If one judged from stories in the media, one would think the main cause of Post-Traumatic Stress Disorder is wartime combat. In fact the most common cause of PTSD is sexual assault.
PTSD is common, and, I believe, underdiagnosed. That's because its symptoms include anxiety and what may look like depressive symptoms. Furthermore, for many years, and perhaps continuing into the present, PTSD was thought of as an illness relating to a specific trauma experienced in the recent or moderately recent past. Some psychiatrists don't look closely at the causes of symptoms and just prescribe a pill for what the symptoms look like. It may take time in therapy for a patient to reveal the complete history of the trauma(s).
Many combat veterans are apparently now receiving disability benefits for PTSD. The illness is treatable, and in my experience, most people recover. I've wondered what our society would look like if everyone who had PTSD received disability benefits and stopped working. Whole industries might grind to a halt, because childhood trauma and sexual violence throughout the life cycle, are common. Perhaps our society doesn't take PTSD suffered by victims of childhood trauma or rape in adulthood as seriously as we take PTSD suffered by combat veterans. Of course, many combat veterans have other disorders on top of PTSD, including Traumatic Brain Injury (TBI). TBI can cause behavioral and mood disturbance and may be misdiagnosed.
I've worked with many combat veterans as well as a large number of people who have experienced childhood trauma. In fact, the vast majority of my patients have experienced some sort of childhood trauma--it's the main reason people come to therapy. Not everyone who has experienced trauma develops PTSD, however. Many factors can affect whether or not someone develops PTSD. I've noticed that many cases of long-term PTSD involve unresolved guilt feelings.
It can be important to distinguish acute stress symptoms from PTSD. It's normal for anyone to experience certain symptoms after experiencing a life-threatening event or witnessing a fatal or life-threatening event. These symptoms can include anxiety, flashbacks and fear of the situation or locale in which the event took place. In most cases the symptoms go away after a few weeks. If not, the individual can be diagnosed with PTSD and will need treatment.
Wednesday, February 5, 2014
Sunday, January 5, 2014
An Introduction to Personality Disorders
The term "personality disorder" was developed decades ago to describe patients who had a superficially normal presentation without psychosis but who, under psychoanalysis, were revealed to have deep disturbances in their psychological functioning. Many of these patients had chronic problems in interpersonal relationships or social/occupational functioning. Some had symptoms of "neurosis" such as anxiety or depression, whereas others had none. To this day, personality disorders remain difficult to treat. Yet, a large percentage of any psychotherapist's caseload is composed of persons with such disorders, as they comprise approximately 10-20 percent of the general population.
Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.
The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship. Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.
What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation, distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist). I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a part of themselves that they don't like. Consequently, others may be either idealized or devalued.
There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted.
Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.
The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship. Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.
What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation, distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist). I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a part of themselves that they don't like. Consequently, others may be either idealized or devalued.
There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted.
Monday, October 14, 2013
The Patient's Responsibility Part II
Once in awhile, a patient will preface what they are going to say by saying "I hope this isn't TMI [too much information]." There is no such thing as TMI for your therapist.
It used to be common knowledge that patients in therapy were supposed to discuss all of their thoughts, feelings and experiences. Dreams and sexual fantasies were common topics in therapy sessions. Of course, most people are not comfortable immediately discussing their most personal thoughts, which is fine. Most people begin by talking about what is going wrong in their life. It's important for the therapist to know more than the superficial details, however. Patients who hide details of what they consider embarrassing material may be leaving out important information.
Sometimes people hide information out of fear. A drug addict who doesn't really want to give up drug use may hide the extent of his/her use in order to avoid confrontation and a referral to an inpatient facility. It's important to trust that the advice a therapist gives is based on clinicial evaluation, not judgment.
I've had some patients who apologized for cursing in sessions. If you feel like cursing to express yourself, go ahead (if you feel like cursing at me, however, I suggest we discuss what is making you angry instead).
