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Surge in firearm sales tied to COVID-19 fears, uncertainty presents risks
Use gentle assumptions and focus on home access to elicit positive answers.
In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.
In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.1 More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.
The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.4 That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.7 Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.8 It seems reasonable to expect such trends not to be diminished by recent events.
Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.
- Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
- Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
- Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
- Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”
References
1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.
2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.
3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.
4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.
5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.
6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.
7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.
8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).
Use gentle assumptions and focus on home access to elicit positive answers.
Use gentle assumptions and focus on home access to elicit positive answers.
In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.
In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.1 More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.
The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.4 That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.7 Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.8 It seems reasonable to expect such trends not to be diminished by recent events.
Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.
- Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
- Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
- Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
- Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”
References
1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.
2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.
3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.
4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.
5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.
6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.
7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.
8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).
In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.
In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.1 More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.
The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.4 That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.7 Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.8 It seems reasonable to expect such trends not to be diminished by recent events.
Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.
- Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
- Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
- Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
- Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”
References
1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.
2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.
3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.
4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.
5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.
6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.
7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.
8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).
Strategies for treating patients with health anxiety
Up to 20% of patients in medical settings experience health anxiety.1,2 In DSM-IV-TR, this condition was called hypochondriasis, and its core feature was having a preoccupation with fears or the idea that one has a serious disease based on a misinterpretation of ≥1 bodily signs or symptoms despite undergoing appropriate medical evaluation.3 In DSM-5, hypochondriasis was removed, and somatic symptom disorder and illness anxiety disorder were introduced.1 Approximately 75% of patients with a previous diagnosis of hypochondriasis meet the diagnostic criteria for somatic symptom disorder, and approximately 25% meet the criteria for illness anxiety disorder.1 In clinical practice, the less pejorative and more commonly used term for these conditions is “health anxiety.”
Patients with health anxiety can be challenging to treat because they persist in believing they have an illness despite appropriate medical evaluation. Clinicians’ responses to such patients can range from feeling the need to do more to alleviate their suffering to strongly disliking them. Although these patients can elicit negative countertransference, we should remember that their lives are being adversely affected due to the substantial functional impairment they experience from their health worries. As psychiatrists, we can help our patients with health anxiety by employing the following strategies.
Maintain constant communication with other clinicians who manage the patient’s medical complaints. A clear line of communication with other clinicians can help minimize inconsistent or conflicting messages and potentially reduce splitting. This also can allow other clinicians to air their concerns, and for you to emphasize to them that patients with health anxiety can have an actual medical disease.
Allow patients to discuss their symptoms without interrupting them. This will help them understand that you are listening to them and taking their worries seriously.2 Elicit further discussion by asking them about2:
- their perception of their health
- how frequently they worry about their health
- fears about what could happen
- triggers for their worries
- how seriously they feel other clinicians regard their concerns
- behaviors they use to subdue their worries
- avoidance behaviors
- the impact their worries have on their lives.
Assess patients for the presence of comorbid mental health conditions such as anxiety disorders, mood disorders, psychotic disorders, personality disorders, and substance use disorders. Treating these conditions can help reduce your patients’ health anxiety–related distress and impairment.
Acknowledge that your patients’ symptoms are real to them and genuinely experienced.2 By focusing on worry as the most important symptom and recognizing how discomforting and serious that worry can be, you can validate your patients’ feelings and increase their motivation for continuing treatment.2
Avoid reassuring patients that they are medically healthy, because any relief your patients gain from this can quickly fade, and their anxiety may worsen.2 Instead, acknowledge their concerns by saying, “It’s clear that you are worried about your health. We have ways of helping this, and this will not affect any other treatment you are receiving.”2 This could allow your patients to recognize that they have health anxiety without believing that their medical problems will be disregarded or dismissed.2
Explain to patients that their perceptions could be symptoms of anxiety instead of an actual medical illness, equating health anxiety to a false alarm.2 Ask patients to summarize any information you present to them, because misinterpreting health information is a core feature of health anxiety.2
1. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Hedman-Lagerlöf E, Tyrer P, Hague J, et al. Health anxiety. BMJ. 2019;364:I774. doi: 10.1136/bmj.I774.
3. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
Up to 20% of patients in medical settings experience health anxiety.1,2 In DSM-IV-TR, this condition was called hypochondriasis, and its core feature was having a preoccupation with fears or the idea that one has a serious disease based on a misinterpretation of ≥1 bodily signs or symptoms despite undergoing appropriate medical evaluation.3 In DSM-5, hypochondriasis was removed, and somatic symptom disorder and illness anxiety disorder were introduced.1 Approximately 75% of patients with a previous diagnosis of hypochondriasis meet the diagnostic criteria for somatic symptom disorder, and approximately 25% meet the criteria for illness anxiety disorder.1 In clinical practice, the less pejorative and more commonly used term for these conditions is “health anxiety.”
Patients with health anxiety can be challenging to treat because they persist in believing they have an illness despite appropriate medical evaluation. Clinicians’ responses to such patients can range from feeling the need to do more to alleviate their suffering to strongly disliking them. Although these patients can elicit negative countertransference, we should remember that their lives are being adversely affected due to the substantial functional impairment they experience from their health worries. As psychiatrists, we can help our patients with health anxiety by employing the following strategies.
Maintain constant communication with other clinicians who manage the patient’s medical complaints. A clear line of communication with other clinicians can help minimize inconsistent or conflicting messages and potentially reduce splitting. This also can allow other clinicians to air their concerns, and for you to emphasize to them that patients with health anxiety can have an actual medical disease.
Allow patients to discuss their symptoms without interrupting them. This will help them understand that you are listening to them and taking their worries seriously.2 Elicit further discussion by asking them about2:
- their perception of their health
- how frequently they worry about their health
- fears about what could happen
- triggers for their worries
- how seriously they feel other clinicians regard their concerns
- behaviors they use to subdue their worries
- avoidance behaviors
- the impact their worries have on their lives.
Assess patients for the presence of comorbid mental health conditions such as anxiety disorders, mood disorders, psychotic disorders, personality disorders, and substance use disorders. Treating these conditions can help reduce your patients’ health anxiety–related distress and impairment.
Acknowledge that your patients’ symptoms are real to them and genuinely experienced.2 By focusing on worry as the most important symptom and recognizing how discomforting and serious that worry can be, you can validate your patients’ feelings and increase their motivation for continuing treatment.2
Avoid reassuring patients that they are medically healthy, because any relief your patients gain from this can quickly fade, and their anxiety may worsen.2 Instead, acknowledge their concerns by saying, “It’s clear that you are worried about your health. We have ways of helping this, and this will not affect any other treatment you are receiving.”2 This could allow your patients to recognize that they have health anxiety without believing that their medical problems will be disregarded or dismissed.2
Explain to patients that their perceptions could be symptoms of anxiety instead of an actual medical illness, equating health anxiety to a false alarm.2 Ask patients to summarize any information you present to them, because misinterpreting health information is a core feature of health anxiety.2
Up to 20% of patients in medical settings experience health anxiety.1,2 In DSM-IV-TR, this condition was called hypochondriasis, and its core feature was having a preoccupation with fears or the idea that one has a serious disease based on a misinterpretation of ≥1 bodily signs or symptoms despite undergoing appropriate medical evaluation.3 In DSM-5, hypochondriasis was removed, and somatic symptom disorder and illness anxiety disorder were introduced.1 Approximately 75% of patients with a previous diagnosis of hypochondriasis meet the diagnostic criteria for somatic symptom disorder, and approximately 25% meet the criteria for illness anxiety disorder.1 In clinical practice, the less pejorative and more commonly used term for these conditions is “health anxiety.”
Patients with health anxiety can be challenging to treat because they persist in believing they have an illness despite appropriate medical evaluation. Clinicians’ responses to such patients can range from feeling the need to do more to alleviate their suffering to strongly disliking them. Although these patients can elicit negative countertransference, we should remember that their lives are being adversely affected due to the substantial functional impairment they experience from their health worries. As psychiatrists, we can help our patients with health anxiety by employing the following strategies.
Maintain constant communication with other clinicians who manage the patient’s medical complaints. A clear line of communication with other clinicians can help minimize inconsistent or conflicting messages and potentially reduce splitting. This also can allow other clinicians to air their concerns, and for you to emphasize to them that patients with health anxiety can have an actual medical disease.
Allow patients to discuss their symptoms without interrupting them. This will help them understand that you are listening to them and taking their worries seriously.2 Elicit further discussion by asking them about2:
- their perception of their health
- how frequently they worry about their health
- fears about what could happen
- triggers for their worries
- how seriously they feel other clinicians regard their concerns
- behaviors they use to subdue their worries
- avoidance behaviors
- the impact their worries have on their lives.
Assess patients for the presence of comorbid mental health conditions such as anxiety disorders, mood disorders, psychotic disorders, personality disorders, and substance use disorders. Treating these conditions can help reduce your patients’ health anxiety–related distress and impairment.
Acknowledge that your patients’ symptoms are real to them and genuinely experienced.2 By focusing on worry as the most important symptom and recognizing how discomforting and serious that worry can be, you can validate your patients’ feelings and increase their motivation for continuing treatment.2
Avoid reassuring patients that they are medically healthy, because any relief your patients gain from this can quickly fade, and their anxiety may worsen.2 Instead, acknowledge their concerns by saying, “It’s clear that you are worried about your health. We have ways of helping this, and this will not affect any other treatment you are receiving.”2 This could allow your patients to recognize that they have health anxiety without believing that their medical problems will be disregarded or dismissed.2
Explain to patients that their perceptions could be symptoms of anxiety instead of an actual medical illness, equating health anxiety to a false alarm.2 Ask patients to summarize any information you present to them, because misinterpreting health information is a core feature of health anxiety.2
1. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Hedman-Lagerlöf E, Tyrer P, Hague J, et al. Health anxiety. BMJ. 2019;364:I774. doi: 10.1136/bmj.I774.
3. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
1. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Hedman-Lagerlöf E, Tyrer P, Hague J, et al. Health anxiety. BMJ. 2019;364:I774. doi: 10.1136/bmj.I774.
3. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
Hormone therapy boosts body image in transgender youth
based on data from 148 individuals.
“Understanding the impact of gender-affirming hormone therapy on the mental health of transgender youth is critical given the health disparities documented in this population,” wrote Laura E. Kuper, PhD, of Children’s Health Systems of Texas, Dallas, and colleagues.
In a study published in Pediatrics, the researchers reviewed data from 148 youth aged 9-18 years who underwent gender-affirming hormone therapy in a multidisciplinary program. The average age of the patients was 15 years; 25 were receiving puberty suppression hormones only, 93 were receiving just feminizing or masculinizing hormones, and 30 were receiving both treatments.
At baseline and at approximately 1 year follow-up, all patients completed the Body Image Scale, Quick Inventory of Depressive Symptoms, and Screen for Child Anxiety Related Emotional Disorders. In addition, clinicians collected information on patients’ suicidal ideation, suicide attempts, and nonsuicidal self-injury.
Overall, the average scores on the Body Image Scale on body dissatisfaction decreased from 70 to 52, and average scores on the Quick Inventory of Depressive Symptoms decreased from 9 to 7; both were statistically significant (P less than .001), as were changes from baseline on the anxiety subscale of the Screen for Child Anxiety Related Emotional Disorders, which decreased from 32 to 29 (P less than .01). No change occurred in the average overall clinician-reported depressive symptoms.
During the follow-up period, the rates of suicidal ideation, suicide attempts, and nonsuicidal self-injury were 38%, 5%, and 17%, respectively. Of patients who reported these experiences, the lifetime histories of suicidal ideation, suicide attempts, and nonsuicidal self-injury were 81%, 15%, and 52%, respectively.
The findings were limited by several factors including some missing data and the relatively small sample size, the researchers noted.
Nonetheless, the results suggest “that youth receiving gender-affirming hormone therapy experience meaningful short-term improvements in body dissatisfaction, and no participants discontinued feminizing or masculinizing hormone therapy.” These results support the use of such therapy, Dr. Kuper and associates wrote.
The study is important because of the need for evidence that hormones actually improve patient outcomes, said Shauna M. Lawlis, MD, of the University of Oklahoma Medical Center, Oklahoma City.
“Especially given the rash of legislation across the country aimed at blocking care for transgender youth, it is helpful to show that these treatments really do decrease patients’ anxiety and depressive symptoms,” she said in an interview. “In addition, previous research has been focused on those who have undergone puberty suppression followed by gender-affirming hormone therapy, but many patients are too far along in puberty for puberty suppression to be effective and providers often go straight to gender-affirming hormones in those cases.”
Dr. Lawlis said she was not at all surprised by the study findings. “In my own practice, I have seen patients improve greatly on gender-affirming hormones with overall improvement in anxiety and depression. As a patient’s outward appearance more closely matches their gender identity, they feel more comfortable in their own bodies and their interactions with the world around them, thus improving these symptoms.”
Dr. Lawlis added that the message for pediatricians who treat transgender youth is simple: Gender-affirming hormones improve patient outcomes. “They are essential for the mental health of this vulnerable population.”
She noted that long-term follow-up studies would be useful. “There is still a lot of concern about regret and detransitioning among health care providers and the general population – showing that patients maintain satisfaction in the long-term would be helpful.
“In addition, long-term studies about other health outcomes (cardiovascular disease, cancer risk, etc.) would also be helpful,” said Dr. Lawlis, who was asked to comment on this study, with which she had no involvement.
The study was supported in part by Children’s Health. The researchers had no financial conflicts to disclose. Dr. Lawlis had no relevant financial disclosures.
SOURCE: Kuper LE et al. Pediatrics. 2020 Mar 27. doi: 10.1542/peds.2019-3006.
based on data from 148 individuals.
“Understanding the impact of gender-affirming hormone therapy on the mental health of transgender youth is critical given the health disparities documented in this population,” wrote Laura E. Kuper, PhD, of Children’s Health Systems of Texas, Dallas, and colleagues.
In a study published in Pediatrics, the researchers reviewed data from 148 youth aged 9-18 years who underwent gender-affirming hormone therapy in a multidisciplinary program. The average age of the patients was 15 years; 25 were receiving puberty suppression hormones only, 93 were receiving just feminizing or masculinizing hormones, and 30 were receiving both treatments.
At baseline and at approximately 1 year follow-up, all patients completed the Body Image Scale, Quick Inventory of Depressive Symptoms, and Screen for Child Anxiety Related Emotional Disorders. In addition, clinicians collected information on patients’ suicidal ideation, suicide attempts, and nonsuicidal self-injury.
Overall, the average scores on the Body Image Scale on body dissatisfaction decreased from 70 to 52, and average scores on the Quick Inventory of Depressive Symptoms decreased from 9 to 7; both were statistically significant (P less than .001), as were changes from baseline on the anxiety subscale of the Screen for Child Anxiety Related Emotional Disorders, which decreased from 32 to 29 (P less than .01). No change occurred in the average overall clinician-reported depressive symptoms.
During the follow-up period, the rates of suicidal ideation, suicide attempts, and nonsuicidal self-injury were 38%, 5%, and 17%, respectively. Of patients who reported these experiences, the lifetime histories of suicidal ideation, suicide attempts, and nonsuicidal self-injury were 81%, 15%, and 52%, respectively.
The findings were limited by several factors including some missing data and the relatively small sample size, the researchers noted.
Nonetheless, the results suggest “that youth receiving gender-affirming hormone therapy experience meaningful short-term improvements in body dissatisfaction, and no participants discontinued feminizing or masculinizing hormone therapy.” These results support the use of such therapy, Dr. Kuper and associates wrote.
The study is important because of the need for evidence that hormones actually improve patient outcomes, said Shauna M. Lawlis, MD, of the University of Oklahoma Medical Center, Oklahoma City.
“Especially given the rash of legislation across the country aimed at blocking care for transgender youth, it is helpful to show that these treatments really do decrease patients’ anxiety and depressive symptoms,” she said in an interview. “In addition, previous research has been focused on those who have undergone puberty suppression followed by gender-affirming hormone therapy, but many patients are too far along in puberty for puberty suppression to be effective and providers often go straight to gender-affirming hormones in those cases.”
Dr. Lawlis said she was not at all surprised by the study findings. “In my own practice, I have seen patients improve greatly on gender-affirming hormones with overall improvement in anxiety and depression. As a patient’s outward appearance more closely matches their gender identity, they feel more comfortable in their own bodies and their interactions with the world around them, thus improving these symptoms.”
Dr. Lawlis added that the message for pediatricians who treat transgender youth is simple: Gender-affirming hormones improve patient outcomes. “They are essential for the mental health of this vulnerable population.”
She noted that long-term follow-up studies would be useful. “There is still a lot of concern about regret and detransitioning among health care providers and the general population – showing that patients maintain satisfaction in the long-term would be helpful.
“In addition, long-term studies about other health outcomes (cardiovascular disease, cancer risk, etc.) would also be helpful,” said Dr. Lawlis, who was asked to comment on this study, with which she had no involvement.
The study was supported in part by Children’s Health. The researchers had no financial conflicts to disclose. Dr. Lawlis had no relevant financial disclosures.
SOURCE: Kuper LE et al. Pediatrics. 2020 Mar 27. doi: 10.1542/peds.2019-3006.
based on data from 148 individuals.
“Understanding the impact of gender-affirming hormone therapy on the mental health of transgender youth is critical given the health disparities documented in this population,” wrote Laura E. Kuper, PhD, of Children’s Health Systems of Texas, Dallas, and colleagues.
In a study published in Pediatrics, the researchers reviewed data from 148 youth aged 9-18 years who underwent gender-affirming hormone therapy in a multidisciplinary program. The average age of the patients was 15 years; 25 were receiving puberty suppression hormones only, 93 were receiving just feminizing or masculinizing hormones, and 30 were receiving both treatments.
At baseline and at approximately 1 year follow-up, all patients completed the Body Image Scale, Quick Inventory of Depressive Symptoms, and Screen for Child Anxiety Related Emotional Disorders. In addition, clinicians collected information on patients’ suicidal ideation, suicide attempts, and nonsuicidal self-injury.
Overall, the average scores on the Body Image Scale on body dissatisfaction decreased from 70 to 52, and average scores on the Quick Inventory of Depressive Symptoms decreased from 9 to 7; both were statistically significant (P less than .001), as were changes from baseline on the anxiety subscale of the Screen for Child Anxiety Related Emotional Disorders, which decreased from 32 to 29 (P less than .01). No change occurred in the average overall clinician-reported depressive symptoms.
During the follow-up period, the rates of suicidal ideation, suicide attempts, and nonsuicidal self-injury were 38%, 5%, and 17%, respectively. Of patients who reported these experiences, the lifetime histories of suicidal ideation, suicide attempts, and nonsuicidal self-injury were 81%, 15%, and 52%, respectively.
The findings were limited by several factors including some missing data and the relatively small sample size, the researchers noted.
Nonetheless, the results suggest “that youth receiving gender-affirming hormone therapy experience meaningful short-term improvements in body dissatisfaction, and no participants discontinued feminizing or masculinizing hormone therapy.” These results support the use of such therapy, Dr. Kuper and associates wrote.
The study is important because of the need for evidence that hormones actually improve patient outcomes, said Shauna M. Lawlis, MD, of the University of Oklahoma Medical Center, Oklahoma City.
“Especially given the rash of legislation across the country aimed at blocking care for transgender youth, it is helpful to show that these treatments really do decrease patients’ anxiety and depressive symptoms,” she said in an interview. “In addition, previous research has been focused on those who have undergone puberty suppression followed by gender-affirming hormone therapy, but many patients are too far along in puberty for puberty suppression to be effective and providers often go straight to gender-affirming hormones in those cases.”
Dr. Lawlis said she was not at all surprised by the study findings. “In my own practice, I have seen patients improve greatly on gender-affirming hormones with overall improvement in anxiety and depression. As a patient’s outward appearance more closely matches their gender identity, they feel more comfortable in their own bodies and their interactions with the world around them, thus improving these symptoms.”
