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Have you ever watched a movie that really made you feel something? Maybe you’ve felt fear while the camera creeps down a dark hallway, anger when the villain gets his way, or joy when everything turns out okay. It seems obvious that movies can make us feel... but why? We aren’t creeping down a dark hallway, and the victory at the end isn’t our own. The answer is actually very simple. Being in a dark hallway does not cause fear. It’s what you think about being in a dark hallway that causes fear. In short: Your thoughts have the power to control your emotions. This is where cognitive behavioral therapy (CBT) comes in. During CBT, you will learn to identify thinking patterns in your everyday life that are causing painful emotions or other problems. Then, by developing new thoughts, you will learn to change how you feel. In this article, we'll dive deeper into thoughts, and the role they play in controlling emotions. Introduction to Thoughts It seems intuitive that how you feel is a result of the situations you face. If something “good” happens, you feel happy, excited, or proud. If something “bad” happens, you feel angry, sad, or worried. For example, imagine you are driving on the highway, and another vehicle cuts you off. As a result, you feel angry. It seems to make sense that you are angry because you were cut off. However, if situations truly caused emotions, every person would react to the same situation in the same way. Of course, this is not the case. Some people become angry after being cut off in traffic, while others brush it off. Why is it that two people in the same situation have different emotions? The answer is that situations do not actually cause emotions. There’s a step in between that often goes unnoticed. It’s how you interpret or think about a situation that determines how you feel. Imagine two different people are cut off by hurried drivers, but they both have different thoughts about the situation: As shown in the example, different thoughts lead to different emotions. So, how does all of this happen without you even noticing it? The answer is something called automatic thoughts. Automatic Thoughts Much of the time, thoughts are overlooked because they happen outside of your awareness. When you have the same thoughts over and over, your brain begins to tune them out. These are called automatic thoughts. Automatic thoughts are like a sound you can hear, but don’t usually notice, such as the hum of a refrigerator. To see automatic thoughts in action, think of something you do so frequently that it feels like second nature. For example, when you commute to work or school for the first time, you might need directions. But before long, it will seem as if you are travelling on autopilot. You don’t look up directions or think about each turn—you just do it. The brain’s ability to run on “autopilot” is important, because it frees up resources for other tasks. But there’s a downside, too. When thoughts happen automatically, outside of your awareness, they aren’t assessed for accuracy. Thoughts with inadequate evidence may be accepted as fact. Irrational Thoughts Another trick the brain uses to make sense of the world is guessing. Imagine you text a friend, and they don’t answer for several hours. You don’t know why they haven’t responded, but your brain will probably try to guess. Your brain could guess something mundane, like: “They must be busy at work.” Or it might guess something more extreme, like: “They must be angry at me.” Sometimes these guesses are accurate, but not always. When guesses lack evidence, they are called irrational thoughts. Over time, even irrational thoughts can become automatic. This means thoughts and beliefs that are not true can shape how you feel, and how you behave, without you knowing. Imagine a person who develops the automatic thought: “People do not like me.” This belief begins to color every situation. When a friend doesn’t return a text message, it feels hurtful. When a stranger scowls at them in the grocery store, it feels personal. Even when they receive a compliment, it feels phony or insincere. Of course, these interpretations of each situation aren’t accurate. They’re shaped by irrational thoughts that are happening automatically, outside of awareness. One goal of CBT is to identify and challenge irrational thoughts. After challenging an irrational thought, you will learn to replace it with a new, rational thought. Doing this will improve how you feel and how you act. By replacing irrational thoughts with rational alternatives, your feelings will better match the situation. Generally, this leads to healthier behaviors that result in better outcomes during everyday situations. The importance of thoughts, and how they interact with feelings, is at the foundation of CBT. Going forward, you will learn to notice your thoughts as they’re happening, evaluate them, and change thoughts that are irrational. To learn more about CBT, check out our video:

Schizophrenia TOPLINE: Suicide is a main cause of death among people with schizophrenia, even years after diagnosis, and deaths from medical conditions and diseases also occur prematurely, results of a long-term study suggest. The results show "an urgent need for new efforts to improve the disparities in health that lead to this increased mortality," the researchers conclude. METHODOLOGY: The life expectancy of patients with schizophrenia is 10-12 years less than in the general population, and as the mortality gap seems to be worsening, it's important to learn more about the patterns behind it. The analysis included 578 participants in the OPUS study, a randomized controlled trial of patients in Denmark with a first-time diagnosis of a schizophrenia spectrum disorder who were assessed after 2, 5, 10, and 20 years. From linked databases, researchers collected clinical and sociodemographic data and information about time and cause of death and determined baseline predictors of mortality and predictors that remained significant during follow-up. The primary outcome was death, which researchers divided into death due to external causes, and death from medical conditions and diseases; secondary outcomes were cause-specific mortality rates. TAKEAWAY: During 20 years of follow-up, 82 participants (14.2%) died, compared to a mortality rate of 4.4% in a matched group from a background population. Mortality rates were higher among men, those aged 40 or older at baseline, and people with substance abuse at the time of diagnosis. About half the deaths were due to external causes, and half were from medical conditions and diseases. The most common external cause was suicide, which accounted for 27.5% of the total number of deaths. The most common medical causes were cardiovascular disease and cancer, both representing 8.3% of the total. At baseline, employment (hazard ratio [HR], 0.47; 95% CI, 0.22 – 0.1; P = .049), psychotic disorders other than schizophrenia (HR, 0.36; 95% CI, 0.15 – 0.83; P = .017), and longer duration of untreated psychosis (HR, 0.57, 95% CI, 0.33 – 0.98; P = .042) predicted lower mortality, while substance use predicted higher mortality (HR, 2.56; 95% CI, 1.50 – 4.36; P < .001). As for predictors of mortality later in the illness, symptom remission without use of antipsychotic medication was associated with a significantly decreased risk for mortality (HR, 0.08; 95% CI, 0.1 – 0.6; P = .013), as was being in recovery (HR, 0.21; 95% CI, 0.05 – 0.84; P = .028), whereas substance use (HR, 3.64; 95% CI, 2.36 – 5.61; P < .001), cancer (HR, 6.31; 95% CI, 3.12 – 12.77), cardiovascular disease (HR, 2.25; 95% CI, 1.36 – 3.71; P = .002), and pulmonary disease (HR, 2.15; 95% CI, 1.36 – 3.42; P = .001) predicted increased mortality. IN PRACTICE: That the rate of death due to suicide remained steady over time underlines the continuous need for suicide-preventive measures for people with schizophrenia, said the authors, adding more regular screening for suicide risk in aging patients with schizophrenia could help prevent some later suicides. SOURCE: The study was conducted by Marie Stefanie Kejser Starzer, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, and the Department of Clinical Medicine, University of Copenhagen, Denmark, and colleagues. It was published online August 1, 2023, in the Schizophrenia Bulletin in the Journal of Psychoses and Related Disorders. LIMITATIONS: Although the cohort was large and follow-up lengthy, the number of deaths is still small. It's possible that those who were lost to follow-up represent a group with an increased risk of morality. The cohort was obtained from a clinical trial, and participants in this trial might not represent all patients with a first schizophrenia spectrum diagnosis. As all patients in Denmark have access to free, well-resourced healthcare, the findings are not representative of all patients. DISCLOSURES: The study was supported by the Tryg Foundation, the Lundbeck Foundation, and Helsefonden. The authors had no competing interests.

