The CEO of the AFSP discusses the big 1-year anniversary of the 988 Sunday July 16 marks the official 1-year anniversary of the National Suicide Prevention Lifeline's new number, 988. Bob Gebbia, CEO of the AFSP, sat down to discuss this important stepping stone in crisis mental health. Bob Gebbia is CEO of the American Foundation for Suicide Prevention, which has become the leading suicide prevention nonprofit organization in the United States. He is also a founding member of the National Council for Suicide Prevention, serves on the National Lifeline Advisory Committee, the Executive Committee of the National Action Alliance for Suicide Prevention, and is the past Chair of the Board of Directors of the National Health Council. What is 988? Crisis and Suicide Hotline? The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week, across the United States. The Lifeline is comprised of a national network of over 200 local crisis centers, combining custom local care and resources with national standards and best practices. The 988 Suicide & Crisis Lifeline is a leader in suicide prevention and mental health crisis care. Since its inception, the Lifeline has engaged in a variety of initiatives to improve crisis services and advance suicide prevention for all, including innovative public messaging, best practices in mental health, and groundbreaking partnerships. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and Vibrant Emotional Health launched the Lifeline on January 1, 2005. Vibrant Emotional Health, the administrator of the grant, works with its partners, the National Association of State Mental Health Program Directors (NASMHPD), National Council for Behavioral Health, and others, to manage the project, along with Living Works, Inc., an internationally respected organization specializing in suicide intervention skills training. The 988 Suicide & Crisis Lifeline has been independently evaluated since its inception by an investigation team from Columbia University’s Research Foundation for Mental Hygiene. The Lifeline receives ongoing consultation and guidance from national and international researchers and experts focused on suicide prevention and crisis response. Here are facts about the benefits of 988. Source: Psychiatric Times

This Pride Month we decided to take a look at two different but intersected perspectives on what this month means in our current environment. The first is from Mental Health America’s President and CEO Schroeder Stribling, and the second is from Mental Health America Director of Public Awareness and Education Em Skehill. Gen X: Schroeder Stribling The joy in Pride Month is indisputable. Millions of LGBTQ+ individuals and communities and supporters come together in waves of colorful celebration, and after all these years it’s still thrilling to call out “Happy Pride!” to a friend across the way. My own lifetime has spanned the years from Stonewall to legalized same-sex marriage. Along the way, the mental health field removed “homosexuality” from the DSM (the diagnostic manual) and the “pathologizing” of sexual orientation and gender expression diminished, alongside widespread condemnation of “conversion therapies” which aimed to “cure” us. LGBTQ+ Remembering our proud history of struggle and progress will power our resolve and sharpen our wisdom. From Harvey Milk and Marsha P. Johnson, to the extravagant balls in “Paris is Burning” and the black-and-pink T-shirts of Act Up proclaiming Silence=Death, to Don’t Ask Don’t Tell to Obergefell – we should remember it all this Pride Month. But now in my 50s, I fear that our progress is eroding. We have seen the introduction of numerous anti-LGBTQ+ legislation at the state level, specifically anti-trans legislation, and threats to drag events this year have been rampant. In my mind this Pride Month, the black-and-white image of drag queens being shoved into a paddy wagon is juxtaposed with the colorful Barbie lawn display I saw in Washington, D.C.: sparkly, decked-out dolls with a sign that read “Drag Is Not a Crime.” It seems the clock is ticking backwards. I am concerned for the queer youth of today. I worry about the mental and emotional toll on LBGTQ+ students in schools where pronoun recognition or queer-positive library books are being debated. I worry for trans adults in states where their access to ongoing medical treatment is threatened. I worry especially for Black, Indigenous, and people of color (BIPOC) youth and young people of all intersectional identities who are at risk of exclusion and discrimination on several fronts. This Pride Month, we commit ourselves to