The basic rules of social interaction mostly don't apply in therapy sessions, the exceptions being that you are supposed to be on time, pay any bill that you owe, and participate. Cursing, talking about sexual behaviors or fantasies and admitting to drug and alcohol use fall into the realm of expression. Without your honest expressions, therapy cannot be effective.
It used to be common knowledge that patients in therapy were supposed to discuss all of their thoughts, feelings and experiences. Dreams and sexual fantasies were common topics in therapy sessions. Of course, most people are not comfortable immediately discussing their most personal thoughts, which is fine. Most people begin by talking about what is going wrong in their life. It's important for the therapist to know more than the superficial details, however. Patients who hide details of what they consider embarrassing material may be leaving out important information.
Sometimes people hide information out of fear. A drug addict who doesn't really want to give up drug use may hide the extent of his/her use in order to avoid confrontation and a referral to an inpatient facility. It's important to trust that the advice a therapist gives is based on clinicial evaluation, not judgment.
I've had some patients who apologized for cursing in sessions. If you feel like cursing to express yourself, go ahead (if you feel like cursing at me, however, I suggest we discuss what is making you angry instead).
The basic rules of social interaction mostly don't apply in therapy sessions, the exceptions being that you are supposed to be on time, pay any bill that you owe, and participate. Cursing, talking about sexual behaviors or fantasies and admitting to drug and alcohol use fall into the realm of expression. Without your honest expressions, therapy cannot be effective.
Monday, October 7, 2013
My Thoughts on Psychiatric Medications
Usually about 20-50 percent of my patients are taking psychiatric medication. Psychiatric medication can be extremely useful, even crucial; however, it is often misprescribed.
About one out of every five times I see a new patient who is already on psychiatric medication, the person has been prescribed the wrong medication. Someone might ask how I know, as I am not a medical doctor. First of all, if a medication isn't working, then someone should not be taking it. Secondly, my consulting work in psychiatric facilities involves reading the entire medical records of patients. I've read the records of severely ill patients who are taking three, four, or even five medications. I spend time discussing clinical care with the prescribers in the hospitals (along with a multidisciplinary team including our team psychiatrist). What this means is that I've become extremely familiar with both the intended effects, side effects and possible adverse reactions of most psychiatric medications.
Some common errors I have seen are: Prescribing dangerous anti-psychotic medications instead of anti-depressants to depressed patients, failing to properly diagnose conditions such as Attention Deficit Hyperactivity Disorder in adults, failing to prescribe mood stabilizers when warranted, prescribing anti-anxiety medications for what is actually depression, failing to consider the consequences of prescribing addictive medications to persons who already have addictions, and more.
Several years ago I had two patients who were being prescribed Zyprexa, an anti-psychotic with potentially serious side effects. I knew this was not the right medication for these two depressed patients. In one case, I called the patient's psychiatrist and suggested changing the medication to something else. The doctor decided to try something different and the patient improved markedly. In the second case, the doctor (a different doctor) ignored my suggestion and the patient tried to kill herself. Fortunately, she did not die, and I made sure she was admitted to a hospital where her medication regimen was changed.
In other cases I have just spoken directly with the patient and suggested they talk to their prescriber about their medication. Sometimes this is effective. In one case, the patient had been taking a medication for panic disorder even though she did not have panic disorder. She had been dutifully taking this medication every day (a highly addictive medication) and had begun to wonder if it was making her sleepy. Her doctor agreed she could reduce the medication and she quickly became less sleepy without developing any more anxiety.
I have often thought in recent years that the practice of medicine in this country leaves much to be desired. The explanation of one of my colleagues is "today doctors treat symptoms instead of illnesses." He's probably right. Without figuring out what the underlying illness is, the medication can be wrong and even dangerously wrong.
If you need psychiatric medication, or a new prescriber, I can refer you to someone whom I believe to be competent.