"By developing strategies that reduce both stigma and normalization, we can create a more supportive environment for those at risk and improve suicide prevention efforts." Suicide, a global public health issue, is often associated with stigma, which can exacerbate the problem and hinder prevention efforts. Stigma surrounding suicide can deter individuals from seeking help and can isolate those who are already vulnerable.1-5 Research shows that suicide stigma is multifaceted, encompassing public stigma, self-stigma, and label avoidance.4 Public stigma refers to the general population’s negative attitudes and beliefs about suicide, while self-stigma is the internalization of these negative attitudes by individuals who are suicidal. Label avoidance is the reluctance to seek help to avoid being labeled “suicidal.” These forms of stigma can lead to discrimination, social isolation, and a reluctance to seek help, which can further increase the risk of suicide.1-3 Moreover, a study by Sheehan, et al,4 revealed that suicide attempt survivors may be subject to double stigma, experiencing both the stigma associated with suicide and the stigma of mental illness. This double stigma can impede recovery and access to care. The study also found that individuals who attempted suicide were often stereotyped as attention-seeking, selfish, incompetent, emotionally weak, and immoral, further contributing to the stigma. However, stigma is not the only societal attitude that can impact suicide rates. A study by Oexle, et al,5 highlighted the concept of suicide normalization, defined as liberal attitudes toward suicide. The study found an inverse relationship between suicide stigma and suicide normalization, suggesting that efforts to reduce suicide stigma could inadvertently increase suicide normalization. This is concerning, as suicide normalization can act as a barrier to seeking help for suicidality. To address these issues, it is crucial to develop strategies that reduce both suicide stigma and suicide normalization. One potential approach is to promote interpersonal contact with individuals who have experienced suicidality and have a recovery story to share. This can help humanize the issue, reduce stigma, and counteract normalization by showing that recovery is possible.5 In conclusion, addressing the stigma associated with suicide is a complex task that requires a nuanced understanding of societal attitudes toward suicide. By developing strategies that reduce both stigma and normalization, we can create a more supportive environment for those at risk and improve suicide prevention efforts. Dr Ajluni is an assistant professor of psychiatry at Wayne State University in Livonia, Michigan. During the preparation of this work, the author used ChatGBT in order to synthesize and summarize information based on my ideas, input, and conclusions. After using this tool/service, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Hopefulness key to mental and physical health The woman arrived for her first therapy session distressed and depressed. Her husband of 20 years had just announced that he was in love with someone else. At 47, she was so upset she had a heart attack and then needed to go on disability from work. "She had her sense of self shaken at the core," said Dan Tomasulo, PhD, a counseling psychologist and academic director of the Spirituality Mind Body Institute at Teachers College of Columbia University, who treated her. "Within about 10 days, her whole life crumbled." Working with her regularly, Tomasulo helped her not just recover from depression and her sense that she had no future, but to thrive. The key? Teaching her how to be hopeful. Hopefulness can be learned, Tomasulo and many other mental health experts contend. Once we learn how to be more hopeful, that habit can help us overcome depression, suicidal thoughts, inertia, bad health habits, and other obstacles and ultimately move forward. Recent surveys suggest that our hopefulness is sorely lagging, and in some populations more than others. In February, the CDC reported that 57% of U.S. teen girls felt persistently sad or hopeless in 2021, double that of boys and the highest level reported since 2011. Overall, 32.3% of U.S. adults reported anxiety or depressive symptoms in 2023, according to an analysis of Census Bureau data by the Kaiser Family Foundation. Among adults 18 to 24, nearly half did. Experts disagree about how much hopelessness drives thoughts of suicide, but at least in depressed people, it's believed to be linked. Learning hopefulness is not only a good skill to have, but it could be lifesaving. Therapists like Tomasulo, who advocate an approach known as positive psychology, as well as educators who have launched hopefulness programs for youths and workers, say anyone can develop or reclaim their sense of hope — if they are willing to work at it. What Is Hope and Hopefulness? Crucial to boosting hopefulness is understanding what it is. Hope is a word we often use. "I hope I win the lottery." Or "I hope I get a better job soon. That hope is simply a wish, experts said. That's "squishy" hope, said Rick Miller, founder of a program at Arizona State University called Kids at Hope, which teaches the value and strategy of hope. "We are talking about cognitive hope," Miller said. That hope, according to the Kansas psychologist who developed the concept 30 years ago, requires having a goal, the ability to stay motivated to meet the goal, and having pathways to get there, even if obstacles occur. This is "learned hopefulness," Miller and others say. The Path From Hopelessness to Hopefulness "Hope is unique among all the positive emotions," Tomasulo said, "because it requires negativity to be activated. With all the other positive emotions, you don't need that. Hope is unique because it requires something [going] wrong." As he helps people discover the route to hopefulness, Tomasulo talks about pebbles and feathers — pebbles are