasia verruciformis, and acne vulgaris.1,2,4
Treatment
Minocycline is the first-line treatment for CARP: 80% of patients may have complete resolution with minocycline, while the remainder experience at least 50% clearance of skin lesions.2 However, recurrence after stopping minocycline treatment is not uncommon. The mechanism by which minocycline works is unknown. Second-line treatment for those who cannot tolerate minocycline are macrolide antibiotics.6 Other treatment options with reported success include oral isotretinoin and topical retinoids, including tretinoin gel and tazarotene cream.3,7 Appropriate strength topical corticosteroids may be used for pruritus.
Ms. Han is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, as well as the vice chair of the department of dermatology and a professor of dermatology and pediatrics at UC San Diego. They report having no conflicts of interest or financial disclosures. Email them at [email protected].
References
1. Clin Cosmet Investig Dermatol. 2016 Aug 25;9:217-23.
2. Br J Dermatol. 2006 Feb;154(2):287-93.
3. Arch Dermatol. 2012 Apr;148(4):505-8.
4. J Am Acad Dermatol. 2003 Dec;49(6):1182-4.
5. Arch Dermatol. 2002 Feb;138(2):276-7.
6. J Am Acad Dermatol. 2001;44(4):652-5.
7. Am J Clin Dermatol. 2006;7(5):305-13.
Confluent and reticulated papillomatosis of Gougerot and Carteaud, also known as Gougerot-Carteaud syndrome, is an uncommon skin disorder of young individuals characterized by hyperkeratotic or verrucous brown papules or plaques that coalesce centrally and by a reticulated pattern peripherally. It was first described by two French dermatologists, Gougerot and Carteaud, in 1927.1 Initially, the distinct entity of CARP was contested, with some dermatologists believing it to be a variant of acanthosis nigricans. However, CARP is now recognized as a distinct, though rare, dermatosis.
Histopathology reveals findings similar to those that may be found in acanthosis nigricans and epidermal nevi. Classic characteristics of CARP include hyperkeratosis, papillomatosis, increased basal melanin pigmentation, and mild acanthosis. Occasionally, there may be perivascular lymphocytic infiltrates in the superficial dermis.3,4
The etiology of CARP is unknown. CARP’s resolution in response to antibiotics and the isolation of two bacterial actinomycetes, Rhodococcus and Dietzia papillomatosis, from skin scrapings of CARP patients have led some to believe that its etiology is bacterial. However, no bacterial species have been consistently isolated from CARP patients. The prevailing theory of the past was that CARP was an abnormal host response to the fungus Malassezia furfur. Inconsistent detection of the fungus in skin scrapings, as well as persistence of the skin lesions after fungal clearance with antifungal therapy, has debunked this theory. An underlying disorder of keratinization resulting in hyperproliferation also has been suggested given reports of familial CARP and electron microscopy studies demonstrating focal-enhanced expression of keratin-16 in the stratum granulosom.5 Other theories include a cutaneous response to underlying endocrinopathies, ultraviolet light, and localized amyloidosis.1
Diagnosis and differential
CARP is poorly recognized by clinicians and frequently initially misdiagnosed due to its similar appearance to other disorders, most commonly tinea versicolor and acanthosis nigricans. Davis et al. proposed criteria for diagnosis of CARP requiring 1) presence of scaly, reticulated and papillomatous brown macules and patches; 2) distribution over the upper trunk and neck; 3) negative fungal staining of scales; 4) no improvement following antifungal treatment; and 5) improvement following minocycline.2
Tinea versicolor may appear similar to CARP, but unlike CARP, will respond to antifungal treatment and may demonstrate hyphae and yeast on KOH preparation. Acanthosis nigricans and CARP both may present with velvety, hyperpigmented plaques in individuals of obese habitus or with insulin resistance, but peripheral reticulation will be absent in acanthosis nigricans. However, acanthosis nigricans and CARP may coexist, and this coexistence is not uncommonly seen in individuals with obesity and/or insulin resistance. Darier’s disease may look similar to cases of CARP without pigmentary change, but it often will have accompanying nail changes. Macular or lichen amyloidosis may present with pruritic brown macules or papules, but skin biopsy will have positive amyloid staining. The use of 70% alcohol swabbing to diagnose terra firma-forme dermatosis, with lesions disappearing with swabbing, is classic and used to differentiate it from CARP. Other conditions to consider include seborrheic dermatitis, epidermal nevi, verruca plana, epidermodysplasia verruciformis, and acne vulgaris.1,2,4
Treatment
Minocycline is the first-line treatment for CARP: 80% of patients may have complete resolution with minocycline, while the remainder experience at least 50% clearance of skin lesions.2 However, recurrence after stopping minocycline treatment is not uncommon. The mechanism by which minocycline works is unknown. Second-line treatment for those who cannot tolerate minocycline are macrolide antibiotics.6 Other treatment options with reported success include oral isotretinoin and topical retinoids, including tretinoin gel and tazarotene cream.3,7 Appropriate strength topical corticosteroids may be used for pruritus.