About one out of every five times I see a new patient who is already on psychiatric medication, the person has been prescribed the wrong medication. Someone might ask how I know, as I am not a medical doctor. First of all, if a medication isn't working, then someone should not be taking it. Secondly, my consulting work in psychiatric facilities involves reading the entire medical records of patients. I've read the records of severely ill patients who are taking three, four, or even five medications. I spend time discussing clinical care with the prescribers in the hospitals (along with a multidisciplinary team including our team psychiatrist). What this means is that I've become extremely familiar with both the intended effects, side effects and possible adverse reactions of most psychiatric medications.
Some common errors I have seen are: Prescribing dangerous anti-psychotic medications instead of anti-depressants to depressed patients, failing to properly diagnose conditions such as Attention Deficit Hyperactivity Disorder in adults, failing to prescribe mood stabilizers when warranted, prescribing anti-anxiety medications for what is actually depression, failing to consider the consequences of prescribing addictive medications to persons who already have addictions, and more.
Several years ago I had two patients who were being prescribed Zyprexa, an anti-psychotic with potentially serious side effects. I knew this was not the right medication for these two depressed patients. In one case, I called the patient's psychiatrist and suggested changing the medication to something else. The doctor decided to try something different and the patient improved markedly. In the second case, the doctor (a different doctor) ignored my suggestion and the patient tried to kill herself. Fortunately, she did not die, and I made sure she was admitted to a hospital where her medication regimen was changed.
In other cases I have just spoken directly with the patient and suggested they talk to their prescriber about their medication. Sometimes this is effective. In one case, the patient had been taking a medication for panic disorder even though she did not have panic disorder. She had been dutifully taking this medication every day (a highly addictive medication) and had begun to wonder if it was making her sleepy. Her doctor agreed she could reduce the medication and she quickly became less sleepy without developing any more anxiety.
I have often thought in recent years that the practice of medicine in this country leaves much to be desired. The explanation of one of my colleagues is "today doctors treat symptoms instead of illnesses." He's probably right. Without figuring out what the underlying illness is, the medication can be wrong and even dangerously wrong.
If you need psychiatric medication, or a new prescriber, I can refer you to someone whom I believe to be competent.
Saturday, June 29, 2013
Can Vitamin D Help Your Mood?
This article in The New York Times focuses on the increased rate of suicide in springtime, but it's more interesting for what it says about a possible link between depression and inflammation:
suicide patterns
"Dr. Kaplin studies depression in patients with multiple sclerosis, an autoimmune inflammatory disease. In M.S., he says, depression and inflammation feed each other: Even after accounting for the psychological effects of any serious illness, M.S. heightens depression risk..."
"Inflammatory cytokines play crucial roles in fighting infection, but they can also cause problems. When people with hepatitis C are given the cytokine interferon to help fight the infection, for instance, up to 40 percent become depressed and one in 50 attempt suicide. Other studies suggest that inflammatory cytokine activity reduces levels of the neurotransmitter serotonin and halts the growth of new brain cells — two hallmarks of depression."
As for the link with springtime, the article notes "One possibility is that many people enter spring sensitized to inflammation by late-winter battles with seasonal infections like colds and flu.
A second possibility involves tree pollen....Yet another possibility involves vitamin D. The low levels caused by lack of sunlight in the winter are thought to lead to inflammation; one recent study tentatively suggested a link to suicide."
In addition to private practice, I also do consulting work in psychiatric hospitals, and I've noted in the past several years that most hospitals are now testing their patients' vitamin D levels. Many patients' tests show vitamin D deficiency (which is easily resolved with supplements in most cases).
I've also noticed that some psychiatrists are prescribing fish oil for their patients--fish oil has a slight anti-inflammatory effect and some believe it reduces depression.
Nutrition and overall health are very important for combatting and preventing emotional illness. I always recommend that my patients receive complete physical exams that test for problems such as vitamin D deficiency, thyroid problems and other common problems that could be implicated in their symptoms.
Wednesday, June 19, 2013
Relaxation
Anxiety disorders appear to be on the increase. This may be due to many factors. There are many simple techniques that can be used to reduce anxiety:
1. Progressive Muscle Relaxation: Tense and release muscles in one part of your body at a time. Start either from your feet or your head, working in one direction. This can help insomnia when done at bedtime.