the negative thoughts, feathers the positive. To cultivate hopefulness, the goal, of course, is to increase the feathers in relation to the pebbles. As you do that, the ratio of positive to negative emotions change, and the positive ones begin to carry more weight. In one of the first meetings, Tomasulo asked the woman with the heart attack and cheating husband to focus on gratitude -- the things she had in her life she was grateful for. Friends had dropped food to her after her hospital stay, she recalled, and then other friends took her out. She had a horse she loved, and while she couldn't ride him yet, she could go to the barn and hang out with him and with her nieces, who also loved the horse. Instead of being stuck in her pain, the woman's perception was changing as she realized more than one thing was happening in her life, not just depression and adultery. Receiving all that kindness allowed her to be kind. When she felt better but wasn't yet back to work, she started volunteering at a food pantry, which boosted her sense of self-worth. Then, very naturally, she started leaning into the future. The feathers were adding up. "Hope is the belief you can have a positive influence on the future and a desire to make that happen," Tomasulo said. Within 6 months, she was back to competitive horse riding, had a much better job, and got through the divorce. "It was not that she forgot about the pain or negativity, but realized she had a choice about what she could focus on," said Tomasulo, who wrote Learned Hopefulness and The Positivity Effect. After much effort, the woman had chosen hopefulness. What the Research Says "Hope is a lot of work," said Crystal Bryce, PhD, associate dean for student affairs and associate professor of medical education at the University of Texas at Tyler, who researches hope in youths and adults. (Researchers measure hope by adding up scores on adult and child hope scales.) Among her findings: Hope levels in children change over time. "We saw a decrease when kids went from seventh to eighth grade, and an increase in hope scores when they went from eighth to ninth." In her study of more than 1,000 youths in grades six to 10, she found that school performance stress may contribute to this decrease, and that fostering increases in hope skills (such as setting goals) before the high school transition might buffer stress and boost achievement. "If you have higher hope, you tend to have lower stress." In another study of 726 students in grades six to 12, those who had higher levels of hope before the pandemic felt more school connectedness during the pandemic, even when they were learning remotely. "Even during what one would call a hopeless time, they were able to find ways to feel connected," Bryce said. Feeling connected, Bryce said, decreases the risk of depression. In a small study of 41 teachers, Bryce found those who reported being emotionally exhausted before the pandemic had lower levels of hope during it. Those who got support from colleagues had higher levels of hope. Teaching Hope to Youth, Workers Others have launched programs to teach hopefulness to children and to adults in the workplace. One is Hopeful Minds, a project developed by iFred (the International Foundation for Research and Education on Hope). The aim is to give students, teachers, and parents the tools needed to develop a hopeful mindset. Its 16 lessons, 45 minutes each, have been downloaded more than 5,000 times in 47 countries, at no cost, according to Kathryn Goetzke, the founder of iFred. Goetzke also founded the Shine Hope Company, which reaches out to workplaces with courses and campaigns on how to foster more hope to improve workers' well-being. Goetzke knows well the journey from hopelessness to hopefulness. Her father died by suicide soon after she started college. In her grief, she said, she soon learned that the coping mechanisms she had were based on hopelessness, not hopefulness. Told she was at high risk of suicide, she began researching hope. On the 30th anniversary of her dad's death, Goetzke's book, The Biggest Little Book About Hope, was released. No one is hopeless at learning to be hopeful, she insisted. "I can teach anyone to be hopeful, but it's up to the person to do the work," she said. Miller, of Arizona State, founded the Kids at Hope program in 2000. The name, he said, is to eliminate the "youth at risk" stereotype for those viewed as disadvantaged. When children with fewer advantages are labeled as "at risk," he said, the expectation they will succeed is diminished. The program now operates in 24 states, in 475 schools and juvenile justice systems. It inspires schools and organizations to create a culture and environment where all kids experience success. "We introduced the science of hope through a series of training modules," Miller said. "We translate the research into simple yet powerful principles and practices that demonstrate how to create and activate hope for all, by all." The basics, Miller said, are that children need to know adults believe in them and are willing to connect with them. Another key is to introduce a concept called mental time travel, which activates hope. It's "the ability for the brain to imagine a future." To date, Kids at Hope has trained more than 125,000 adults and reached more than 1.1 million children, ages 3 to 18. With an "it takes a village" view, the organization has trained not only teachers, but social workers, bus drivers, custodians, superintendents, juvenile prosecuting attorneys, and others, Miller said. "Hopeful people seem to do better in life than people without hope," Miller said. "They do better socially, emotionally, economically, and live longer. "While squishy hope comes and goes, cognitive hope is a choice we get to make every day because it comes with a strategy." While definitions of hope vary, Miller likes this one: "If resilience is the ability to bounce back, hope is the ability to bounce forward."