Dr. Lawlis added that the message for pediatricians who treat transgender youth is simple: Gender-affirming hormones improve patient outcomes. “They are essential for the mental health of this vulnerable population.”
She noted that long-term follow-up studies would be useful. “There is still a lot of concern about regret and detransitioning among health care providers and the general population – showing that patients maintain satisfaction in the long-term would be helpful.
“In addition, long-term studies about other health outcomes (cardiovascular disease, cancer risk, etc.) would also be helpful,” said Dr. Lawlis, who was asked to comment on this study, with which she had no involvement.
The study was supported in part by Children’s Health. The researchers had no financial conflicts to disclose. Dr. Lawlis had no relevant financial disclosures.
SOURCE: Kuper LE et al. Pediatrics. 2020 Mar 27. doi: 10.1542/peds.2019-3006.
FROM PEDIATRICS
Psychiatrists deemed ‘essential’ in time of COVID-19
New American Psychiatric Association poll shows depth of anxiety
The coronavirus pandemic weighs heavily on psychiatric patients with conditions such as anxiety, depression and PTSD. Meanwhile, a national poll released March 25 by the American Psychiatric Association shows that almost half of all Americans are anxious about contracting COVID-19 and 40% are anxious about becoming seriously ill or dying from the virus. In light of stressors on patients and nonpatients alike, mental health professionals have a key role in helping to alleviate suffering tied to the public health crisis, according to psychiatrists from across the country.
“There’s so much we can do to help people put order on this chaos,” said Shaili Jain, MD, section chief of outpatient mental health with the Veterans Affairs Palo Alto (Calif.) Health Care System, in an interview. “We are essential workers in this time.”
Dr. Jain, who specializes in treating PTSD, said those patients are especially vulnerable to the stress and disruptions spawned by the pandemic. “When you go to the grocery store and there’s no food, that can be triggering for people who survived situations with a feeling of calamity or panic,” she said. “People are reporting worsening of nightmares and spontaneous panic attacks after having been stable with symptoms for many months. These are the kinds of stories that are starting to filter through.”
To make things even more difficult, she said, shelter-in-place orders are preventing patients from taking advantage of healthy coping strategies, such as working out at the gym or going to support groups. “We have an invaluable role to play in trying to prevent long-term consequences by going into problem-solving modes with patients.” Dr. Jain offered several tips that might help patients who are suffering:
- Use technology to stay in touch with support communities and boost self-care. “How can you be flexible with FaceTime, Skype, or phone even if you might not be able to have that face-to-face time? What are you doing to double down on your efforts at self-care – listening to music, reading, daily meditation, or walks? Double down on what you can do to prevent anxiety and stress levels from building up.”
- Take breaks from the news, which can contribute to hypervigilance and disrupted sleep. “I’m seeing that people are going down these rabbit holes of having the news or social media on 24/7,” Dr. Jain said. “You have to stay informed. But you need to pick trusted news sources and have chunks of time that are free of coronavirus coverage.” Understand that life is going to be difficult for a while. “We’re doing a lot of reassurance and education,” she said, “helping people to know and accept that the next few days, weeks, and months are going to be stressful.”
Dr. Jain cautioned colleagues, however, that “there will be a tsunami” of mental illness when the coronavirus crisis lifts. She is especially concerned about patient populations that are socioeconomically disadvantaged already and how their lives with be affected by lost wages, unemployment, and business failures. “Medical professionals will see the consequences of this in the days and weeks and months after the pandemic has settled,” she predicted.
The APA poll shows that, early in the crisis, more than 60% of people are anxious about family and loved ones contracting COVID-19.
Maintaining ‘reflective space’ essential
At the Austen Riggs Center, a psychiatric residential treatment facility in Stockbridge, Mass., staff and patients are adjusting to new rules that aim to prevent transmission of the novel coronavirus. “Social distancing requirements are having a huge impact,” said Eric M. Plakun, MD, medical director and CEO of Austen Riggs, in an interview. “You can’t have groups in the same way; you can’t have families come in for a family meeting; you can’t have quite the same the freedom to come and go. A lot of management issues are being addressed, but it is crucial also to maintain the ‘reflective space’ essential to do the kind of clinical work we do.” One approach, he said, is virtual meetings with colleagues that address on-the-job management issues, but also leave a space for how staff members are feeling.
“It’s easy to get into crisis-response mode,” he said, “where you’re always managing but never leave a space to talk about vulnerability, helplessness, and fear.”
As the facility’s staff adjusts by embracing teleconference technology and adapting group meetings to the 6-feet-apart rule,
Dr. Plakun said he said, noting that patients have approached staff members to say they want to collaborate about changes. “That’s a credible offer we intend to accept.”
Still, communicating with patients as a whole about the coronavirus can be difficult. As Dr. Plakun noted, it’s now impossible to bring 75 people together into one room for a meeting. “If you have four to five smaller meetings, how do you maintain some congruence in the information that’s presented?”
Dr. Plakun suggested that colleagues find time to engage in the familiar, such as face-to-face clinical work. “That’s been the most reassuring and rewarding part of my day since it feels almost like normal,” he said.
Stocking up on medications
Jessica “Jessi” Gold, MD, MS, an assistant professor at Washington University in St. Louis, often treats college students. Asian students started to worry early in the pandemic, she said in an interview.
“At the beginning, there were a lot of concerns about the public’s view: ‘Did this come from China? Is it China’s fault?’ A lot of our students felt that if they coughed, and they were a white person, they’d be OK. But if they were Asian, everyone would wonder why they were in class and not at home. That got worse over time: the fear about – and anxiety from – stoking racism.”
Later, as classes began to be canceled, Dr. Gold started to see the psychological effects of disruption and uncertainty about the future. “This can lead people to feel like what they knew before is just not there anymore. This can obviously cause anxiety but also has the potential to cause depression.” Patients also might slip into overuse of alcohol and drugs, or they might engage in other kinds of harmful behavior. Eating disorders, for example, “are ways to have control when other things aren’t in control,” she said.
Dr. Gold pointed to research into the mental health after effects of quarantines, such as those imposed during the SARS outbreak. A review of 24 studies published this year found that most “reported negative psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects” (Lancet. 2020;395:912-20).
Dr. Gold is urging patients to recall the warning signs that alerted them to psychological downturns in the past: “Try to remember what those warning signs are and pay attention to whether you see them.” And, Dr. Gold said, she asks patients to think about what has helped them get better.
In some cases, she said, patients are already preparing themselves for experiencing mental distress by stocking up on medications. “Some people have a bottle of 10-20 pills that they only use in emergencies and keep as a kind of security blanket,” she said, and she’s seen some of them ask for refills. It seems they’ve either taken the pills recently or want to stash them just in case. This makes sense, since their anxiety is higher, she said.
Dr. Gold cautioned that psychiatrists need to be careful to not overextend themselves when they’re not treating patients. “It is easy to be therapist to friends, family, and colleagues,” she said, “but we need to take care of ourselves, too.”
Dr. Jain is author of “The Unspeakable Mind: Stories of Trauma and Healing From the Frontlines of PTSD Science” (New York: Harper, 2019). She has no other disclosures. Dr. Plakun and Dr. Gold reported no relevant disclosures.
New American Psychiatric Association poll shows depth of anxiety
New American Psychiatric Association poll shows depth of anxiety
The coronavirus pandemic weighs heavily on psychiatric patients with conditions such as anxiety, depression and PTSD. Meanwhile, a national poll released March 25 by the American Psychiatric Association shows that almost half of all Americans are anxious about contracting COVID-19 and 40% are anxious about becoming seriously ill or dying from the virus. In light of stressors on patients and nonpatients alike, mental health professionals have a key role in helping to alleviate suffering tied to the public health crisis, according to psychiatrists from across the country.
“There’s so much we can do to help people put order on this chaos,” said Shaili Jain, MD, section chief of outpatient mental health with the Veterans Affairs Palo Alto (Calif.) Health Care System, in an interview. “We are essential workers in this time.”
Dr. Jain, who specializes in treating PTSD, said those patients are especially vulnerable to the stress and disruptions spawned by the pandemic. “When you go to the grocery store and there’s no food, that can be triggering for people who survived situations with a feeling of calamity or panic,” she said. “People are reporting worsening of nightmares and spontaneous panic attacks after having been stable with symptoms for many months. These are the kinds of stories that are starting to filter through.”
To make things even more difficult, she said, shelter-in-place orders are preventing patients from taking advantage of healthy coping strategies, such as working out at the gym or going to support groups. “We have an invaluable role to play in trying to prevent long-term consequences by going into problem-solving modes with patients.” Dr. Jain offered several tips that might help patients who are suffering:
- Use technology to stay in touch with support communities and boost self-care. “How can you be flexible with FaceTime, Skype, or phone even if you might not be able to have that face-to-face time? What are you doing to double down on your efforts at self-care – listening to music, reading, daily meditation, or walks? Double down on what you can do to prevent anxiety and stress levels from building up.”
- Take breaks from the news, which can contribute to hypervigilance and disrupted sleep. “I’m seeing that people are going down these rabbit holes of having the news or social media on 24/7,” Dr. Jain said. “You have to stay informed. But you need to pick trusted news sources and have chunks of time that are free of coronavirus coverage.” Understand that life is going to be difficult for a while. “We’re doing a lot of reassurance and education,” she said, “helping people to know and accept that the next few days, weeks, and months are going to be stressful.”
Dr. Jain cautioned colleagues, however, that “there will be a tsunami” of mental illness when the coronavirus crisis lifts. She is especially concerned about patient populations that are socioeconomically disadvantaged already and how their lives with be affected by lost wages, unemployment, and business failures. “Medical professionals will see the consequences of this in the days and weeks and months after the pandemic has settled,” she predicted.
The APA poll shows that, early in the crisis, more than 60% of people are anxious about family and loved ones contracting COVID-19.