understanding the lived experience of LGBTQ+ youth, being responsive to their needs, and following their leadership. Millennial: Em Skehill The joy in Pride Month is indisputable. While we love our queerness all year, June is a time when we get to see, experience, and celebrate ourselves even more loudly. The sense of community and love among LGBTQ+ folks often feels stronger and deeper, and it’s a time I feel more connected than ever to our queer ancestors across the globe. Those positive feelings aren’t gone this year, but they are certainly complicated by current events. In 2023, it feels like we have gone backwards after coming so far – trans rights are being stripped away, and in many areas it isn’t safe to celebrate, or even visibly identify as queer. Within the queer community there’s an unspoken understanding that this year, Pride is scary. With the increase in mass violence – especially toward identity groups, and even more so toward the trans community – Pride celebrations feel like an obvious target. Multiple far-right extremist groups are planning to escalate attacks on our community this month. While we hope these plans are thwarted, many feel like there’s no way to guarantee both our safety and our pride. On a less threatening, but still hurtful, level, we see our month watered down by rainbow capitalism – corporations using Pride Month as a performative business strategy without actually supporting the LGBTQ+ community. It turns the focus of Pride away from LGBTQ+ protests, rights, and freedom and toward mainstream companies – many of which, sadly, drop their support come July 1. This year, we’ve felt that ally ship taken away from us before June even began with a number of businesses deciding to cancel planned events or merchandise releases related to Pride. You may have seen this tweet circulating recently: “For pride month this year, can straight people focus less on ‘love is love’ and more on ‘queer and trans people are in danger.’” Many people consider themselves an ally in that they support LGBTQ+ rights and join in Pride celebrations, but it hurts when they don’t show up in the ways that we need them. We’re challenged this month with holding our love for Pride and everything it means, while enduring an onslaught of identity-based discrimination, hate, and trauma. We’re experiencing multiple feelings at once that really run the gamut – from joy to sadness to fear. Pride Month grew out of the 1969 Stonewall Riots. This month isn’t rooted in celebration, but in resistance, human rights, and reclaiming our narratives from people who hate or deny our existence. Part of that does include celebrating us. Joy is a form of resistance. Whether you identify as LGBTQ+, are questioning your identity, an ally, or simply curious to learn more, we hope everyone takes some time this month to consider how the current environment is affecting your mind or those around you. Learn more with our resources. Mental Health America will continue standing with the LGBTQ+ community and working to make our country safe for all, no matter how they identify. Source: Mental Health of America

Whether is due to lack of treatment and follow-up or poor compliance with medication. studies show postpartum black women experience three times higher maternal mortality rates than than their white and hispanic counterparts. Learn more about this topic from the Psychiatric Times article below: There are significantly larger rates of maternal mortality in the peri- and postpartum period in the United States compared with other countries across the world. The US is considered a first-world country, with a systemic prioritization placed on access and utilization of health care. However, mortality rates are 10 times that of similar first world countries. Out of every 100,000 live births, approximately 33 lead to maternal death in the US. This is in comparison to other first-world countries such as Japan or Australia, where deaths are 2 to 3 per 100,000 live births.1 Figure. Peri/postpartum Maternal Mortality Rates by Year and Race When separating out maternal mortality rates by race in the year 2021, Black women in the US experienced a far worse outcome. Maternal mortality rates were 70 in 100,000 live births. Comparatively, in white women, approximately 27 out of 100,000 live births resulted in maternal mortality.1 Preliminary data from 2022 indicate an across-the-board drop to pre-COVID-19-pandemic levels, underlying the role the pandemic played in access to adequate health care.2 See the Figure for peri/postpartum mortality rates for Black compared to white women through