Depression, Anxiety Do Not Increase Overall Risk for Cancer HealthDay News — Depression and anxiety are not related to an increased risk for most cancers, according to a study published online Aug. 7 in Cancer. Researchers observed no associations between depression or anxiety and overall or for breast, prostate, colorectal, and alcohol-related cancers. However, associations were seen for depression and anxiety (symptoms and diagnoses) with the incidence of lung cancer and smoking-related cancers (hazard ratios, 1.06 to 1.60), although these associations were substantially reduced when additionally adjusting for known risk factors, including smoking, alcohol use, and body mass index (hazard ratios, 1.04 to 1.23). “Our results may come as a relief to many patients with cancer who believe their diagnosis is attributed to previous anxiety or depression,” van Tuijl said in a statement. “However, further research is needed to understand exactly how depression, anxiety, health behaviors, and lung cancer are related.” Analysis: Depression, Anxiety Do Not Increase the Risk of Cancer Aug. 11, 2023 – While depression and anxiety have been linked to a wide range of other health problems, a new analysis shows there is no link between the two psychiatric disorders and the risk of most major cancers. The findings were published this week in Cancer, the journal of the American Cancer Society. The authors wrote that they undertook the study because depression and anxiety have long been thought to be linked to increased cancer risk, but previous research on the connection has been inconclusive. This latest analysis combined data from 18 previous studies and included 319,613 people, who among them had 25,803 cases of cancer. The follow-up period for some people was as much as 26 years. The researchers found no associations between depression or anxiety and overall cancer risk, nor did they find a link with breast cancer, prostate cancer, colorectal cancer, or alcohol-related cancers. They did find that depression and anxiety were associated with a 6% increased risk of developing lung cancer or smoking-related cancers, but the researchers concluded that behaviors like smoking and alcohol use were likely the driving factors, not depression and anxiety. The authors noted that previous studies have found that people who are depressed are more likely to be smokers. “Our results may come as a relief to many patients with cancer who believe their diagnosis is attributed to previous anxiety or depression,” said study author Lonneke A. van Tuijl, PhD, who studies anxiety and mood disorders, in a statement. She is a post-doctoral researcher at the University Medical Center Groningen in The Netherlands. “However,” she added, “further research is needed to understand exactly how depression, anxiety, health behaviors, and lung cancer are related.” SOURCES: Cancer: “Depression, anxiety, and the risk of cancer: An individual participant data meta-analysis.” Wiley: “Robust analysis challenges theory that depression and anxiety increase cancer risk.” Analysis: Depression, Anxiety Do Not Increase the Risk of Cancer Full Article

Correcting the Automatic Negative Thoughts That Steal Your Happiness and Rob Your Joy One of the most effective techniques we use with all patients at Amen Clinics is what we call (ANT Therapy, or learning how to kill the ANTs (automatic negative thoughts). I coined this term in the early 90s after a hard day at the office with many patients in crisis. After coming home that evening I found an ant infestation in my kitchen. Gross!! As I started to clean up the thousands of ants, the acronym came to me. I thought of my patients from that day--like my infested kitchen, my patients' brains were also infested by the negative thoughts that were robbing them of their joy and stealing their happiness. The next day brought a can of ant spray to a work as a visual aid and have been working diligently ever since to help my patients eradicate their ANTs. Automatic Negative Thoughts Here are the "ANT Killing" principles we use to help people feel better fast. 1. Every time you have a thought, your brain releases chemicals? That's how our brains work: you have a thought ... your brain releases chemicals . an electrical transmission goes across your brain and you become aware of what you're thinking. Thoughts are real and they have a direct impact on how you feel and how you behave. 2. Every time you have a mad thought, an unkind thought, a sad thought, or a cranky thought, your brain releases negative chemicals that make you feel bad. Think about the last time you were mad. How did you feel physically? When most people are mad, their muscles get tense, their heart beats faster, their hands start to sweat, and they may even begin to feel a little dizzy. Your body reacts to everynegative thought you have. 3. Every time you have a good thought, a happy thought, a hopeful thought, or a kind thought your brain releases chemicals that make your body feel good. Think about the last time you had really happy thought. What did you feel inside your body? When most people are happy their muscles relax, their heartbeat and breath slow. Your body also reacts to your good thoughts. 4. Thoughts are very powerful! They can make your mind and body feel good or they can make you feel bad. Every cell in your body is affected by every thought you have. That is why when people get emotionally upset they often develop physical symptoms, such as headaches or stomachaches. 5. Thoughts lie; they lie a lot, but it is your unquestioned or un-investigated thoughts that make us sad, mad, nervous, or out of control. Unfortunately, if you never challenge your thoughts you just "believe them." The negative thoughts invade your mind like ants at a picnic. One negative thought, like one ant at a picnic, is not a big deal. Two or three negative thoughts, like two or three ants at a picnic, become more irritating. And ten or twenty negative thoughts can cause real problems. 6. You can train your thoughts to be positive and hopeful or you can just allow them to be negative and upset you. Once you learn about your thoughts, you can chose to think good thoughts and feel good, or you can choose to think bad thoughts and feel lousy. That's right, it's up to you. Research has shown that positive emotionsespecially a sense of awe can reduce inflammation that will hurt your health. You can learn how to change your thoughts and change the way you feel. Nine Different Types of ANTs (10+) (or ways we distort reality to make it worse than it really is) 1. All or nothing thinking: thoughts that things are all good or all bad. 2. "Always" thinking thinking in words like always, never, no one, every one, every time, everything. 3. Focusing on the negative: only seeing the bad in a situation. (mental filtering) 4. Fortune telling: predicting the worst possible outcome to a situation with little or no evidence for it. ( catastrophing) 5. Mind reading: believing you know what another person is thinking even though they haven't told you. 6. Thinking with your feelings) believing negative feelings without ever questioning them. 7. Guilt beatings: thinking in words like "should, must, ought or have to." 8. Labeling: attaching a negative label to yourself or to someone else. 9. Blame: blaming someone else for the problems you have. ANT Killing Exercise: *Whenever you feel sad, mad, nervous or out of control, write down your automatic negative thoughts, label them, then talk back to them. Here are some ANT Killing examples: ANT Your thoughts matter. Kill the ANTs and train your thoughts to be positive and it will benefit your mind, mood, and body. Kill the ANTs Worksheet: When you notice an ANT: 1. Write it down. 2. Identify the type of ANT it is. 3. Kill the ANT by talking back to it - challenge the thought! What's your ANT? Identify the distortion - then challenge that thought with a more realistic perspective! Source: Amen Clinics/Dr. Aaron Beck (CBT)