Maintaining ‘reflective space’ essential
At the Austen Riggs Center, a psychiatric residential treatment facility in Stockbridge, Mass., staff and patients are adjusting to new rules that aim to prevent transmission of the novel coronavirus. “Social distancing requirements are having a huge impact,” said Eric M. Plakun, MD, medical director and CEO of Austen Riggs, in an interview. “You can’t have groups in the same way; you can’t have families come in for a family meeting; you can’t have quite the same the freedom to come and go. A lot of management issues are being addressed, but it is crucial also to maintain the ‘reflective space’ essential to do the kind of clinical work we do.” One approach, he said, is virtual meetings with colleagues that address on-the-job management issues, but also leave a space for how staff members are feeling.
“It’s easy to get into crisis-response mode,” he said, “where you’re always managing but never leave a space to talk about vulnerability, helplessness, and fear.”
As the facility’s staff adjusts by embracing teleconference technology and adapting group meetings to the 6-feet-apart rule,
Dr. Plakun said he said, noting that patients have approached staff members to say they want to collaborate about changes. “That’s a credible offer we intend to accept.”
Still, communicating with patients as a whole about the coronavirus can be difficult. As Dr. Plakun noted, it’s now impossible to bring 75 people together into one room for a meeting. “If you have four to five smaller meetings, how do you maintain some congruence in the information that’s presented?”
Dr. Plakun suggested that colleagues find time to engage in the familiar, such as face-to-face clinical work. “That’s been the most reassuring and rewarding part of my day since it feels almost like normal,” he said.
Stocking up on medications
Jessica “Jessi” Gold, MD, MS, an assistant professor at Washington University in St. Louis, often treats college students. Asian students started to worry early in the pandemic, she said in an interview.
“At the beginning, there were a lot of concerns about the public’s view: ‘Did this come from China? Is it China’s fault?’ A lot of our students felt that if they coughed, and they were a white person, they’d be OK. But if they were Asian, everyone would wonder why they were in class and not at home. That got worse over time: the fear about – and anxiety from – stoking racism.”
Later, as classes began to be canceled, Dr. Gold started to see the psychological effects of disruption and uncertainty about the future. “This can lead people to feel like what they knew before is just not there anymore. This can obviously cause anxiety but also has the potential to cause depression.” Patients also might slip into overuse of alcohol and drugs, or they might engage in other kinds of harmful behavior. Eating disorders, for example, “are ways to have control when other things aren’t in control,” she said.
Dr. Gold pointed to research into the mental health after effects of quarantines, such as those imposed during the SARS outbreak. A review of 24 studies published this year found that most “reported negative psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects” (Lancet. 2020;395:912-20).
Dr. Gold is urging patients to recall the warning signs that alerted them to psychological downturns in the past: “Try to remember what those warning signs are and pay attention to whether you see them.” And, Dr. Gold said, she asks patients to think about what has helped them get better.
In some cases, she said, patients are already preparing themselves for experiencing mental distress by stocking up on medications. “Some people have a bottle of 10-20 pills that they only use in emergencies and keep as a kind of security blanket,” she said, and she’s seen some of them ask for refills. It seems they’ve either taken the pills recently or want to stash them just in case. This makes sense, since their anxiety is higher, she said.
Dr. Gold cautioned that psychiatrists need to be careful to not overextend themselves when they’re not treating patients. “It is easy to be therapist to friends, family, and colleagues,” she said, “but we need to take care of ourselves, too.”
Dr. Jain is author of “The Unspeakable Mind: Stories of Trauma and Healing From the Frontlines of PTSD Science” (New York: Harper, 2019). She has no other disclosures. Dr. Plakun and Dr. Gold reported no relevant disclosures.
The coronavirus pandemic weighs heavily on psychiatric patients with conditions such as anxiety, depression and PTSD. Meanwhile, a national poll released March 25 by the American Psychiatric Association shows that almost half of all Americans are anxious about contracting COVID-19 and 40% are anxious about becoming seriously ill or dying from the virus. In light of stressors on patients and nonpatients alike, mental health professionals have a key role in helping to alleviate suffering tied to the public health crisis, according to psychiatrists from across the country.
“There’s so much we can do to help people put order on this chaos,” said Shaili Jain, MD, section chief of outpatient mental health with the Veterans Affairs Palo Alto (Calif.) Health Care System, in an interview. “We are essential workers in this time.”
Dr. Jain, who specializes in treating PTSD, said those patients are especially vulnerable to the stress and disruptions spawned by the pandemic. “When you go to the grocery store and there’s no food, that can be triggering for people who survived situations with a feeling of calamity or panic,” she said. “People are reporting worsening of nightmares and spontaneous panic attacks after having been stable with symptoms for many months. These are the kinds of stories that are starting to filter through.”
To make things even more difficult, she said, shelter-in-place orders are preventing patients from taking advantage of healthy coping strategies, such as working out at the gym or going to support groups. “We have an invaluable role to play in trying to prevent long-term consequences by going into problem-solving modes with patients.” Dr. Jain offered several tips that might help patients who are suffering:
- Use technology to stay in touch with support communities and boost self-care. “How can you be flexible with FaceTime, Skype, or phone even if you might not be able to have that face-to-face time? What are you doing to double down on your efforts at self-care – listening to music, reading, daily meditation, or walks? Double down on what you can do to prevent anxiety and stress levels from building up.”
- Take breaks from the news, which can contribute to hypervigilance and disrupted sleep. “I’m seeing that people are going down these rabbit holes of having the news or social media on 24/7,” Dr. Jain said. “You have to stay informed. But you need to pick trusted news sources and have chunks of time that are free of coronavirus coverage.” Understand that life is going to be difficult for a while. “We’re doing a lot of reassurance and education,” she said, “helping people to know and accept that the next few days, weeks, and months are going to be stressful.”
Dr. Jain cautioned colleagues, however, that “there will be a tsunami” of mental illness when the coronavirus crisis lifts. She is especially concerned about patient populations that are socioeconomically disadvantaged already and how their lives with be affected by lost wages, unemployment, and business failures. “Medical professionals will see the consequences of this in the days and weeks and months after the pandemic has settled,” she predicted.
The APA poll shows that, early in the crisis, more than 60% of people are anxious about family and loved ones contracting COVID-19.
Maintaining ‘reflective space’ essential
At the Austen Riggs Center, a psychiatric residential treatment facility in Stockbridge, Mass., staff and patients are adjusting to new rules that aim to prevent transmission of the novel coronavirus. “Social distancing requirements are having a huge impact,” said Eric M. Plakun, MD, medical director and CEO of Austen Riggs, in an interview. “You can’t have groups in the same way; you can’t have families come in for a family meeting; you can’t have quite the same the freedom to come and go. A lot of management issues are being addressed, but it is crucial also to maintain the ‘reflective space’ essential to do the kind of clinical work we do.” One approach, he said, is virtual meetings with colleagues that address on-the-job management issues, but also leave a space for how staff members are feeling.
“It’s easy to get into crisis-response mode,” he said, “where you’re always managing but never leave a space to talk about vulnerability, helplessness, and fear.”
As the facility’s staff adjusts by embracing teleconference technology and adapting group meetings to the 6-feet-apart rule,
Dr. Plakun said he said, noting that patients have approached staff members to say they want to collaborate about changes. “That’s a credible offer we intend to accept.”
Still, communicating with patients as a whole about the coronavirus can be difficult. As Dr. Plakun noted, it’s now impossible to bring 75 people together into one room for a meeting. “If you have four to five smaller meetings, how do you maintain some congruence in the information that’s presented?”
Dr. Plakun suggested that colleagues find time to engage in the familiar, such as face-to-face clinical work. “That’s been the most reassuring and rewarding part of my day since it feels almost like normal,” he said.
Stocking up on medications
Jessica “Jessi” Gold, MD, MS, an assistant professor at Washington University in St. Louis, often treats college students. Asian students started to worry early in the pandemic, she said in an interview.
“At the beginning, there were a lot of concerns about the public’s view: ‘Did this come from China? Is it China’s fault?’ A lot of our students felt that if they coughed, and they were a white person, they’d be OK. But if they were Asian, everyone would wonder why they were in class and not at home. That got worse over time: the fear about – and anxiety from – stoking racism.”
Later, as classes began to be canceled, Dr. Gold started to see the psychological effects of disruption and uncertainty about the future. “This can lead people to feel like what they knew before is just not there anymore. This can obviously cause anxiety but also has the potential to cause depression.” Patients also might slip into overuse of alcohol and drugs, or they might engage in other kinds of harmful behavior. Eating disorders, for example, “are ways to have control when other things aren’t in control,” she said.
Dr. Gold pointed to research into the mental health after effects of quarantines, such as those imposed during the SARS outbreak. A review of 24 studies published this year found that most “reported negative psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects” (Lancet. 2020;395:912-20).
Dr. Gold is urging patients to recall the warning signs that alerted them to psychological downturns in the past: “Try to remember what those warning signs are and pay attention to whether you see them.” And, Dr. Gold said, she asks patients to think about what has helped them get better.
In some cases, she said, patients are already preparing themselves for experiencing mental distress by stocking up on medications. “Some people have a bottle of 10-20 pills that they only use in emergencies and keep as a kind of security blanket,” she said, and she’s seen some of them ask for refills. It seems they’ve either taken the pills recently or want to stash them just in case. This makes sense, since their anxiety is higher, she said.
Dr. Gold cautioned that psychiatrists need to be careful to not overextend themselves when they’re not treating patients. “It is easy to be therapist to friends, family, and colleagues,” she said, “but we need to take care of ourselves, too.”
Dr. Jain is author of “The Unspeakable Mind: Stories of Trauma and Healing From the Frontlines of PTSD Science” (New York: Harper, 2019). She has no other disclosures. Dr. Plakun and Dr. Gold reported no relevant disclosures.
Is COVID-19 leading to a mental illness pandemic?
People living through this crisis are experiencing trauma
We are in the midst of an epidemic and possibly pandemic of anxiety and distress. The worry that folks have about themselves, families, finances, and work is overwhelming for millions.
I speak with people who report periods of racing thoughts jumping back in time and thinking of roads not taken. They also talk about their thoughts jumping forward with life plans of what they’ll do to change their lives in the future – if they survive COVID-19.
that is well-controlled with care (and even without care). Those people are suffering even more. Meanwhile, people with obsessive-compulsive disorder that had been under control appear to have worsened with the added stress.