years 2018-2021. At present, there are no dismantling studies examining the specific variables that contribute to the high rates of mortality in peri-and postpartum Black women. Several variables have been examined (eg, socioeconomic status, level of education/career status, access to health care, social support system, advocacy efforts, pre- or concurrent levels of medical and mental health comorbidities) and none of these alone were found to be the contributory variable.3 A Black woman with a high-level career, level of notoriety, and a higher socioeconomic status, is still at the same risk of mortality as a Black woman who does not fall within these categories. The abovementioned variables appear to be under a larger umbrella of “pervasive systemic racism” that most researchers and clinicians hypothesize to be the causal factor of high levels of mortality in peri- and postpartum Black women in the US. Mental health comorbidities and treatment participation in Black peri- and postpartum women are some of the most important variables when considering mortality. The presence of undiagnosed and untreated anxiety and depression can influence access to and proper health care (eg, efficiently address biological comorbidities such as high blood pressure), impact infant care and wellness, and access to building effective social support systems. In the US, studies have found that the rates of peri-and postpartum depression and anxiety do not differ between Black and white women. During the peri- and postpartum period, the diagnostic rates of anxiety and depression are between 10 and 33%.4-6 Although studies show anxiety and depression rates do not differ in white vs Black peri- and postpartum women, Black women are 3 times less likely to report their symptoms and seek out evidence-based care.4,5 Thus, the rates for Black peri- and postpartum women are likely higher than studies have indicated due to low levels of reporting. While mental health may be one piece in a larger puzzle, it remains a very important one. It is comingled with the several variables listed above and is a contributing factor when considering mortality rates. The American College for Obstetrics and Gynecologists recommends, across race, screening for anxiety and depression at least once during the peri-natal period, “closer monitoring” for those with a history of anxiety and depression, and at the one-time 6- to 8-week postpartum check-up appointment.7 Juxtapose this with evidence-based mental health clinicians, who more routinely use screening measures (weekly, if not biweekly) and have access to their patients frequently enough to follow through on early detection. The Edinburg Postnatal Depression Scale8 or Beck Anxiety/Depression Inventories9,10are the most common measures used to detect clinical anxiety and depression in peri- and postpartum women. However, while even they have good psychometric properties, they are not sensitive to cultural and race differences in women specific to the peri- and postpartum period. After the 6- to 8-week postpartum appointment, care of the patient typically transfers back to the primary care physician. During this interval of time, the paucity of continuous care, especially when patients may experience active depression and/or anxiety, is cause for concern for self-advocacy and commitment to care. Some researchers have found there are disproportionate levels of access to and active engagement in treatment across Black postpartum women with depression.11 White postpartum women were 2 times as likely, even if actively symptomatic, to successfully initiate mental health care.11 Interestingly, Black women have been found to prefer psychotherapy over psychotropic medications,12-14 emphasizing the importance of access to mental health care prior to and after birth. Medical and mental health comorbidities in Black women during the peri- and postpartum stage can influence the experience and outcome of the birthing and postpartum recovery process. The intertwined nature of pre-existing and/or concurrent anxiety and/or depression and medical comorbidities during the pregnancy, birth, and recovery process is individual and complicated by systemic racism underlying decades-old medical systems. Case Example “Tara” (identifying information and situation changed to protect patient confidentiality), a 35-year-old Black woman resided in Upper East Side of New York City. She had been married to her husband, Benny, for 10 years. They had gone through several rounds of IVF to successfully conceive and carry a baby to term. She had been diagnosed with major depressive