Detaching from Emotional Pain (Grounding) "No feeling is final." -Rainer Maria Rilke (20th-century German poet) Using Grounding to Detach from Emotional Pain WHAT IS GROUNDING? Grounding is a set of simple strategies to detach from emotional pain (e.g., drug cravings, self-harm impulses, anger, sadness). Distraction works by focusing outward on the external world, rather than inward toward the self. You can also think of it as "distraction," "centering," "a safe place," "looking outward," or "healthy detachment." Grounding - to help control emotional volatility WHY DO GROUNDING? When you are overwhelmed with emotional pain, you a need a way to detach so that you can gain control over your feelings and stay safe. As long as you are grounding, you cannot possibly use substances or hurt yourself! Grounding "anchors" you to the present and to reality. Many people with PTSD and substance abuse struggle with feeling either too much (overwhelming emotions and memories) or too little (numbing and dissociation). In grounding, you a attain a balance between the two: conscious of reality and able to tolerate it. Remember that pain is a feeling; it is not who you are. When you get caught up in it, it feels like you are your pain, and that is all that exists. But it is only one part of your experience-the others are just hidden and can be found again through grounding. Guidelines Grounding can be done any time, any place, anywhere, and no one has to know. • Use grounding when you are faced with a trigger, enraged, dissociating, having a substance craving, or whenever your emotional pain goes above 6 (on a 0-10 scale). Grounding puts healthy distance between you and these negative feelings. Grounding - to help control emotional volatility Keep your eyes open, scan the room, and turn the light on to stay in touch with the present. Rate your mood before and after grounding, to test whether it worked. Before grounding, rate your level of emotional pain (0-10, where 10 means "extreme pain"). Then rerate it afterward. Has it gone down? No talking about negative feelings or journal writing-you want to distract away from negative feelings, not get in touch with them. Stay neutral-avoid judgments of "good" and "bad." For example, instead of "The walls are blue; I dislike blue because it reminds me of depression," simply say "The walls are blue" and move on. Focus on the present, not the past or future. • Note that grounding is not the same as relaxation training. Grounding is much more active, focuses on distraction strategies, and is intended to help extreme negative feelings. It is believed to be more effective than relaxation training for PTSD. WAYS OF GROUNDING Three major ways of grounding are described below-mental, physical, and soothing. "Mental" means focusing your mind; "physical" means focusing on your senses (e.g., touch, hearing); and "soothing" means talking to yourself in a very kind way. You may find that one type works better for you, or all types may be helpful. Mental Grounding Detaching from Emotional Pain (Grounding Describe your environment in detail, using all your senses-for example, "The walls are white; there are five pink chairs; there is a wooden bookshelf against the wall . . . Describe objects, sounds, textures, colors, smells, shapes, numbers, and temperature. You can do this anywhere. For example, on the subway: 'I'm on the subway. I'lI see the river soon. Those are the windows. This is the bench. The metal bar is silver. The subway map has four colors." Play a "categories" game with yourself. Try to think of "types of dogs," "jazz musicians," "states that begin with 'A' "cars," 'TV shows," "writers," "sports," "songs," or "cities." Do an age progression. If you have regressed to younger age (e.g., 8 years old), you can slowly work your way 80)back up (e.g., "I'm now 9; I'm now 10; I'm now 11 . ") until you are back to your current age. Describe an everyday activity in great detail. For example, describe a meal that you cook (e.g., "First l peel the potatoes and cut"). them into quarters; then I boil the water; then make an herb marinade of oregano, basil, garlic, and olive oil . Imagine. Use an image: Glide along on skates away from your pain; change the TV channel to get to a better show; think of a wall a as a buffer between you and your pain. Say a safety statement. "My name is located in the date is _; I am safe right now. I am in the present, not the past. am you focus on the letters and read not on something,the meaning, saying of each words. Use humor. Think of something funny to jolt yourself out of your mood. Count to 10 or say the alphabet, very s ... l... o . . . w... l... y. Physical Grounding * Run cool or warm water over your hands. * Grab tightly onto your chair as hard as you can. * Touch various objects around you: a pen, keys, your clothing, the table, the walls. Notice textures, colors, materials, weight, temperature. Compare objects you touch: s one colder? Lighter? * Dig your heels into the floor-literally "grounding" them! Notice the tension centered in your heels as you do this. Remind yourself that you are connected to the ground. * Carry a grounding object in your pocket-a small object (a small rock, clay, a ring, a a piece of cloth or yarn) that you can touch whenever you feel triggered. * Jump up and down. *Notice your body: the weight of your body in the chair; wiggling your toes in your socks; the feel of your back against the chair. You are connected to the world. * Stretch. Extend your fingers, arms, or legs as far as you can; roll your head around. * Clench and release your fists. * Walk slowly, noticing each footstep, saying "left" or "right" with each step. *Eat something, describing the flavors in detail to yourself. * Focus on your breathing, noticing each inhale and exhale (e.g., a favorite color, or a soothing word such as "safe" or "easy"). Soothing Grounding + Say kind statements, as if you were talking to a small child-forexample, "You are a good person going through~ a hard time. You'll get through this." +Think of favorites. Think of your favorite color, animal, season, food, time of day, TV show. + Picture people you care about (e.g., your children), and look at photographs of them. + Remember the words to an inspiring song, quotation, or poem that makes you feel better (e.g., the AA Serenity Prayer). + Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or a favorite room); focus on everything about that place-the sounds, colors, shapes, objects, textures. + Say a coping statement: "I can handle this, "This feeling will pass." + Plan a safe treat for yourself, such as a piece of candy, a nice a dinner, or a warm bath. Think of things you are looking forward to in the next week-perhaps time with a friend, going to a movie, or going on a hike. WHAT IF GROUNDING DOES NOT WORK? Grounding does work! But, like any other skill, you need to practice to make it as powerful as possible. Below are suggestions to help make it work for you. * Practice as often as possible, even when you don't need it, SO that you'll know it by heart. * Practice faster. Speeding up the pace gets you focused on the outside world quickly. * Try grounding for a looooooonnnnngggg time (20-30 minutes). And repeat, repeat, repeat. * Try to notice which methods you like best-physical, mental, or soothing grounding methods, or some combination. * Create your own methods of grounding. Any method you make up may be worth much more than those you read here, because it is yours. * Start grounding early in a negative mood cycle. Start when a substance craving just starts or when you have just started having a flashback. Start before anger gets out of control. * Make up an index card on which you list your best grounding methods and how long to use them. * Have others assist you in grounding. Teach friends or family about grounding, so that they can help guide you with it if you become overwhelmed. * Prepare in advance. Locate places at home, in your car, and at work where you have materials and reminders for grounding. * Create a cassette tape of a grounding message that you can play when needed. Consider asking your therapist or someone close to you to record it if you want to hear someone else's voice. * Think about why grounding works. Why might it be that by focusing on the external world, you become more aware of an inner peacefulness? Notice the methods that work for you-why might those be more powerful for you than other methods? * Don't give up! From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press.