Social distancing has disrupted our everyday routines. For many, there is no work, no spending time with people we care about, no going to movies or shows, no doing discretionary shopping, no going to school. Parents with children at home report frustration about balancing working from home with completing home-schooling packets. Physicians on the front lines of this unprecedented time report not having the proper protective equipment and worrying about the possibility of exposing their families to SARS-CoV-2.
We hear stories about the illness and even deaths of some young and middle-aged people with no underlying conditions, not to mention the loss of older adults. People are bursting into tears, and becoming easily frustrated and angry. Add in nightmares, ongoing anxiety states, insomnia, and decreased concentration.
We are seeing news reports of people stocking up on guns and ammunition and a case of one taking – and dying from – nonpharmaceutical grade chloroquine in an effort to prevent COVID-19.
I spoke with Juliana Tseng, PsyD, a clinical psychologist based in New York, and she said that the hype, half-truths, and false information from some outlets in the popular media are making things worse. Dr. Tseng added that the lack of coordination among local, state, and federal governments also is increasing fear and alienation.
As I see this period in time, my first thoughts are that we are witnessing a national epidemic of trauma. Specifically, what we have here is a clinical picture of PTSD.
PTSD is defined clearly as a traumatic disorder with a real or perceived fracture with life. Isolation (which we are creating as a way to “flatten the curve” or slow the spread of COVID-19), although that strategy is in our best personal and public health interests, is both painful and stressful. Frustration, flashbacks of past life experiences plus flashbacks of being ill are reported in people I’ve spoken with. Avoidance, even though it is planned in this instance, is part of the PTSD complex.
What can we as mental health professionals do to help alleviate this suffering?
First, of course, we must listen to the scientific experts and the data – and tell people to do the same. Most experts will say that COVID-19 is a mild or moderate illness for the vast majority of people. We also must encourage people to observe precautions outlined by the Centers for Disease Control and Prevention, such as distancing from people, hand washing, and avoiding those who are ill. Explain to people that, currently, there is no vaccine to prevent COVID-19. Treatment is mainly supportive, and some medication trials are being explored. However, we can empower people by helping them to develop skills aimed at increasing the ability to relax and focus on more positive aspects of life to break the chain of the stress and tension of anxiety as well as control the PTSD.
For more than 40 years, I have helped people master relaxation techniques and guided imagery. When taught properly, people are able to use these techniques on their own.
To begin, I teach people how to relax, using a simple three-point method:
- Get comfortable in a nice chair, and slowly count from one to three. At the count of one, do one thing: “roll your eyes up to the top of your head.”
- At the count of two, do two things, “close your lids on your eyes and take a deep breath.”
- At three, exhale slowly, relax your eyes, and concentrate on a restful feeling of floating.
- Do this for about 30 seconds to a minute.
- Count backward, from three to two to one and open your eyes.
The person will notice how nice and restful they will feel.
After that exercise, get the person to move to the graduate level and go beyond just relaxation. In the following exercise, people can go into a relaxed state by imagining a movie screen. Tell the person to do two things:
1. Look at the imagined movie screen and project on it any pleasant scene you wish; this is your screen. You will feel yourself becoming more and more relaxed. The person can do this one, two, three or whatever times a day. The exercise can last 1 minute or 5.
2. Incorporate the 1, 2, 3 relaxation described earlier, allowing yourself to float into this restful state and go to your movie screen. Now, on the screen, imagine a thick line down the center, and on the left side, project your worries and anxieties and fears. The idea is to see but not experience them. Then shift to the ride side of the screen, and again, visualize any pleasant scene you wish. Again, do this for 1 minute or 5 minutes, whatever works.
You will notice that the pleasant scene on the right will overcome the anxiety scene on the left, in that pleasantness, in most instances, overcomes anxiety. For many, these techniques have proved very useful – whether the problem is anxiety or fear – or both. In my experience, these techniques are a good beginning for controlling PTSD and successfully treating it.
We are in the midst of what could be the biggest public health crisis that America has faced since the 1918 pandemic, also known as the Spanish flu. The lockdowns, quarantines, and the myriad of other disruptions can lead to alienation. In fact, it would be strange for us not to experience strong emotions under these extreme conditions. Life will get better! In the meantime, let’s encourage people to hope, pray, and use relaxation techniques and guided imagery approaches to help control anxiety, worry, stress, and issues related to PTSD. These approaches can give our minds and bodies periods of relaxation and recovery, and ultimately, they can calm our minds.
Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.
People living through this crisis are experiencing trauma
People living through this crisis are experiencing trauma
We are in the midst of an epidemic and possibly pandemic of anxiety and distress. The worry that folks have about themselves, families, finances, and work is overwhelming for millions.
I speak with people who report periods of racing thoughts jumping back in time and thinking of roads not taken. They also talk about their thoughts jumping forward with life plans of what they’ll do to change their lives in the future – if they survive COVID-19.
that is well-controlled with care (and even without care). Those people are suffering even more. Meanwhile, people with obsessive-compulsive disorder that had been under control appear to have worsened with the added stress.
Social distancing has disrupted our everyday routines. For many, there is no work, no spending time with people we care about, no going to movies or shows, no doing discretionary shopping, no going to school. Parents with children at home report frustration about balancing working from home with completing home-schooling packets. Physicians on the front lines of this unprecedented time report not having the proper protective equipment and worrying about the possibility of exposing their families to SARS-CoV-2.
We hear stories about the illness and even deaths of some young and middle-aged people with no underlying conditions, not to mention the loss of older adults. People are bursting into tears, and becoming easily frustrated and angry. Add in nightmares, ongoing anxiety states, insomnia, and decreased concentration.
We are seeing news reports of people stocking up on guns and ammunition and a case of one taking – and dying from – nonpharmaceutical grade chloroquine in an effort to prevent COVID-19.
I spoke with Juliana Tseng, PsyD, a clinical psychologist based in New York, and she said that the hype, half-truths, and false information from some outlets in the popular media are making things worse. Dr. Tseng added that the lack of coordination among local, state, and federal governments also is increasing fear and alienation.
As I see this period in time, my first thoughts are that we are witnessing a national epidemic of trauma. Specifically, what we have here is a clinical picture of PTSD.
PTSD is defined clearly as a traumatic disorder with a real or perceived fracture with life. Isolation (which we are creating as a way to “flatten the curve” or slow the spread of COVID-19), although that strategy is in our best personal and public health interests, is both painful and stressful. Frustration, flashbacks of past life experiences plus flashbacks of being ill are reported in people I’ve spoken with. Avoidance, even though it is planned in this instance, is part of the PTSD complex.
What can we as mental health professionals do to help alleviate this suffering?
First, of course, we must listen to the scientific experts and the data – and tell people to do the same. Most experts will say that COVID-19 is a mild or moderate illness for the vast majority of people. We also must encourage people to observe precautions outlined by the Centers for Disease Control and Prevention, such as distancing from people, hand washing, and avoiding those who are ill. Explain to people that, currently, there is no vaccine to prevent COVID-19. Treatment is mainly supportive, and some medication trials are being explored. However, we can empower people by helping them to develop skills aimed at increasing the ability to relax and focus on more positive aspects of life to break the chain of the stress and tension of anxiety as well as control the PTSD.
For more than 40 years, I have helped people master relaxation techniques and guided imagery. When taught properly, people are able to use these techniques on their own.
To begin, I teach people how to relax, using a simple three-point method:
- Get comfortable in a nice chair, and slowly count from one to three. At the count of one, do one thing: “roll your eyes up to the top of your head.”
- At the count of two, do two things, “close your lids on your eyes and take a deep breath.”
- At three, exhale slowly, relax your eyes, and concentrate on a restful feeling of floating.
- Do this for about 30 seconds to a minute.
- Count backward, from three to two to one and open your eyes.
The person will notice how nice and restful they will feel.
After that exercise, get the person to move to the graduate level and go beyond just relaxation. In the following exercise, people can go into a relaxed state by imagining a movie screen. Tell the person to do two things:
1. Look at the imagined movie screen and project on it any pleasant scene you wish; this is your screen. You will feel yourself becoming more and more relaxed. The person can do this one, two, three or whatever times a day. The exercise can last 1 minute or 5.
2. Incorporate the 1, 2, 3 relaxation described earlier, allowing yourself to float into this restful state and go to your movie screen. Now, on the screen, imagine a thick line down the center, and on the left side, project your worries and anxieties and fears. The idea is to see but not experience them. Then shift to the ride side of the screen, and again, visualize any pleasant scene you wish. Again, do this for 1 minute or 5 minutes, whatever works.
You will notice that the pleasant scene on the right will overcome the anxiety scene on the left, in that pleasantness, in most instances, overcomes anxiety. For many, these techniques have proved very useful – whether the problem is anxiety or fear – or both. In my experience, these techniques are a good beginning for controlling PTSD and successfully treating it.
We are in the midst of what could be the biggest public health crisis that America has faced since the 1918 pandemic, also known as the Spanish flu. The lockdowns, quarantines, and the myriad of other disruptions can lead to alienation. In fact, it would be strange for us not to experience strong emotions under these extreme conditions. Life will get better! In the meantime, let’s encourage people to hope, pray, and use relaxation techniques and guided imagery approaches to help control anxiety, worry, stress, and issues related to PTSD. These approaches can give our minds and bodies periods of relaxation and recovery, and ultimately, they can calm our minds.
Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.
We are in the midst of an epidemic and possibly pandemic of anxiety and distress. The worry that folks have about themselves, families, finances, and work is overwhelming for millions.
I speak with people who report periods of racing thoughts jumping back in time and thinking of roads not taken. They also talk about their thoughts jumping forward with life plans of what they’ll do to change their lives in the future – if they survive COVID-19.
that is well-controlled with care (and even without care). Those people are suffering even more. Meanwhile, people with obsessive-compulsive disorder that had been under control appear to have worsened with the added stress.
Social distancing has disrupted our everyday routines. For many, there is no work, no spending time with people we care about, no going to movies or shows, no doing discretionary shopping, no going to school. Parents with children at home report frustration about balancing working from home with completing home-schooling packets. Physicians on the front lines of this unprecedented time report not having the proper protective equipment and worrying about the possibility of exposing their families to SARS-CoV-2.