disorder and generalized anxiety during her IVF process and remained symptomatic (seeing a psychologist), but choosing to remain unmedicated during her pregnancy. She was a pediatrician and well-versed in medical language and how to advocate for herself. At her 38-week appointment, her OB/GYN, with permission, broke her water, as Tara was dilated and complaining of severe back pain, suspected to be labor pains. Her blood pressure was borderline high (130 systolic/88 diastolic), but her OBGYN reported that was to be expected undergoing labor pains at now almost 4 cm dilated. Tara had a very smooth natural vaginal delivery and reported to her husband that she did not expect her first birth go so well. Twenty-four hours after delivery, Tara woke up in a sweat and reported that she did not “feel well.” Her nurse came in and took her temperature, noticing it was barely above normal at 99.9 oF. Tara reported her pain was at a level of a “6” on a scale from 0-10. The nurse asked Tara and her husband about any pre-existing conditions and they reported that she was medically healthy, and had been diagnosed with depression and anxiety. The nurse ordered acetaminophen for Tara and told her she would be back in 2 hours to check on her and to get some rest. Benny reported that Tara looked better after 30 minutes. Tara awoke 1 hour later in pain. The nurse came in and noticed Tara had passed a large blood clot (can be part of the normal process of expelling birthing remains after a vaginal birth). She said that Tara would be fine and that she would order a narcotic pain killer. Tara’s pain subsided after being given the pain killer and while she was asleep the nurse reported to her husband that “some women just cannot handle the pain of childbirth, especially when they have a low tolerance for discomfort being diagnosed with anxiety and depression.” After being discharged from the hospital, Tara continued to experience high levels of generalized pain. She called her OB/GYN and was encouraged to take more narcotics. Two to 3 days after taking narcotics, Tara’s pain continued. Her husband called an ambulance. Tara coded and passed away en route to the emergency room. Autopsy results revealed Tara had been suffering from eclampsia that had gone undiagnosed, as her blood pressure clinically elevated into dangerous levels within days after her discharge from the hospital. Her physical complaints were misinterpreted as an anxious reaction to her birthing process and were not diagnosed and treated properly. Improved Avenues for Care and Future Research Upon reflection and examination of Tara’s care, it is noticeable there were several issues consisting of lack of patient advocacy, miscommunication among medical professionals and with the patient, disregard and/or the misinterpretation of symptoms experienced by the patient, minimally adequate medical and mental health care, and concerns of micro-aggressions and overt racism. If these issues had been sufficiently addressed, it may had resulted in Tara’s survival, rather than her unnecessary death. Currently, several community-based programs have been developed to increase positive birthing outcomes and decrease medical and mental health comorbidities in Black peri-and postpartum women. Prevention programs, such as the Milwaukee Birthing Project, employed a “life course perspective” including building support systems and skills aimed to reduce a cumulative life stressor response (systemic racism) thought to contribute to both infant and maternal mortality rates.15 Each mother was paired with a “big sister” to communicate with on a biweekly basis with goals such as improving prenatal care, birth outcomes, increasing social network access, and more. These were part of a larger 12-point plan to reduce the disparity in the Black-white birthing outcome. Results were promising, indicating improved birth outcomes compared with a control group, but the data was limited due to poor follow-up with participants.15 Table. 