Too Much Distance: Learning to Say "Yes" in Relationships Why is it important to say "yes"? It means connecting with others. It is a way of recognizing that we are all human and all need social contact. It is a healthy way of respecting your role as part of a larger community. It means becoming known to others. Learning to Say "Yes" in Relationships SITUATIONS WHERE YOU CAN LEARN TO SAY "YES" Asking someone out for coffee. Telling your therapist how you really feel. Asking someone for a favor. Joining a club or organization. Calling a hotline. • Being vulnerable about your "weak" feelings. Letting people get to know you. Soothing "young" parts of yoursel * Any others that you notice? Write them on the back of the page. EXAMPLES: SAYING "YES" IN SUBSTANCE ABUSE AND PTSD With Others With Yourself Substance a "I am having a drug craving-please help talk Abuse me through it." can give myself treats that are healthy rather than destructive." "Please come with me to an AA meeting.' "I need your help-I am scared." "I will try speaking at an AA meeting." PTSD " need to reach out to people when I'm upset." would like you to call and check in on me "I can start creating healthy friendships step to see if I'm okay." by step.' HOW TO SAY "YES" * Try different ways: • Share an activity: "Would you like to go a to a movie with me?" Say how you feel: "I feel so alone; it is hard for me to talk about this." • Focus on the other person: "Tell me about your struggles with cocaine." Watch how others do it: Go to a gathering and a listen to others relate. * Plan for rejection. Everyone gets rejected at times. It is a normal part of life. Let go of that person and move on to someone else who might be available. * Practice in advance, if possible. Therapy may be safe place to rehearse. (cont.) From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details). 276 HANDOUT 3 (page 2 of 2) Setting Boundaries in Relationships * Choose safe people. Select people who are friendly and supportive. * Know that it's normal to make mistakes along the way. It will feel uncomfortable to reach out to others at rst. Allow yourself room to grow-it will get easier over time. fi * Set goals. Keep yourself moving forward by making a clear plan, just as you would in other areas of your life. Decide to make one social call a week, or try one new meeting a week. * Recognize that you may feel very "young." Parts of you may feel vulnerable, like a child who a is just learn- ing how to relate to people. That is expected, as parts of you may not have had a chance a to develop due to PTSD or substance abuse. * Start small. Start with a simple event (e.g., saying hello or smiling) rather than a huge one (e.g., asking someone out on a date). a * Notice what you have in common rather than how you are different. Work hard to see your similarities with others; this can make it easier to connect. ROLE PLAYS FOR SAYING "YES" * Try rehearsing the following situations out loud. With Others ) You talk about your impulse to hurt yourself before doing it. -> You ask someone at work to go to lunch. -> You tell your therapist you missed her when she was away on vacation. > You call your sponsor when you feel like drinking. › You tell someone, "I love you." } You tell someone how alone you feel. - You admit a weakness to someone. - You talk to your friend honestly about your anger at him. - It is 4:00 A.M. and you are so depressed you can't sleep. Whom can you call? is The weekend is coming and you have no plans with anyone. What can you do? With Yourself You feel scared; how can you soothe yourself? You have worked hard; how can you give yourself a safe treat? a Part of you ("the child within") feels hurt. How can you talk to that part? -› You are angry at yourself for failing a test. How can you forgive yourself?

Cannabis Addiction Is a Drug to Treat Cannabis Addiction Finally Within Reach? BORDEAUX, France — Could AEF0117, a drug that has a novel mechanism of action in the brain, be the drug to fight cannabis addiction? Results from a phase 2a clinical trial that examined the efficacy of AEF0117 in patients with cannabis use disorder have created quite a stir. The study was published in Nature Medicine. Not only did AEF0117 weaken the effects of cannabis, but it also decreased a person's desire to use it, all without causing withdrawal symptoms. These findings have generated a significant buzz in the scientific and medical community. "In the past, 8% of cannabis users would develop an addiction — today, this figure is 15%. Addiction to cannabis has become the main reason for seeking treatment at specialist drug clinics," said Pier Vincenzo Piazza, MD, PhD, psychiatrist, neurobiologist, and general director of Aelis Farma, the biopharmaceutical company that developed AEF0117. This rise in cases can be explained by the increase in THC content in cannabis over the years. THC content increased from 5% in the 1970s to 30% today. Although cannabis is still less addictive than tobacco (33% of users become addicted), cocaine, heroin, or alcohol (25% of users become addicted), the number of cannabis users is increasing. Currently, 14.2 million in the United States and more than half a million in France use cannabis. CB1 Receptor Inhibition Neutral CB1 Receptor Antagonists as Pharmacotherapies for Substance Use Disorders: Rationale, Evidence, and Challenge AEF0117 is the first signaling-specific inhibitor of the CB1 receptor. THC acts in the brain via CB1 cannabinoid receptors located on neurons. The total inhibition of CB1 receptors has long been an avenue of research, but the adverse effects caused by CB1 receptor antagonists are incompatible with a therapeutic approach. "We thought that it would be impossible to modulate part of a receptor by a molecule. But in 2014, we discovered this unexpected natural mechanism precisely at the level of the CB1 cannabinoid receptors," Piazza told Medscape French Edition. At the time, he was the director of the Magendie Neurology Center (Inserm ― the French National Institute of Health and Medical Research) in Bordeaux, France. Along with his colleagues, he demonstrated that in response to high doses of THC, a hormone, pregnenolone, is synthesized and becomes bound to CB1 receptors, which reduces some of the effects of THC. The discovery of this new mechanism was published in Science in 2014. "It then took 2 years to create a synthetic molecule that could mimic the effects of pregnenolone on the CB1 receptors," Piazza continued. Unlike pregnenolone, the new molecule needed to to be fully absorbable, stable, and not transformable into other steroids. Triple Action AEF0117 was assessed as part of a placebo-controlled, double-blind, phase 2a study. The participants were volunteers who had a cannabis addiction. In the treated group, the volunteers received either 0.06 mg (n = 14) or 1 mg (n = 15) of the investigational drug. Use of AEF0117 was associated with a significant reduction in the positive subjective effects of cannabis (19% for the 0.06-mg dose and 38% for the 1-mg dose; P < .04). The investigators showed an association with reduced cannabis use, as measured by self-administration (P < .05). No adverse events were linked to the treatment in comparison with placebo. Furthermore, there were no withdrawal symptoms, even among healthy volunteers who would smoke several grams