Ms. Han is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, as well as the vice chair of the department of dermatology and a professor of dermatology and pediatrics at UC San Diego. They report having no conflicts of interest or financial disclosures. Email them at [email protected].
References
1. Clin Cosmet Investig Dermatol. 2016 Aug 25;9:217-23.
2. Br J Dermatol. 2006 Feb;154(2):287-93.
3. Arch Dermatol. 2012 Apr;148(4):505-8.
4. J Am Acad Dermatol. 2003 Dec;49(6):1182-4.
5. Arch Dermatol. 2002 Feb;138(2):276-7.
6. J Am Acad Dermatol. 2001;44(4):652-5.
7. Am J Clin Dermatol. 2006;7(5):305-13.
Confluent and reticulated papillomatosis of Gougerot and Carteaud, also known as Gougerot-Carteaud syndrome, is an uncommon skin disorder of young individuals characterized by hyperkeratotic or verrucous brown papules or plaques that coalesce centrally and by a reticulated pattern peripherally. It was first described by two French dermatologists, Gougerot and Carteaud, in 1927.1 Initially, the distinct entity of CARP was contested, with some dermatologists believing it to be a variant of acanthosis nigricans. However, CARP is now recognized as a distinct, though rare, dermatosis.
Histopathology reveals findings similar to those that may be found in acanthosis nigricans and epidermal nevi. Classic characteristics of CARP include hyperkeratosis, papillomatosis, increased basal melanin pigmentation, and mild acanthosis. Occasionally, there may be perivascular lymphocytic infiltrates in the superficial dermis.3,4
The etiology of CARP is unknown. CARP’s resolution in response to antibiotics and the isolation of two bacterial actinomycetes, Rhodococcus and Dietzia papillomatosis, from skin scrapings of CARP patients have led some to believe that its etiology is bacterial. However, no bacterial species have been consistently isolated from CARP patients. The prevailing theory of the past was that CARP was an abnormal host response to the fungus Malassezia furfur. Inconsistent detection of the fungus in skin scrapings, as well as persistence of the skin lesions after fungal clearance with antifungal therapy, has debunked this theory. An underlying disorder of keratinization resulting in hyperproliferation also has been suggested given reports of familial CARP and electron microscopy studies demonstrating focal-enhanced expression of keratin-16 in the stratum granulosom.5 Other theories include a cutaneous response to underlying endocrinopathies, ultraviolet light, and localized amyloidosis.1
Diagnosis and differential
CARP is poorly recognized by clinicians and frequently initially misdiagnosed due to its similar appearance to other disorders, most commonly tinea versicolor and acanthosis nigricans. Davis et al. proposed criteria for diagnosis of CARP requiring 1) presence of scaly, reticulated and papillomatous brown macules and patches; 2) distribution over the upper trunk and neck; 3) negative fungal staining of scales; 4) no improvement following antifungal treatment; and 5) improvement following minocycline.2
Tinea versicolor may appear similar to CARP, but unlike CARP, will respond to antifungal treatment and may demonstrate hyphae and yeast on KOH preparation. Acanthosis nigricans and CARP both may present with velvety, hyperpigmented plaques in individuals of obese habitus or with insulin resistance, but peripheral reticulation will be absent in acanthosis nigricans. However, acanthosis nigricans and CARP may coexist, and this coexistence is not uncommonly seen in individuals with obesity and/or insulin resistance. Darier’s disease may look similar to cases of CARP without pigmentary change, but it often will have accompanying nail changes. Macular or lichen amyloidosis may present with pruritic brown macules or papules, but skin biopsy will have positive amyloid staining. The use of 70% alcohol swabbing to diagnose terra firma-forme dermatosis, with lesions disappearing with swabbing, is classic and used to differentiate it from CARP. Other conditions to consider include seborrheic dermatitis, epidermal nevi, verruca plana, epidermodysplasia verruciformis, and acne vulgaris.1,2,4