5 Areas of Well-Being for Health Care Providers to Address16 The UNC Collaborative Center for Maternal and Infant Health has sought to recommend a more comprehensive approach. Depression in the peri- and postpartum period has been found to have an intergenerational aspect, where adults who have been neglected tend to pass on the neglect to the care of their infant.16 Therefore, in addition to the recommendation of evidence-based mental health treatment (eg, cognitive-behavioral treatment for anxiety and depression), the 4th trimester project recommends health care providers address 5 other areas of well-being (Table).16 This research has found that postpartum care (termed 4th trimester), should be designed for a Black woman’s individual needs and constraints, should be implemented prior to birth; improve upon patient-provider communication; focus on retention and activation of information received from the provider to the patient; and should be empathic, culturally-sensitive, and aware of systemic racism underlying the US health care system.17,18 These programs have called for a more holistic approach to peri- and postpartum health care in Black women. Assessing and treating mental health concerns, such as anxiety and depression, is vital in peri- and postpartum Black women, but it is also not the entire clinical package that is needed. One of the major obstacles to following through with a more holistic approach is continuity of care. While health care providers have been found to provide helpful recommendations, the onus of responsibility for follow through on the recommendations relies solely on the patient, who may not have the financial, social, mental, physical, or logistic support to successfully implement adequate care. Providers may fall victim themselves to perpetuating an ineffective health care system, not knowing the limitations of the patients themselves.17 Larger changes in US government policy and grant allocation, as well as peri- and postpartum education of providers (eg, effective and empathic communication systems with marginalized groups and recognizing the role of systemic racism, etc) and patients (eg, education in mental and physical health of the mother and infant at different stages in peri- and postpartum care, etc), are needed to drastically improve peri- and postpartum mortality (and morbidity) of marginalized groups, especially that of Black women. Dr Kaplan is a clinical psychologist and director of the Washington Anxiety Center of Capitol Hill. Dr Dumessa is a clinical psychologist at the Washington Anxiety Center of Capitol Hill.Ms Ruiz is research assistant and graduate student at the Washington Anxiety Center of Capitol Hill and the Catholic University of America. References 1. Hoyert DL. Maternal mortality rates in the United States, 2021. Centers for Disease Control and Prevention, National Center for Health Statistics. 2023. Accessed July 20, 2023. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.pdf. 2. Provisional maternal deaths. Centers for Disease Control and Prevention, National Center for Health Statistics. July 12, 2023. Accessed July 20, 2023. https://www.cdc.gov/nchs/nvss/vsrr/provisional-maternal-deaths.htm. 3. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5):1071-1083. 4. Kozhimannil KB, Trinacty CM, Busch AB, et al. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011;62(6):619-625. 5. Dagher RK, Pérez-Stable EJ, James RS. Socioeconomic and racial/ethnic disparities in postpartum consultation for mental health concerns among US mothers. Arch Womens Ment Health. 2021;24(5):781-791. 6. Ponting C, Urizar GG Jr, Dunkel Schetter C. Psychological interventions for prenatal anxiety in Latinas and Black women: a scoping review and recommendations. Front Psychiatry. 2022;13:820343. 7. ACOG Statement on Depression Screening. American College of Obstetricians and Gynecologists. January 26, 2016. Accessed July 20, 2023. https://www.acog.org/news/news-releases/2016/01/acog-statement-on-depression-screening. 8. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786. 9. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571. 10. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893-897. 11. Kozhimannil KB, Trinacty CM, Busch AB, et al. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011;62(6):619-625. 12. Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care. 2003;41(4):479-489. 13. Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006;33(4):323-331. 14. Goodman JH. Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009;36(1):60-69. 15. Mkandawire-Valhmu L, Lathen L, Baisch MJ, et al. Enhancing healthier birth outcomes by creating supportive spaces for pregnant African American women living in Milwaukee. Matern Child Health J. 2018;22(12):1797-1804. 16. Chamberlain C, Gee G, Harfield S, et al. Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period. PLoS One. 2019;14(3):e0213460. 17. Verbiest S, Tully K, Simpson M, Stuebe A. Elevating mothers’ voices: recommendations for improved patient-centered postpartum care. J Behav Med. 2018;41(5):577-590. 18. Timilsina S, Dhakal R. Knowledge on postnatal care among postnatal mothers. Saudi Journal of Medical and Pharmaceutical Sciences. 2015;1(4):87-92.