of cannabis a day. "I call this triple action: reduced positive effects of cannabis, reduced desire to use it, and a lack of withdrawal symptoms linked to the partial receptor inhibition," said Piazza. Commenting on the study for Medscape, Guillaume Davido, MD, a psychiatrist who specializes in addiction studies at Bichat Hospital in Paris, said, "Patients really miss the psychoactive anxiolytic effect of cannabis when they stop using it. This is what makes stopping so difficult. Getting rid of this 'honeymoon' effect with the product is a considerable step forward." Davido is sure AEF0117 will be approved for prescription use. It should be used in conjunction with appropriate psychotherapeutic care, as is the case with the treatment of alcohol addiction, which combines medication with cognitive-behavioral therapy (CBT). Currently, CBT is the only recommended treatment for cannabis use disorder. Currently, no treatments are approved for cannabis use disorder, said Davido. "At the moment, we can only provide medicinal products to treat cannabis withdrawal symptoms, such as irritability, sleep disorders, and anxiety." New Trial Recruiting A phase 2b trial has been launched in the United States. It is in the process of recruiting 330 participants with cannabis addiction at 11 sites. Recruitment is scheduled to be completed by October. The three doses to be assessed in this new trial, which is being conducted in collaboration with Columbia University Irving Medical Center in New York, will be around 1 mg. "We tested two very different doses (0.06 mg and 1 mg) of AEF0117, because in animals, very low doses block some of the effects of cannabis," said Piazza. "But it became apparent that we would need a much higher dose to stop the desire for cannabis use completely." The results should be available by mid-2024. "And if its therapeutic efficacy is confirmed, a whole new pharmacology of receptors is opened up to us," said Piazza. Piazza is the general director of Aelis Farma, the biopharmaceutical company developing AEF0117.

Amid Shortages Federal Agencies Ask Drugmakers to Boost Output of ADHD Meds | Community Healthcare SystemVisit Agencies are also asking prescribers to carefully monitor their prescribing practices. HealthDay News — While demand for prescription stimulants is surging, a shortage of the drugs persists, so federal officials have stepped in and asked drug companies to ramp up production of the medications. Officials from both the US Food and Drug Administration and the US Drug Enforcement Administration made the joint request. “The FDA and DEA do not manufacture drugs and cannot require a pharmaceutical company to make a drug, make more of a drug, or change the distribution of a drug,” FDA Commissioner Robert Califf, M.D., and Drug Enforcement Administration leader Anne Milgram wrote in a letter issued. “That said, we are working closely with numerous manufacturers, agencies, and others in the supply chain to understand, prevent, and reduce the impact of these shortages.” The agencies are also asking prescribers to carefully monitor their prescribing practices. “The lack of availability of certain medications in recent months has been understandably frustrating for patients and their families,” Califf and Milgram wrote in their letter. Reasons for the shortage include manufacturing delays by 1 drugmaker last fall. Meanwhile, demand for prescription stimulants for adults surged during the pandemic, according to a US Centers for Disease Control and Prevention report. The FDA first announced a shortage of Adderall last October. The DEA limits the amount of stimulants that can be produced, but manufacturers have not been reaching that upper limit, the joint letter noted. A 2022 analysis showed they were 30% short of the quota. The agency is asking manufacturers to relinquish any quota they cannot meet so the DEA can redistribute it, while it is “committed to reviewing and improving” the quota process.

Interpreting the latest suicide data. KEY POINTS The number of suicides in the U.S. climbed 2.6 percent in 2022, to just under 50,000. The suicide rate has been climbing steadily since 2000. Study Shows Impact of Adults on Reducing Student Suicide Men are four times more likely than women to die by suicide. Men die by suicide 3.5x more often than women. Suicide Prevention Men in non-urban areas are particularly at risk of suicide due to social and economic factors. Suicide and suicide attempts in the Pacific Islands: A Systematic Literature Review We’re past the point of using metaphors like alarms and wake-up calls. They have been going off for years, and the provisional figures from the Centers for Disease Control and Prevention (CDC) on suicide in 2022 once again convey a grim increase in deaths that has been the general trend since 2000. Though the overall number of suicides declined in 2019 and 2020, the figure has once again risen in 2021 and 2022—by 5 percent and 2.6 percent, respectively. There is no positive spin that one can put on the fact that just under 50,000 Americans chose to end their lives last year. And while there may not be a silver lining in this story, we at least have the epidemiological tools to better understand where more suicides are happening and who is more likely to die by suicide, which may eventually help us understand why the number of suicides is climbing. Though it is a category error to treat suicide as no different than a disease, there are most certainly social factors that are contributing to the rise in suicides, and they are affecting some communities more than others. Three preliminary things are worth noting. First, while the number of suicides has trended upward since 2000 and may seem unprecedented, the annual suicide rate is similar to what it was for much of the 1960s and 1970s (see Figure 1). Figure 1. OECD (2023), Suicide rates (indicator). The second is that the rise in suicides since 2000 has been accompanied by an increase in the number of overdose deaths, which has accelerated more recently due to the rising presence of fentanyl in the illicit drug trade and the COVID-19 pandemic (see Figure 2). Moreover, many of the antecedent social factors propelling the rise in drug use and overdose deaths are almost certainly driving the surge in suicides. Third, 90 percent of completed suicides occur in patients with a mental illness. However, the percentage of people who have a mental illness and take their own lives is only 5 percent. Moreover, an estimated 50 percent of suicide victims are people with no known psychiatric illness, even at their time of death. Figure 2. Overdose deaths and suicide deaths in the U.S. All that said, here’s what the epidemiological data says. Where? Within the U.S., density appears to be inversely associated with suicide rates, with large metropolitan areas like New York seeing suicide rates half that of rural areas. As of 2021, the states with the highest suicide rates per 100,000 were Wyoming (32.3), Montana (32.0), and Alaska (30.8). The states with the lowest suicide rates were New Jersey (7.1 percent), New York (7.9 percent), and Massachusetts (8 percent). Alaska has the lowest population density, followed by Wyoming and then Montana. Conversely, New Jersey is the most densely populated state, New York ranks seventh, and Massachusetts ranks third. Who? As Figure 3 shows, men have been about four times more likely to die by suicide than women for the last 20 years. There are also clear racial and ethnic disparities in suicide rates; non-Hispanic Whites and Non-Hispanic American Indian or Alaska Natives have significantly higher rates than average, while Hispanic, Non-Hispanic Black, and Non-Hispanic Asian or Pacific Islander individuals all have lower than average rates. Figure 3. Suicide rates for men and women. Source: Garnett MF, Curtin SC, Stone DM. Suicide mortality in the United States, 2000–2020. NCHS Data Brief, no 433. Hyattsville, MD: National Center for Health Statistics. 