We hear stories about the illness and even deaths of some young and middle-aged people with no underlying conditions, not to mention the loss of older adults. People are bursting into tears, and becoming easily frustrated and angry. Add in nightmares, ongoing anxiety states, insomnia, and decreased concentration.
We are seeing news reports of people stocking up on guns and ammunition and a case of one taking – and dying from – nonpharmaceutical grade chloroquine in an effort to prevent COVID-19.
I spoke with Juliana Tseng, PsyD, a clinical psychologist based in New York, and she said that the hype, half-truths, and false information from some outlets in the popular media are making things worse. Dr. Tseng added that the lack of coordination among local, state, and federal governments also is increasing fear and alienation.
As I see this period in time, my first thoughts are that we are witnessing a national epidemic of trauma. Specifically, what we have here is a clinical picture of PTSD.
PTSD is defined clearly as a traumatic disorder with a real or perceived fracture with life. Isolation (which we are creating as a way to “flatten the curve” or slow the spread of COVID-19), although that strategy is in our best personal and public health interests, is both painful and stressful. Frustration, flashbacks of past life experiences plus flashbacks of being ill are reported in people I’ve spoken with. Avoidance, even though it is planned in this instance, is part of the PTSD complex.
What can we as mental health professionals do to help alleviate this suffering?
First, of course, we must listen to the scientific experts and the data – and tell people to do the same. Most experts will say that COVID-19 is a mild or moderate illness for the vast majority of people. We also must encourage people to observe precautions outlined by the Centers for Disease Control and Prevention, such as distancing from people, hand washing, and avoiding those who are ill. Explain to people that, currently, there is no vaccine to prevent COVID-19. Treatment is mainly supportive, and some medication trials are being explored. However, we can empower people by helping them to develop skills aimed at increasing the ability to relax and focus on more positive aspects of life to break the chain of the stress and tension of anxiety as well as control the PTSD.
For more than 40 years, I have helped people master relaxation techniques and guided imagery. When taught properly, people are able to use these techniques on their own.
To begin, I teach people how to relax, using a simple three-point method:
- Get comfortable in a nice chair, and slowly count from one to three. At the count of one, do one thing: “roll your eyes up to the top of your head.”
- At the count of two, do two things, “close your lids on your eyes and take a deep breath.”
- At three, exhale slowly, relax your eyes, and concentrate on a restful feeling of floating.
- Do this for about 30 seconds to a minute.
- Count backward, from three to two to one and open your eyes.
The person will notice how nice and restful they will feel.
After that exercise, get the person to move to the graduate level and go beyond just relaxation. In the following exercise, people can go into a relaxed state by imagining a movie screen. Tell the person to do two things:
1. Look at the imagined movie screen and project on it any pleasant scene you wish; this is your screen. You will feel yourself becoming more and more relaxed. The person can do this one, two, three or whatever times a day. The exercise can last 1 minute or 5.
2. Incorporate the 1, 2, 3 relaxation described earlier, allowing yourself to float into this restful state and go to your movie screen. Now, on the screen, imagine a thick line down the center, and on the left side, project your worries and anxieties and fears. The idea is to see but not experience them. Then shift to the ride side of the screen, and again, visualize any pleasant scene you wish. Again, do this for 1 minute or 5 minutes, whatever works.
You will notice that the pleasant scene on the right will overcome the anxiety scene on the left, in that pleasantness, in most instances, overcomes anxiety. For many, these techniques have proved very useful – whether the problem is anxiety or fear – or both. In my experience, these techniques are a good beginning for controlling PTSD and successfully treating it.
We are in the midst of what could be the biggest public health crisis that America has faced since the 1918 pandemic, also known as the Spanish flu. The lockdowns, quarantines, and the myriad of other disruptions can lead to alienation. In fact, it would be strange for us not to experience strong emotions under these extreme conditions. Life will get better! In the meantime, let’s encourage people to hope, pray, and use relaxation techniques and guided imagery approaches to help control anxiety, worry, stress, and issues related to PTSD. These approaches can give our minds and bodies periods of relaxation and recovery, and ultimately, they can calm our minds.
Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.
Steven, Linda, and predictive processing
Steven, a 45-year-old engineer, and Linda, a 40-year-old data processor, have been married for 12 years and have a 10-year-old child. In 2018, Steven was fired from his job after he exploded at his boss, who he felt had gone out of his way to humiliate Steven.
He was having difficulty finding a new job. Linda had to pick up extra hours at work and became annoyed with Steven. “What do you do all day? Why can’t you finish all these half-done house projects? What is the matter with you?” Linda felt that he was only half-heartedly looking for a new job and wondered whether he preferred letting her be the breadwinner and the boss.
Steven agreed to seek individual therapy to assuage his wife’s concerns. After several sessions, Steven realized that his father had criticized him in a way similar to the way his wife did, and that this was similar to his perception of his former boss. He began to discuss his parents’ backgrounds to try to understand their behavior. Steven began to change his behavior, looking for work more seriously and finishing up home projects. However, Linda did not accept that these changes were “real” and continued to berate him. She stated that he was doing this only temporarily to appease his therapist. Steven tried to explain why he had changed, with descriptions of his father’s behavior toward him. Months went by, and despite securing an interview for a job and having finished the projects at home, Linda remained steadfast in denying his change. Steven and Linda were referred to couples therapy.
In the first session, Steven complained that Linda had to have everything done exactly her way, and he opined that she liked to be the dominant force in the relationship. Linda countered with: “One time on TV there was this woman complaining about the glass ceiling.” Meanwhile, he said things such as “women seem to think that men work because they like to work.” She countered: “I think he got himself fired on purpose!”
Predictive models
Linda had formed a mental model of her husband based on her experience of his repetitive behavior over the 15 years that they had known each other. She had long ago decided that she needed to nag him to get him to do anything productive. This had occurred early in their relationship, and it was her fixed belief about her husband.
Steven entered their relationship believing that Linda would be critical of him, regardless of what he did. This belief was not a conscious belief, more of an expectation based on his prior relationship with his father. He ignored her nagging until it became so persistent than he would eventually do what she asked. When Steven began to resolve his anger toward his father more effectively, he became less begrudging of others and more self-motivated. Linda’s continued nagging made Steven wonder whether it was “worth it” to make self-improvement changes, as Linda did not appreciate his efforts to change.
When we get to “know someone” in a coupled relationship, our experience of the other person falls into predictive patterns. We expect the “usual” responses from them: We “know” how they will respond. This predictability makes it easy for us to understand the other person, so that we do not have to continually analyze and reanalyze each utterance or behavior as a new experience.
Steven’s predictive model of Linda reflects his predictive model of the other as indicative of the fact that he will be always berated. He, at some level, expects others to berate him. Linda prefers to maintain her current model of her husband and believe that his changes are not real, rather than do the work of changing her internal model – work that she does not think is necessary. In their couples therapy, predictive modeling “explains” how Linda and Steven use their internal models of each other to direct their interactions.
Couples therapy helps them describe the change they both want. As Linda approaches Steven, her internal model must now change to incorporate his new interactional style. Of course, she will be suspicious that he might “relapse.” But understanding that he desires to interact with her in this new way, and that she actually would prefer to stop nagging him, helps her to develop a new model of interaction with him.
Relational theories are numerous: Why add one more?
Predictive processing is a paradigm shift in psychiatry. This shift moves psychiatry away from psychodynamic explanations of behavior to explanations that are brain based. Psychodynamic explanations are how our prior experiences in the world get played out in the current world. Predictive processing explains how the brain incorporates the dynamics of child rearing and prior relational interactions into internal models that we use to reduce the work of repeatedly reinterpreting people’s behavior.
The historical explanations that create internal models are interesting, especially to Steven, who felt there was a connection between his prior experiences and his current experiences. Acknowledging the psychodynamic cause is helpful, but it is the how of relational change that is the work of couples therapy.
The positives of predictive modeling
or built a certain way or that the other person lacks the will to change. A neuroscience-based visualization of our internal models of other people helps us more neutrally describe the iterative process that occurs. Other systemic family models use their own languages to achieve the same end, but as Carlos E. Sluzki, MD, opines: We need to update our models to keep up with the times!
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest to disclose. The case, which was changed to protect patients’ confidentiality, was provided by David M. Allen, MD, professor of psychiatry emeritus at the University of Tennessee Health Science Center, Memphis. Dr. Allen is author of three books, “Coping with Critical, Demanding, and Dysfunctional Parents” (New Harbinger Publications, 2018); “How Dysfunctional Families Spur Mental Disorders” (Praeger, 2010); and “Psychotherapy with Borderline Patients: An Integrated Approach” (Lawrence Erlbaum Associates, 2003).
References
Friston K. Entropy (Basel). 2012 Nov;14(11):2100-21.
Sluzki CE. Fam Process. 2007;46(2):173-84.
Steven, a 45-year-old engineer, and Linda, a 40-year-old data processor, have been married for 12 years and have a 10-year-old child. In 2018, Steven was fired from his job after he exploded at his boss, who he felt had gone out of his way to humiliate Steven.
He was having difficulty finding a new job. Linda had to pick up extra hours at work and became annoyed with Steven. “What do you do all day? Why can’t you finish all these half-done house projects? What is the matter with you?” Linda felt that he was only half-heartedly looking for a new job and wondered whether he preferred letting her be the breadwinner and the boss.
Steven agreed to seek individual therapy to assuage his wife’s concerns. After several sessions, Steven realized that his father had criticized him in a way similar to the way his wife did, and that this was similar to his perception of his former boss. He began to discuss his parents’ backgrounds to try to understand their behavior. Steven began to change his behavior, looking for work more seriously and finishing up home projects. However, Linda did not accept that these changes were “real” and continued to berate him. She stated that he was doing this only temporarily to appease his therapist. Steven tried to explain why he had changed, with descriptions of his father’s behavior toward him. Months went by, and despite securing an interview for a job and having finished the projects at home, Linda remained steadfast in denying his change. Steven and Linda were referred to couples therapy.