2. When worrying about an upcoming event, ask yourself "What's the worst that could happen?" You may then realize that whatever the worst is, it won't be catastrophic and you can probably handle it.
3. Evaluate your fears--are they logical? How likely is it that the bad outcomes you imagine will happen?
4. Drink less coffee and evaluate medications you are taking, such as Sudafed, that can increase anxiety. Some sleep medications may cause rebound anxiety the following day.
There can also be complex reasons for excessive anxiety, such as an underlying lack of self confidence or fear of being alone and/or independent.
1. Progressive Muscle Relaxation: Tense and release muscles in one part of your body at a time. Start either from your feet or your head, working in one direction. This can help insomnia when done at bedtime.
2. When worrying about an upcoming event, ask yourself "What's the worst that could happen?" You may then realize that whatever the worst is, it won't be catastrophic and you can probably handle it.
3. Evaluate your fears--are they logical? How likely is it that the bad outcomes you imagine will happen?
4. Drink less coffee and evaluate medications you are taking, such as Sudafed, that can increase anxiety. Some sleep medications may cause rebound anxiety the following day.
There can also be complex reasons for excessive anxiety, such as an underlying lack of self confidence or fear of being alone and/or independent.
Wednesday, February 15, 2012
My Thoughts on Marriage
I've worked with patients who are getting married, patients who are getting engaged, and patients who are getting separated or divorced. These different experiences have convinced me that some people underestimate or misunderstand marriage.
Occasionally I've had patients who have been in long term relationships without getting married tell me that marriage is "just a piece of paper." If that were true, why would gay people be fighting for the right to get married? Legally, marriage has certain benefits. But more importantly, it's a public declaration of a relationship.
A few years ago, someone wrote a popular book, "He's Just Not That Into You," which included a chapter called "If He's Not Marrying You, He's Just Not That Into You." It's true. If a man really wants to commit to a woman, he wants to marry her. If he doesn't want marriage, it's because he wants to keep his options open.
Marriage includes legal responsibilities toward a spouse. Sometimes, people who really, really want to be married marry someone who isn't financially responsible, truthful or ethical. Later, they find out that they are responsible for their spouse's debts. Don't marry someone who mismanages money or who is dishonest. You will regret such a decision.
I've found that people also underestimate the trauma of divorce. Depending on many factors, divorces can take years and cost thousands of dollars or tens of thousands of dollars in legal fees.
People tend to evaluate prospective marital partners based on shared interests and goals and on sexual attraction. Although these things may be important, it's just as important to marry someone who is a good person and who really wants to be married. Don't marry someone who's ambivalent about marriage and don't marry someone who can't be trusted. Better to stay single than have a bad marriage with a bad divorce.
Occasionally I've had patients who have been in long term relationships without getting married tell me that marriage is "just a piece of paper." If that were true, why would gay people be fighting for the right to get married? Legally, marriage has certain benefits. But more importantly, it's a public declaration of a relationship.
A few years ago, someone wrote a popular book, "He's Just Not That Into You," which included a chapter called "If He's Not Marrying You, He's Just Not That Into You." It's true. If a man really wants to commit to a woman, he wants to marry her. If he doesn't want marriage, it's because he wants to keep his options open.
Marriage includes legal responsibilities toward a spouse. Sometimes, people who really, really want to be married marry someone who isn't financially responsible, truthful or ethical. Later, they find out that they are responsible for their spouse's debts. Don't marry someone who mismanages money or who is dishonest. You will regret such a decision.
I've found that people also underestimate the trauma of divorce. Depending on many factors, divorces can take years and cost thousands of dollars or tens of thousands of dollars in legal fees.
People tend to evaluate prospective marital partners based on shared interests and goals and on sexual attraction. Although these things may be important, it's just as important to marry someone who is a good person and who really wants to be married. Don't marry someone who's ambivalent about marriage and don't marry someone who can't be trusted. Better to stay single than have a bad marriage with a bad divorce.
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