2022. What is truly astonishing is what happens when you split ethnic groups along the rural or non-rural divide for men (see Figure 4). The graph on the right appears to be a continuation of the graph on the left, but it’s actually a visualization of this divide. When? While the non-rural or rural divide and patterns among ethnicities are fairly straightforward, age is not. Moreover, the age groups with the highest suicide rates skew a bit older than one might expect. Among women, it’s the 45 to 64 age group. For men, it’s those who are over 75. Additionally, every age group for females is lower than for males, except for those aged 10-14. Figure 4. Suicide rates by race/ethnicity. How? Guns have become the most common method of suicide among both men and women within the U.S. In 2021, 54 percent (26,328) of all firearm deaths were suicides compared to 43 percent of deaths which were murders (20,958). The remaining 3 percent included accidents (549), shootings by police officers (537), or deaths with undetermined circumstances (458). Raw Numbers While rates fluctuate from year to year for varying groups, I want to stress that the largest number of suicides each year continues to be middle-aged White males who die by firearm in non-rural areas. Similarly, suicide rates within rural areas may be elevated, but the raw number of deaths is still far higher in non-rural areas because more people live there. Takeaways There is no doubt that there is a mental health crisis in America, and non-Hispanic American Indian/Alaskan Native and non-Hispanic White men in non-urban areas are perhaps struggling as much, if not more, than anyone else, as the data shows. For decades, unique cultural hurdles have prevented men in these communities from asking for help, such as stigmas against seeking assistance or limited access to mental health care. However, we have not seen the high suicide rates described above. Something else has to be fueling the problem. It seems clear that the widely reported macroeconomic trends that have resulted in disproportionate levels of poverty, drug use, and despair are the issues driving the epidemic of non-urban suicide more than social stigmas. While this should not stop us from providing resources for short-term crisis intervention, long-term suicide prevention will require meaningful economic changes and a resurgence of hope. If you or someone you love is contemplating suicide, seek help immediately.

The series explores the origins of the first opioid crisis in the United States. The recent Netflix TV series Painkiller (2023) depicts the first opioid crisis in the United States. The plot merges an article by Patrick Keefe—“The Family That Built an Empire of Pain”—and a book by Barry Meier—Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic. The series explores the dynamics originating the first opioid epidemic in the 1990s and holds the Sackler family, owners of Purdue Pharma, responsible for it while denouncing the deceitful marketing strategies they used to sell the addictive drug oxycontin. The story is told in a mixed resemblance to Hollywood’s academy winner The Big Short (2015) and Scorsese’s mafia films. Most of the characters are fictional and contrast with real testimonies of victims from the epidemic at the beginning of each episode. The result nonetheless seems a little in-cohesive. Throughout the series, we can see how 1 family is destroyed after the father is prescribed oxycontin following a back surgery intertwined with the story of Richard Sackler and the steps he took to build his “empire of deceit.” The series does a good job of making the viewer frustrated at seeing how a group of psychopathic businessmen become filthy rich by causing major damage in society. Furthermore, it destroys the idea of human integrity: Everyone has a price, and everyone is corruptible by money. The spectator is left in an existential crisis, only to be rescued by the protagonist, Edie Flowers—a lawyer whose family was affected by the crack epidemic and brings the case against Purdue Pharma. Painkiller has a villain, Richard Sackler, and a heroine, Edie Flowers. Richard is the son of Raymond Sackler and nephew of Arthur and Mortimer Sackler, the patriarchs who bought Purdue Pharma, starting the Sackler dynasty. Arthur Sackler is inaccurately portrayed as a frivolous psychiatrist who practiced lobotomy before coming up with the idea of marketing thorazine. After dying of a heart attack, his nephew took over the company; however, his hostile ghost will appear to Richard Sackler throughout the series to remind him of the legacy of the family. Richard seems to have an unresolved Oedipus complex when dealing with the introjection of his uncle and his family’s legacy as a bad object and an inferiority complex. Psychiatrically, that relates to his narcissism, his obsession with greed and power, and his lack of remorse for the impact and consequences of his practices, deeming him incapacitated to feel empathy for anyone. However, the repression is not always effective and the neurosis here is manifested in the spirit of his uncle, who torments him reminding him of his failure to keep the family legacy. In contrast, Edie Flowers is a victim of the prior crack epidemic. As a result of it, her mother died, and her brother went to jail. Edie and her brother became estranged. She blamed him for selling crack to her mom. Now, as an adult and as a lawyer, she will have an opportunity to redeem and heal with an act of altruism. By bringing a case against the Sackler family, she can restore justice and undo the guilt of not having saved her family. The TV series is effective at expanding solidarity for the victims of the first opioid epidemic and the subsequent epidemics. However, it is told in a sensationalized manner, leaving the viewer with the biased idea that 1 individual could be responsible for the whole current opioid problem in North America. As we know, in the real world, the factors related to the current opioid crisis in society are much more complex and the individuals are neither all good nor all bad. However, as physicians, we can learn a few lessons from Painkiller. Marketing aims to sell, and often at the cost of offering biased science, advice, and practice. It is our responsibility to read and critique what we are taught and what we read, to stay humble, and to constantly search truth. At an individual level, we must evaluate and foresee the impact that prescription patterns of opioids, benzodiazepines, stimulants, and antipsychotics will have on our patients and our society in both the short and the long term. As clinicians, we are an important and essential element in the chain, and thus we are responsible.