I have been practicing yoga on and off for the past 4–5 years, which may have been hindered by my intermittent periods of laziness. However, I will keep active by lifting weights, running (okay that is a lie), walking, swimming, playing basketball. I try to exercise at least 3–4x a week. One of the things I love to do, which I need to do consistently do, on a daily basis is, yoga. I use to go to yoga classes approximately 3–4 times a week. One of the things that I love is that its origin is from the Indian culture. I remember approximately 5 years ago, during a charity event, I saw this 80 year old Indian gentleman complete a headstand for approximately 1 and half hours, which was unbelievable. I think he had been practicing yoga for over 60 years, which was reflected in his youthfulness and inner calmness. I think the guy in the picture, who is not that guy, must be 85–90 years old. I was just amazed at how strong he was but I think that yoga is much more than strength. It is much more about synchrony of your body and mind. The foundation of yoga stems from deep breath, which helps to invigorate your life energy “prana”. Yoga is a practice that helps to align your body, by using your breath as a vehicle to help you achieve relaxation of your mind and body. I remember when I would consistently go to classes, I noticed that my body was stronger, yet the soreness radiated throughout my body, not in a painful achy way. But rather, an invigorating soreness, where I put my muscles were lengthened. After just completing my last yoga session today, I noticed that my spine and posture felt more erect. I think that its pretty amazing how we can use our own body, without an equipment, except possibly a mat and water, to help to become stronger, flexible, and better balanced. I try to challenge myself with various harder poses, because it forces me to work on my increasing my awareness to help me achieve internal balance. I am going to attempt to do yoga everyday for at least 45 minutes, which is definitely possible, because the following day you don’t feel excessively sore. I think the reason why there is never excessive soreness may be that, though you are strengthening your muscles, you are also stretching and lengthen them. I think that increase oxygen, through deep breathing, may help minimize anaerobic activity of the muscles. I think the best type of yoga is slow. We live in a very fast paced world, why not help slow our mind down and unwind with relax, while helping to improve the health of your body. The benefit of the internet is that you can do yoga at home. If you are interested in trying yoga as a beginner, I will recommend: I think her videos are very informative and she demonstrates the postures very well at a slower pace. I have been in classes with many instructors over the course of 4–5 years, but I prefer the slower pace, unless you want high intensity cardio, when doing yoga, which is an option. I think her style is pretty great, if interested, check out her YouTube channel, which is free. Source"Medium" Dr. Vilash Reddy

Mindfulness was introduced through Buddhism, which strongly influences concepts and aspects of DBT, developed by Dr. Marsha Linehan. It is a state of awareness in which one intentionally pays attention to the present moment without judgment. One of the pillars of DBT mindfulness skills: is the WHAT and HOW skills, to help our brain more accurately process distressing events in life. We will learn to observe our emotions, thoughts, feelings as though they are on a conveyor belt, limiting being engulfed by it. It takes consistent practice and repetition. The purpose of the WHAT skills is to help focus your attention on the present moment. By observing, describing, and participating (which we will break down). The HOW skills reflect the core qualities of that present moment attention, or how to do the WHAT skills. The WHAT skills allow us to build strength and be in control of emotions and thoughts, and the HOW skills reinforce more technique and adjustments in our WHAT skills, like a feedback loop. Quite simple, these are brain exercises to create new ways of thinking and reacting. WHAT Skills (i.e. our strength building exercises) OBSERVE: Observing is about noticing what is going on both internally and externally in the present moment. Wordless watching - just notice the present moment. You can observe your external environment with your 5 senses (sight, smell, touch, taste, sound), but perhaps more challenging is learning to observe your inner experience (thoughts, emotions, bodily sensations). The key to both is to observe without trying to change what is observed, simply noticing and allowing whatever is arising moment to moment. Thoughts and feelings come as go, as long as you don't set an anchor. - Self Observation - focusing attention on the sensations of your body inside and outside. The body is always and only in the present. The mind wanders out of the present, and although your body may react to where your mind wanders, it does so in the present moment. The body helps remind us that we are here now, in this place, in this moment. A formal practice such as body scan meditation can be helpful. DESCRIBE: Describing builds upon the skill of observing. It is about