Treatment
Minocycline is the first-line treatment for CARP: 80% of patients may have complete resolution with minocycline, while the remainder experience at least 50% clearance of skin lesions.2 However, recurrence after stopping minocycline treatment is not uncommon. The mechanism by which minocycline works is unknown. Second-line treatment for those who cannot tolerate minocycline are macrolide antibiotics.6 Other treatment options with reported success include oral isotretinoin and topical retinoids, including tretinoin gel and tazarotene cream.3,7 Appropriate strength topical corticosteroids may be used for pruritus.
Ms. Han is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, as well as the vice chair of the department of dermatology and a professor of dermatology and pediatrics at UC San Diego. They report having no conflicts of interest or financial disclosures. Email them at [email protected].
References
1. Clin Cosmet Investig Dermatol. 2016 Aug 25;9:217-23.
2. Br J Dermatol. 2006 Feb;154(2):287-93.
3. Arch Dermatol. 2012 Apr;148(4):505-8.
4. J Am Acad Dermatol. 2003 Dec;49(6):1182-4.
5. Arch Dermatol. 2002 Feb;138(2):276-7.
6. J Am Acad Dermatol. 2001;44(4):652-5.
7. Am J Clin Dermatol. 2006;7(5):305-13.
A 17-year-old male presents to the dermatology clinic for brown lesions on his central chest and back that have been present for about a year. The brown areas gradually have become scaly over time. They are asymptomatic. His pediatrician had given him hydrocortisone ointment to apply to the lesions, but there was no improvement. Review of systems was otherwise negative.
Preventing substance use
Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. , such as parent education and early recognition in pediatric practice.
Substance abuse risk
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
References
1. Hum Genet. 2012 Jun;131(6):779-89.
2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. , such as parent education and early recognition in pediatric practice.
Substance abuse risk
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
References
1. Hum Genet. 2012 Jun;131(6):779-89.
2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. , such as parent education and early recognition in pediatric practice.
Substance abuse risk
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
References
1. Hum Genet. 2012 Jun;131(6):779-89.
2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
More to psychiatry than just neuroscience; The impact of childhood trauma
More to psychiatry than just neuroscience
In his editorial “Advancing clinical neuroscience literacy among psychiatric practitioners” (From the Editor,
I find that many of my patients look for more or different drugs to fix their dysfunctional patterns in life—many of which stem from their dysfunctional and traumatic childhoods. Thus, it is more than just drugs and neurochemical pathways, more than just the “dysregulated neural circuitry,” that we need to focus on in our psychiatric practice.
I finished my psychiatric residency in 1972, before we knew much about neuroscience. Since then, we have learned so much about neuroscience and the specific neuroscience mechanisms involved in the brain and mind. Those advances have done much to aid our core understanding of psychiatric disorders. However, let us not forget that there is more to the mind than just neurochemistry, and more to our practice of psychiatry than just neuroscience.
Leonard Korn, MD
Psychiatrist
Portsmouth Regional Hospital
Portsmouth, New Hampshire
Dr. Nasrallah responds
It is now widely accepted in our field that all psychological phenomena and all human behaviors are associated with neurobiological components. All life events, especially traumatic experiences, are transduced into structural and chemical changes, often within minutes. The formation of dendritic spines to encode the memory of one’s experiences throughout waking hours is well established in neuroscience, and hundreds of studies have been published about this.