In the first session, Steven complained that Linda had to have everything done exactly her way, and he opined that she liked to be the dominant force in the relationship. Linda countered with: “One time on TV there was this woman complaining about the glass ceiling.” Meanwhile, he said things such as “women seem to think that men work because they like to work.” She countered: “I think he got himself fired on purpose!”
Predictive models
Linda had formed a mental model of her husband based on her experience of his repetitive behavior over the 15 years that they had known each other. She had long ago decided that she needed to nag him to get him to do anything productive. This had occurred early in their relationship, and it was her fixed belief about her husband.
Steven entered their relationship believing that Linda would be critical of him, regardless of what he did. This belief was not a conscious belief, more of an expectation based on his prior relationship with his father. He ignored her nagging until it became so persistent than he would eventually do what she asked. When Steven began to resolve his anger toward his father more effectively, he became less begrudging of others and more self-motivated. Linda’s continued nagging made Steven wonder whether it was “worth it” to make self-improvement changes, as Linda did not appreciate his efforts to change.
When we get to “know someone” in a coupled relationship, our experience of the other person falls into predictive patterns. We expect the “usual” responses from them: We “know” how they will respond. This predictability makes it easy for us to understand the other person, so that we do not have to continually analyze and reanalyze each utterance or behavior as a new experience.
Steven’s predictive model of Linda reflects his predictive model of the other as indicative of the fact that he will be always berated. He, at some level, expects others to berate him. Linda prefers to maintain her current model of her husband and believe that his changes are not real, rather than do the work of changing her internal model – work that she does not think is necessary. In their couples therapy, predictive modeling “explains” how Linda and Steven use their internal models of each other to direct their interactions.
Couples therapy helps them describe the change they both want. As Linda approaches Steven, her internal model must now change to incorporate his new interactional style. Of course, she will be suspicious that he might “relapse.” But understanding that he desires to interact with her in this new way, and that she actually would prefer to stop nagging him, helps her to develop a new model of interaction with him.
Relational theories are numerous: Why add one more?
Predictive processing is a paradigm shift in psychiatry. This shift moves psychiatry away from psychodynamic explanations of behavior to explanations that are brain based. Psychodynamic explanations are how our prior experiences in the world get played out in the current world. Predictive processing explains how the brain incorporates the dynamics of child rearing and prior relational interactions into internal models that we use to reduce the work of repeatedly reinterpreting people’s behavior.
The historical explanations that create internal models are interesting, especially to Steven, who felt there was a connection between his prior experiences and his current experiences. Acknowledging the psychodynamic cause is helpful, but it is the how of relational change that is the work of couples therapy.
The positives of predictive modeling
or built a certain way or that the other person lacks the will to change. A neuroscience-based visualization of our internal models of other people helps us more neutrally describe the iterative process that occurs. Other systemic family models use their own languages to achieve the same end, but as Carlos E. Sluzki, MD, opines: We need to update our models to keep up with the times!
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest to disclose. The case, which was changed to protect patients’ confidentiality, was provided by David M. Allen, MD, professor of psychiatry emeritus at the University of Tennessee Health Science Center, Memphis. Dr. Allen is author of three books, “Coping with Critical, Demanding, and Dysfunctional Parents” (New Harbinger Publications, 2018); “How Dysfunctional Families Spur Mental Disorders” (Praeger, 2010); and “Psychotherapy with Borderline Patients: An Integrated Approach” (Lawrence Erlbaum Associates, 2003).
References
Friston K. Entropy (Basel). 2012 Nov;14(11):2100-21.
Sluzki CE. Fam Process. 2007;46(2):173-84.
Steven, a 45-year-old engineer, and Linda, a 40-year-old data processor, have been married for 12 years and have a 10-year-old child. In 2018, Steven was fired from his job after he exploded at his boss, who he felt had gone out of his way to humiliate Steven.
He was having difficulty finding a new job. Linda had to pick up extra hours at work and became annoyed with Steven. “What do you do all day? Why can’t you finish all these half-done house projects? What is the matter with you?” Linda felt that he was only half-heartedly looking for a new job and wondered whether he preferred letting her be the breadwinner and the boss.
Steven agreed to seek individual therapy to assuage his wife’s concerns. After several sessions, Steven realized that his father had criticized him in a way similar to the way his wife did, and that this was similar to his perception of his former boss. He began to discuss his parents’ backgrounds to try to understand their behavior. Steven began to change his behavior, looking for work more seriously and finishing up home projects. However, Linda did not accept that these changes were “real” and continued to berate him. She stated that he was doing this only temporarily to appease his therapist. Steven tried to explain why he had changed, with descriptions of his father’s behavior toward him. Months went by, and despite securing an interview for a job and having finished the projects at home, Linda remained steadfast in denying his change. Steven and Linda were referred to couples therapy.
In the first session, Steven complained that Linda had to have everything done exactly her way, and he opined that she liked to be the dominant force in the relationship. Linda countered with: “One time on TV there was this woman complaining about the glass ceiling.” Meanwhile, he said things such as “women seem to think that men work because they like to work.” She countered: “I think he got himself fired on purpose!”
Predictive models
Linda had formed a mental model of her husband based on her experience of his repetitive behavior over the 15 years that they had known each other. She had long ago decided that she needed to nag him to get him to do anything productive. This had occurred early in their relationship, and it was her fixed belief about her husband.
Steven entered their relationship believing that Linda would be critical of him, regardless of what he did. This belief was not a conscious belief, more of an expectation based on his prior relationship with his father. He ignored her nagging until it became so persistent than he would eventually do what she asked. When Steven began to resolve his anger toward his father more effectively, he became less begrudging of others and more self-motivated. Linda’s continued nagging made Steven wonder whether it was “worth it” to make self-improvement changes, as Linda did not appreciate his efforts to change.
When we get to “know someone” in a coupled relationship, our experience of the other person falls into predictive patterns. We expect the “usual” responses from them: We “know” how they will respond. This predictability makes it easy for us to understand the other person, so that we do not have to continually analyze and reanalyze each utterance or behavior as a new experience.
Steven’s predictive model of Linda reflects his predictive model of the other as indicative of the fact that he will be always berated. He, at some level, expects others to berate him. Linda prefers to maintain her current model of her husband and believe that his changes are not real, rather than do the work of changing her internal model – work that she does not think is necessary. In their couples therapy, predictive modeling “explains” how Linda and Steven use their internal models of each other to direct their interactions.
Couples therapy helps them describe the change they both want. As Linda approaches Steven, her internal model must now change to incorporate his new interactional style. Of course, she will be suspicious that he might “relapse.” But understanding that he desires to interact with her in this new way, and that she actually would prefer to stop nagging him, helps her to develop a new model of interaction with him.
Relational theories are numerous: Why add one more?
Predictive processing is a paradigm shift in psychiatry. This shift moves psychiatry away from psychodynamic explanations of behavior to explanations that are brain based. Psychodynamic explanations are how our prior experiences in the world get played out in the current world. Predictive processing explains how the brain incorporates the dynamics of child rearing and prior relational interactions into internal models that we use to reduce the work of repeatedly reinterpreting people’s behavior.
The historical explanations that create internal models are interesting, especially to Steven, who felt there was a connection between his prior experiences and his current experiences. Acknowledging the psychodynamic cause is helpful, but it is the how of relational change that is the work of couples therapy.
The positives of predictive modeling
or built a certain way or that the other person lacks the will to change. A neuroscience-based visualization of our internal models of other people helps us more neutrally describe the iterative process that occurs. Other systemic family models use their own languages to achieve the same end, but as Carlos E. Sluzki, MD, opines: We need to update our models to keep up with the times!
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest to disclose. The case, which was changed to protect patients’ confidentiality, was provided by David M. Allen, MD, professor of psychiatry emeritus at the University of Tennessee Health Science Center, Memphis. Dr. Allen is author of three books, “Coping with Critical, Demanding, and Dysfunctional Parents” (New Harbinger Publications, 2018); “How Dysfunctional Families Spur Mental Disorders” (Praeger, 2010); and “Psychotherapy with Borderline Patients: An Integrated Approach” (Lawrence Erlbaum Associates, 2003).
References
Friston K. Entropy (Basel). 2012 Nov;14(11):2100-21.
Sluzki CE. Fam Process. 2007;46(2):173-84.
Physicians and health systems can reduce fear around COVID-19
A message from a Chief Wellness Officer
We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.
Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.
It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.
First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.
Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.
So, what can physicians do?
- Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
- Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
- Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
- Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
- Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
- Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. which has a series of really excellent meditation and relaxation tools.
- Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
- Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
- Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.
Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.
This article first appeared on Medscape.com.
A message from a Chief Wellness Officer
We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.
Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.
It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.
First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.
Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.
So, what can physicians do?
- Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
- Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
- Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
- Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
- Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
- Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. which has a series of really excellent meditation and relaxation tools.
- Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
- Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
- Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.
Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.
This article first appeared on Medscape.com.
A message from a Chief Wellness Officer
We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.
Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.
It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.
First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.
Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.
So, what can physicians do?
- Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
- Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
- Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
- Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
- Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
- Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. which has a series of really excellent meditation and relaxation tools.
- Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
- Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
- Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.
Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.
This article first appeared on Medscape.com.
What psychiatrists can do to prepare for the coming pandemic
Coronavirus fever is gripping the world. What I hope to do here is open a discussion of what psychiatrists and other clinicians can do to mitigate the psychological consequences of COVID-19. I am focusing on the right now.
The psychological consequences are fear of the disease, effects of possible quarantine, and the potential effects of the economic slowdown on the world economy.
Fear of the disease is gripping the nation. With invisible diseases, that is not irrational. If you do not know whether you are exposed and/or spreading it to coworkers, children, or aged parents, then the fear of contagion is logical. So I would not “poo-poo” the “worried well.” – especially if you have parents in nursing homes.
The quarantine issue is harder. I have long thought that quarantine would be harder to implement in the United States than in nations like China. But self or home quarantine is currently the de facto solution for those who have been exposed. What are some remedies?
For everybody, having an adequate supply of basic supplies at home is essential. As in preparing for a snowstorm or hurricane, adequate food, water, and yes, toilet paper, is important to relieve anxiety.