putting words to our experience (what is observed). Label what you observe in your own words. Be sure to focus the facts versus your interpretations or opinions about what is observed. In other words, stick to the “who, what, where, and when.” For self-observation in particular, describing what we notice helps us to separate from what is observed. With mindfulness, we come to know that we are not our thoughts, not our emotions, and not our behaviors --we are the awareness of those things, the witness (observer) and the narrator (describer). To practice, try using the phrasing “I am noticing_____.” This can be especially helpful when we are stuck in negative or self-critical repetitive patterns of thinking. Noticing having a thought that “there is something wrong with me” (i.e. the fact) feels much different than “there is something wrong with me” (i.e. interpreting the thought as true). PARTICIPATE: Participating is about engaging in the present moment. The key to participating mindfully is to enter fully into an activity without self-consciousness (no separation of self from one’s ongoing events and interactions). Throw yourself in the present moment. Don't worry about about tomorrow or focus on yesterday. Fully experience the moment without being self-conscious. Each moment is an opportunity to participate. HOW Skills (Mental Exercise to Recondition your thought focus) NON-JUDGEMENTALLY: Non-judgment is perhaps the most difficult quality of mindfulness to understand and apply to our attention. No good or bad, just observe the facts. Acknowledge the harmful and helpful. You cant go through life without making a judgement. The goal is to catch it and replace with a more realistic perspective. When you find yourself judging, don't judge the judge. Mindfulness asks us to try to practice a life of non-resistance, neither cling to nor push away any experience, to connect to our experience versus our thoughts about our experience. This is the practice of non-judgment. One important point in DBT, is to recognize that suffering = pain x resistance. The more we resist the more it persists. Resistance is essentially the process of judging the pain as “bad” or “wrong.” Thus, judging increases our suffering. Our judgment can be linked back to our animal survival instinct. We are programmed to avoid pain (= bad) and to approach pleasure (= good), in order to maximize our survival as a species. The problem is, our mammalian brains never learned to decipher between physical and emotional pain nor real or imagined danger. Often in our modern lives the pain we experience is not a threat to our survival and our instinctual aversion to pain can create more suffering in the long run. Approaching our pain and difficult emotions with non-judgment is the first step to reducing unnecessary suffering. What does this look like? Feeling depressed without beating yourself up for feeling that way Feeling stressed about kids not going back to school without adding guilt on top of that Feeling lonely because of social distancing without interpreting it as no one cares about you Noticing your white privilege and your role in individual and systemic racial injustices without getting stuck in shame (or if shame does arise, then nonjudgmentally noticing that) . ONE-MINDFULLY: Stay focused: One mindfully is the quality of focusing on one thing at a time. It is the opposite of multitasking, which plagues our society at large. We are so bombard with multievents that we get anxiety, stressed out, and overwhelmed very easily.The purpose of being one-mindful, is to fully engage in the task at hand. When attention is divided, it is less effective. Let go of distractions. Literally turn off your phone, shut off your email. Your brains needs rest and can only focus on one thing at a time contrary to popular belief. This area of concentration lies in the Prefrontal Cortex, a suspected underdeveloped areas, which may be contributing to increased number of kids diagnosed with "ADHD", which is a genetic disorder. However, in the era of quick attention span many kids are suspected of having the underlying disorder. I EFFECTIVELY: Do What Works: Focus on what works to achieve your goals. Don't let emotions control your behavior. Cut the cord between feeling and behavior. Play by the rules (that you have established). Act skillfully as you achieve your goes. Let go of negative feelings that resonant from the past, as the past does not dictate the present or future. It takes hard work but try to work on each aspect everyday. You will improve with practice like anything in life. As mindfulness has its roots in Buddhism, I want to end with a story about how the Buddha reached enlightenment that has been helpful for me in applying mindfulness to my life. The story goes that the Buddha was meditating under the Bodhi tree all night long trying to understand the roots of suffering. The shadow god, Mara (who represents the universal evil energies) tried everything he knew to make him fail—sending him violent storms, beautiful temptresses, raging demons, etc. The Buddha met them all with a non-judgmental attention (neither reacting to nor pushing away), and as morning came, he became the Buddha, a “fully realized being.” Thich Nhat Hanh tells the story