Psychotherapy is a neurobiological intervention that induces neuroplasticity and leads to structural brain repair, because talking, listening, triggering memories, inducing insight, and “connecting the dots” in one’s behavior are all biological events.1,2 There is no such thing as a purely psychological process independent of the brain. The mind is the product of ongoing complex, intricate activity of brain neurocircuits whose neurobiological activity is translated into thoughts, emotions, impulses, and behaviors. The mind is perpetually tethered to its neurological roots.
Thus, reductionism actually describes a scientific fact and is not a term with pejorative connotations used to shut down scientific discourse about the biological basis of human behavior. By advancing their clinical neuroscience literacy, psychiatric practitioners will understand that they deal with a specific brain pathology in every patient that they treat and that the medications and psychotherapeutic interventions they employ are synergistic biological treatments.3
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
References
1. Nasrallah HA. Repositioning psychotherapy as a neurobiological intervention. Current Psychiatry. 2013;12(12):18-19.
2. Nasrallah HA. Out-of-the-box questions about psychotherapy. Current Psychiatry. 2010;9(10):13-14.
3. Nasrallah HA. Medications with psychotherapy: a synergy to heal the brain. C urrent Psychiatry. 2006;5(10):11-12.
The impact of childhood trauma
I enjoyed Dr. Nasrallah’s article “Beyond DSM-5: Clinical and biologic features shared by major psychiatric syndromes” (From the Editor, Current Psychiatry. October 2017, p. 4,6-7), but there was only 1 mention of childhood trauma, which shares features with most of the commonalities he described, such as inflammation, smaller brain volumes, gene and environment interaction, shortened telomeres, and elevated cortisol levels. The Adverse Childhood Experiences Study1 taught us about the impact of childhood trauma on the entire organism. We need to focus on that commonality.
Susan Jones, MD
Child and Adolescent Psychiatrist
Virginia Treatment Center for Children
Assistant Professor
Virginia Commonwealth University
School of Medicine
Richmond, Virginia
Reference
1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258
Dr. Nasrallah responds
It is worth pointing out that childhood trauma predominantly leads to psychotic and mood disorders in adulthood, and the criteria I mentioned would then hold true.
More to psychiatry than just neuroscience
In his editorial “Advancing clinical neuroscience literacy among psychiatric practitioners” (From the Editor,
I find that many of my patients look for more or different drugs to fix their dysfunctional patterns in life—many of which stem from their dysfunctional and traumatic childhoods. Thus, it is more than just drugs and neurochemical pathways, more than just the “dysregulated neural circuitry,” that we need to focus on in our psychiatric practice.
I finished my psychiatric residency in 1972, before we knew much about neuroscience. Since then, we have learned so much about neuroscience and the specific neuroscience mechanisms involved in the brain and mind. Those advances have done much to aid our core understanding of psychiatric disorders. However, let us not forget that there is more to the mind than just neurochemistry, and more to our practice of psychiatry than just neuroscience.
Leonard Korn, MD
Psychiatrist
Portsmouth Regional Hospital
Portsmouth, New Hampshire
Dr. Nasrallah responds
It is now widely accepted in our field that all psychological phenomena and all human behaviors are associated with neurobiological components. All life events, especially traumatic experiences, are transduced into structural and chemical changes, often within minutes. The formation of dendritic spines to encode the memory of one’s experiences throughout waking hours is well established in neuroscience, and hundreds of studies have been published about this.
Psychotherapy is a neurobiological intervention that induces neuroplasticity and leads to structural brain repair, because talking, listening, triggering memories, inducing insight, and “connecting the dots” in one’s behavior are all biological events.1,2 There is no such thing as a purely psychological process independent of the brain. The mind is the product of ongoing complex, intricate activity of brain neurocircuits whose neurobiological activity is translated into thoughts, emotions, impulses, and behaviors. The mind is perpetually tethered to its neurological roots.