Psychiatrists can encourage patients to have an adequate supply of their medications. That may mean that we prescribe more pills. If the patient has suicidal tendencies, we can ask other family members to safeguard those medications.
A salient question is how likely people who are addicted to alcohol or opiates are to stay in place if they are withdrawing. In previous presentations, delivered some 20 years ago, I have (facetiously) suggested horse-drawn wagons of beer to avoid people breaking quarantine in search of the substances they are physically dependent on.
For people in methadone clinics who require daily visits that kind of approach may be harder. I do not have a solution, other than to plan for the eventuality of large-scale withdrawal and the behavioral consequences, which, unfortunately, often involve crime. Telemedicine may be a solution, but we are not yet equipped for it.
The longer-term psychological impacts of a major economic slowdown are not yet known. Based on past epidemics and other disasters, they might include unemployment and the related consequences of domestic violence and suicide.
COVID-19 is spreading fast. As clinicians, we must take steps to protect ourselves and our patients. Because this is a new virus, we have a lot to learn about it. We must be agile, because our actions will need to change over time.
Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington.
Coronavirus fever is gripping the world. What I hope to do here is open a discussion of what psychiatrists and other clinicians can do to mitigate the psychological consequences of COVID-19. I am focusing on the right now.
The psychological consequences are fear of the disease, effects of possible quarantine, and the potential effects of the economic slowdown on the world economy.
Fear of the disease is gripping the nation. With invisible diseases, that is not irrational. If you do not know whether you are exposed and/or spreading it to coworkers, children, or aged parents, then the fear of contagion is logical. So I would not “poo-poo” the “worried well.” – especially if you have parents in nursing homes.
The quarantine issue is harder. I have long thought that quarantine would be harder to implement in the United States than in nations like China. But self or home quarantine is currently the de facto solution for those who have been exposed. What are some remedies?
For everybody, having an adequate supply of basic supplies at home is essential. As in preparing for a snowstorm or hurricane, adequate food, water, and yes, toilet paper, is important to relieve anxiety.
Psychiatrists can encourage patients to have an adequate supply of their medications. That may mean that we prescribe more pills. If the patient has suicidal tendencies, we can ask other family members to safeguard those medications.
A salient question is how likely people who are addicted to alcohol or opiates are to stay in place if they are withdrawing. In previous presentations, delivered some 20 years ago, I have (facetiously) suggested horse-drawn wagons of beer to avoid people breaking quarantine in search of the substances they are physically dependent on.
For people in methadone clinics who require daily visits that kind of approach may be harder. I do not have a solution, other than to plan for the eventuality of large-scale withdrawal and the behavioral consequences, which, unfortunately, often involve crime. Telemedicine may be a solution, but we are not yet equipped for it.
The longer-term psychological impacts of a major economic slowdown are not yet known. Based on past epidemics and other disasters, they might include unemployment and the related consequences of domestic violence and suicide.
COVID-19 is spreading fast. As clinicians, we must take steps to protect ourselves and our patients. Because this is a new virus, we have a lot to learn about it. We must be agile, because our actions will need to change over time.
Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington.
Coronavirus fever is gripping the world. What I hope to do here is open a discussion of what psychiatrists and other clinicians can do to mitigate the psychological consequences of COVID-19. I am focusing on the right now.
The psychological consequences are fear of the disease, effects of possible quarantine, and the potential effects of the economic slowdown on the world economy.
Fear of the disease is gripping the nation. With invisible diseases, that is not irrational. If you do not know whether you are exposed and/or spreading it to coworkers, children, or aged parents, then the fear of contagion is logical. So I would not “poo-poo” the “worried well.” – especially if you have parents in nursing homes.
The quarantine issue is harder. I have long thought that quarantine would be harder to implement in the United States than in nations like China. But self or home quarantine is currently the de facto solution for those who have been exposed. What are some remedies?
For everybody, having an adequate supply of basic supplies at home is essential. As in preparing for a snowstorm or hurricane, adequate food, water, and yes, toilet paper, is important to relieve anxiety.
Psychiatrists can encourage patients to have an adequate supply of their medications. That may mean that we prescribe more pills. If the patient has suicidal tendencies, we can ask other family members to safeguard those medications.
A salient question is how likely people who are addicted to alcohol or opiates are to stay in place if they are withdrawing. In previous presentations, delivered some 20 years ago, I have (facetiously) suggested horse-drawn wagons of beer to avoid people breaking quarantine in search of the substances they are physically dependent on.
For people in methadone clinics who require daily visits that kind of approach may be harder. I do not have a solution, other than to plan for the eventuality of large-scale withdrawal and the behavioral consequences, which, unfortunately, often involve crime. Telemedicine may be a solution, but we are not yet equipped for it.
The longer-term psychological impacts of a major economic slowdown are not yet known. Based on past epidemics and other disasters, they might include unemployment and the related consequences of domestic violence and suicide.
COVID-19 is spreading fast. As clinicians, we must take steps to protect ourselves and our patients. Because this is a new virus, we have a lot to learn about it. We must be agile, because our actions will need to change over time.
Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington.
Burnout: A concept that rebrands mental illness for professionals
Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.
Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?
According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.
Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.
The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.
I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.
Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?
I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.
Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.
Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?
According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.
Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.
The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.
I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.
Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?
I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.
Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.
Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?
According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.
Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.
The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.
I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.
Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?
I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.
Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
FDA rules to ban ESDs for self-injurious, aggressive behavior
The Food and Drug Administration has banned all electrical stimulation devices used for self-injurious or aggressive behavior because of an unreasonable risk of illness or injury. This marks only the third time the FDA has banned a medical device since it gained the authority to do so.
Electrical stimulation devices (ESDs) administer electric shocks through electrodes attached to the skin during self-injurious or aggressive behavior in an attempt to condition the patient to stop engaging in that behavior, according to the FDA press release. Current evidence indicates that use of these devices can lead to worsening of underlying symptoms, depression, anxiety, PTSD, pain, burns, and tissue damage; in contrast, evidence supporting their use is weak. In addition, many patients exposed to ESDs have intellectual or developmental disabilities and might not be able to adequately communicate their level of pain.
“Since ESDs were first marketed more than 20 years ago, we have gained a better understanding of the danger these devices present to public health. Through advancements in medical science, there are now more treatment options available to reduce or stop self-injurious or aggressive behavior, thus avoiding the substantial risk ESDs present,” William H. Maisel, MD, MPH, director of the Office of Product Evaluation and Quality in the FDA’s Center for Devices and Radiological Health, said in the release.
The ruling follows a 2016 proposal to ban ESDs from the marketplace; the proposed rule received more than 1,500 comments from stakeholders, such as parents of people with intellectual and developmental disabilities, state agencies and their sister public-private organizations, the affected manufacturer and residential facility, some of the facility’s employees, and parents of individual residents, as well as from state and federal legislators and advocacy groups. Nearly all supported the ban.
The rule will go into effect 30 days after publication of the rule in the Federal Register, and compliance is required within 180 days.
The Food and Drug Administration has banned all electrical stimulation devices used for self-injurious or aggressive behavior because of an unreasonable risk of illness or injury. This marks only the third time the FDA has banned a medical device since it gained the authority to do so.
Electrical stimulation devices (ESDs) administer electric shocks through electrodes attached to the skin during self-injurious or aggressive behavior in an attempt to condition the patient to stop engaging in that behavior, according to the FDA press release. Current evidence indicates that use of these devices can lead to worsening of underlying symptoms, depression, anxiety, PTSD, pain, burns, and tissue damage; in contrast, evidence supporting their use is weak. In addition, many patients exposed to ESDs have intellectual or developmental disabilities and might not be able to adequately communicate their level of pain.
“Since ESDs were first marketed more than 20 years ago, we have gained a better understanding of the danger these devices present to public health. Through advancements in medical science, there are now more treatment options available to reduce or stop self-injurious or aggressive behavior, thus avoiding the substantial risk ESDs present,” William H. Maisel, MD, MPH, director of the Office of Product Evaluation and Quality in the FDA’s Center for Devices and Radiological Health, said in the release.
The ruling follows a 2016 proposal to ban ESDs from the marketplace; the proposed rule received more than 1,500 comments from stakeholders, such as parents of people with intellectual and developmental disabilities, state agencies and their sister public-private organizations, the affected manufacturer and residential facility, some of the facility’s employees, and parents of individual residents, as well as from state and federal legislators and advocacy groups. Nearly all supported the ban.
The rule will go into effect 30 days after publication of the rule in the Federal Register, and compliance is required within 180 days.
The Food and Drug Administration has banned all electrical stimulation devices used for self-injurious or aggressive behavior because of an unreasonable risk of illness or injury. This marks only the third time the FDA has banned a medical device since it gained the authority to do so.
Electrical stimulation devices (ESDs) administer electric shocks through electrodes attached to the skin during self-injurious or aggressive behavior in an attempt to condition the patient to stop engaging in that behavior, according to the FDA press release. Current evidence indicates that use of these devices can lead to worsening of underlying symptoms, depression, anxiety, PTSD, pain, burns, and tissue damage; in contrast, evidence supporting their use is weak. In addition, many patients exposed to ESDs have intellectual or developmental disabilities and might not be able to adequately communicate their level of pain.
“Since ESDs were first marketed more than 20 years ago, we have gained a better understanding of the danger these devices present to public health. Through advancements in medical science, there are now more treatment options available to reduce or stop self-injurious or aggressive behavior, thus avoiding the substantial risk ESDs present,” William H. Maisel, MD, MPH, director of the Office of Product Evaluation and Quality in the FDA’s Center for Devices and Radiological Health, said in the release.
The ruling follows a 2016 proposal to ban ESDs from the marketplace; the proposed rule received more than 1,500 comments from stakeholders, such as parents of people with intellectual and developmental disabilities, state agencies and their sister public-private organizations, the affected manufacturer and residential facility, some of the facility’s employees, and parents of individual residents, as well as from state and federal legislators and advocacy groups. Nearly all supported the ban.
The rule will go into effect 30 days after publication of the rule in the Federal Register, and compliance is required within 180 days.