Thus, reductionism actually describes a scientific fact and is not a term with pejorative connotations used to shut down scientific discourse about the biological basis of human behavior. By advancing their clinical neuroscience literacy, psychiatric practitioners will understand that they deal with a specific brain pathology in every patient that they treat and that the medications and psychotherapeutic interventions they employ are synergistic biological treatments.3
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
References
1. Nasrallah HA. Repositioning psychotherapy as a neurobiological intervention. Current Psychiatry. 2013;12(12):18-19.
2. Nasrallah HA. Out-of-the-box questions about psychotherapy. Current Psychiatry. 2010;9(10):13-14.
3. Nasrallah HA. Medications with psychotherapy: a synergy to heal the brain. C urrent Psychiatry. 2006;5(10):11-12.
The impact of childhood trauma
I enjoyed Dr. Nasrallah’s article “Beyond DSM-5: Clinical and biologic features shared by major psychiatric syndromes” (From the Editor, Current Psychiatry. October 2017, p. 4,6-7), but there was only 1 mention of childhood trauma, which shares features with most of the commonalities he described, such as inflammation, smaller brain volumes, gene and environment interaction, shortened telomeres, and elevated cortisol levels. The Adverse Childhood Experiences Study1 taught us about the impact of childhood trauma on the entire organism. We need to focus on that commonality.
Susan Jones, MD
Child and Adolescent Psychiatrist
Virginia Treatment Center for Children
Assistant Professor
Virginia Commonwealth University
School of Medicine
Richmond, Virginia
Reference
1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258
Dr. Nasrallah responds
It is worth pointing out that childhood trauma predominantly leads to psychotic and mood disorders in adulthood, and the criteria I mentioned would then hold true.
More to psychiatry than just neuroscience
In his editorial “Advancing clinical neuroscience literacy among psychiatric practitioners” (From the Editor,
I find that many of my patients look for more or different drugs to fix their dysfunctional patterns in life—many of which stem from their dysfunctional and traumatic childhoods. Thus, it is more than just drugs and neurochemical pathways, more than just the “dysregulated neural circuitry,” that we need to focus on in our psychiatric practice.
I finished my psychiatric residency in 1972, before we knew much about neuroscience. Since then, we have learned so much about neuroscience and the specific neuroscience mechanisms involved in the brain and mind. Those advances have done much to aid our core understanding of psychiatric disorders. However, let us not forget that there is more to the mind than just neurochemistry, and more to our practice of psychiatry than just neuroscience.
Leonard Korn, MD
Psychiatrist
Portsmouth Regional Hospital
Portsmouth, New Hampshire
Dr. Nasrallah responds
It is now widely accepted in our field that all psychological phenomena and all human behaviors are associated with neurobiological components. All life events, especially traumatic experiences, are transduced into structural and chemical changes, often within minutes. The formation of dendritic spines to encode the memory of one’s experiences throughout waking hours is well established in neuroscience, and hundreds of studies have been published about this.
Psychotherapy is a neurobiological intervention that induces neuroplasticity and leads to structural brain repair, because talking, listening, triggering memories, inducing insight, and “connecting the dots” in one’s behavior are all biological events.1,2 There is no such thing as a purely psychological process independent of the brain. The mind is the product of ongoing complex, intricate activity of brain neurocircuits whose neurobiological activity is translated into thoughts, emotions, impulses, and behaviors. The mind is perpetually tethered to its neurological roots.
Thus, reductionism actually describes a scientific fact and is not a term with pejorative connotations used to shut down scientific discourse about the biological basis of human behavior. By advancing their clinical neuroscience literacy, psychiatric practitioners will understand that they deal with a specific brain pathology in every patient that they treat and that the medications and psychotherapeutic interventions they employ are synergistic biological treatments.3
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
References
1. Nasrallah HA. Repositioning psychotherapy as a neurobiological intervention. Current Psychiatry. 2013;12(12):18-19.
2. Nasrallah HA. Out-of-the-box questions about psychotherapy. Current Psychiatry. 2010;9(10):13-14.
3. Nasrallah HA. Medications with psychotherapy: a synergy to heal the brain. C urrent Psychiatry. 2006;5(10):11-12.
The impact of childhood trauma
I enjoyed Dr. Nasrallah’s article “Beyond DSM-5: Clinical and biologic features shared by major psychiatric syndromes” (From the Editor, Current Psychiatry. October 2017, p. 4,6-7), but there was only 1 mention of childhood trauma, which shares features with most of the commonalities he described, such as inflammation, smaller brain volumes, gene and environment interaction, shortened telomeres, and elevated cortisol levels. The Adverse Childhood Experiences Study1 taught us about the impact of childhood trauma on the entire organism. We need to focus on that commonality.
Susan Jones, MD
Child and Adolescent Psychiatrist
Virginia Treatment Center for Children
Assistant Professor
Virginia Commonwealth University
School of Medicine
Richmond, Virginia
Reference
1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258
Dr. Nasrallah responds
It is worth pointing out that childhood trauma predominantly leads to psychotic and mood disorders in adulthood, and the criteria I mentioned would then hold true.
Physician wellness needs attention at personal, institutional, and cultural levels
Do you know we have record rates of physician burnout, dissatisfaction, and suicide? Ongoing shortages in primary care, without improvement in sight? Physicians exiting medicine earlier than in the past?
What about burnout? Do you know it affects patients as well as their doctors? Affects physicians’ families and friends? Increases mistakes and malpractice risk? Affects patient adherence and outcomes? Is costly to the entire system?
How do we start to fix this? : personal wellness, organizational wellness, and wellness within the culture of medicine.
The high level of physician burnout indicates that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters because it affects the bottom line.
Wellness within the culture of medicine is the third level of our framework. Western medicine has its own set of customs, traditions, and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice, and commitment also are included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.
When examining physician wellness at the cultural level, we also must address discrimination within medicine. Overt racism, misogyny, ageism, and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine. It’s difficult to experience wellness at the same time as discrimination.
At every level, physician wellness depends upon continuous, usually low-tech activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.
Dr. Stepien practices pediatrics in Juneau, Alaska. She is on the Pediatric News editorial advisory board. Email her at [email protected]
Do you know we have record rates of physician burnout, dissatisfaction, and suicide? Ongoing shortages in primary care, without improvement in sight? Physicians exiting medicine earlier than in the past?
What about burnout? Do you know it affects patients as well as their doctors? Affects physicians’ families and friends? Increases mistakes and malpractice risk? Affects patient adherence and outcomes? Is costly to the entire system?
How do we start to fix this? : personal wellness, organizational wellness, and wellness within the culture of medicine.
The high level of physician burnout indicates that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters because it affects the bottom line.
Wellness within the culture of medicine is the third level of our framework. Western medicine has its own set of customs, traditions, and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice, and commitment also are included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.
When examining physician wellness at the cultural level, we also must address discrimination within medicine. Overt racism, misogyny, ageism, and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine. It’s difficult to experience wellness at the same time as discrimination.
At every level, physician wellness depends upon continuous, usually low-tech activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.
Dr. Stepien practices pediatrics in Juneau, Alaska. She is on the Pediatric News editorial advisory board. Email her at [email protected]
Do you know we have record rates of physician burnout, dissatisfaction, and suicide? Ongoing shortages in primary care, without improvement in sight? Physicians exiting medicine earlier than in the past?
What about burnout? Do you know it affects patients as well as their doctors? Affects physicians’ families and friends? Increases mistakes and malpractice risk? Affects patient adherence and outcomes? Is costly to the entire system?
How do we start to fix this? : personal wellness, organizational wellness, and wellness within the culture of medicine.
The high level of physician burnout indicates that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters because it affects the bottom line.
Wellness within the culture of medicine is the third level of our framework. Western medicine has its own set of customs, traditions, and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice, and commitment also are included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.
When examining physician wellness at the cultural level, we also must address discrimination within medicine. Overt racism, misogyny, ageism, and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine. It’s difficult to experience wellness at the same time as discrimination.
At every level, physician wellness depends upon continuous, usually low-tech activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.
Dr. Stepien practices pediatrics in Juneau, Alaska. She is on the Pediatric News editorial advisory board. Email her at [email protected]