that in the years that followed, Mara continued to appear and each time the Buddha would say “I see you Mara…come, let’s have tea.” Inviting our individual “Maras” to tea is what mindfulness asks us to do. As mindfulness has its roots in Buddhism, I want to end with a story about how the Buddha reached enlightenment that has been helpful for me in applying mindfulness to my life. The story goes that the Buddha was meditating under the Bodhi tree all night long trying to understand the roots of suffering. The shadow god, Mara (who represents the universal evil energies) tried everything he knew to make him fail—sending him violent storms, beautiful temptresses, raging demons, etc. The Buddha met them all with a non-judgmental attention (neither reacting to nor pushing away), and as morning came, he became the Buddha, a “fully realized being.” Thich Nhat Hanh tells the story that in the years that followed, Mara continued to appear and each time the Buddha would say “I see you Mara…come, let’s have tea.” Inviting our individual “Maras” to tea is what mindfulness asks us to do. Source: Dr. Marsha Linehan (DBT); Seattle Counseling and Wellness

One of my favorite philosophers who constantly makes me reflect on life from a bird's eye perspective. He is incredible intelligent as he knows stances of various religious, where he ultimately found that Buddhism aligns with his values. I enjoy listening to his lectures everyday, as he inspires me to think outside the box. Alan Wilson Watts (6 January 1915 – 16 November 1973) was an English writer, speaker and self-styled "philosophical entertainer",[2] known for interpreting and popularising Japanese, Chinese and Indian traditions of Buddhist, Taoist, and Hindu philosophy for a Western audience. Born in Chislehurst, England, he moved to the United States in 1938 and began Zen training in New York. He received a master's degree in theology from Seabury-Western Theological Seminary and became an Episcopal priest in 1945. He left the ministry in 1950 and moved to California, where he joined the faculty of the American Academy of Asian Studies.[3] Watts gained a following while working as a volunteer programmer at the KPFA radio station in Berkeley. He wrote more than 25 books and articles on religion and philosophy, introducing the emerging hippie counter culture to The Way of Zen (1957), one of the first best selling books on Buddhism. In Psychotherapy East and West (1961), he argued that Buddhism could be thought of as a form of psychotherapy. He considered Nature, Man and Woman (1958) to be, "from a literary point of view—the best book I have ever written".[4] He also explored human consciousness and psychedelics in works such as "The New Alchemy" (1958) and The Joyous Cosmology (1962). After Watts' death, his lectures found posthumous popularity through regular broadcasts on public radio, especially in California and New York, and more recently on the internet, on sites and apps such as YouTube[5] and Spotify. The bulk of his recorded audio talks were recorded during the 1960s and early 1970s. Please visit: https://alanwatts.org/

Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms. The physical symptoms may or may not be associated with a diagnosed medical condition, but the person is experiencing symptoms and believes they are sick (that is, not faking the illness). A person is not diagnosed with somatic symptom disorder solely because a medical cause can’t be identified for a physical symptom. The emphasis is on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion. Somatic Symptom Disorder Diagnosis One or more physical symptoms that are distressing or cause disruption in daily life Excessive thoughts, feelings or behaviors related to the physical symptoms or health concerns with at least one of the following: Ongoing thoughts that are out of proportion with the seriousness of symptoms Ongoing high level of anxiety about health or symptoms Excessive time and energy spent on the symptoms or health concerns At least one symptom is constantly present, although there may be different symptoms and symptoms may come and go People with somatic symptom disorder typically go to a primary care physician rather than a psychiatrist or other mental health professional. Individuals with somatic symptom disorder may experience difficulty accepting that their concerns about their symptoms are excessive. They may continue to be fearful and worried even when they are shown evidence that they do not have a serious condition. Some people have only pain as their dominant symptom. Somatic symptom disorder usually begins by age 30. Treatment Treatment for somatic symptom disorder is intended to help control symptoms and to allow the person to function as normally as possible. Treatment for somatic symptom disorder typically involves the person having regular visits with a trusted health care professional. The physician can offer support and reassurance, monitor heath and symptoms and avoid unnecessary tests and treatments. Psychotherapy (talk therapy) can help the individual change their thinking and behavior, and learn ways to cope with pain or other symptoms, deal with stress and improve functioning. Antidepressant or anti-anxiety medications can be useful if the person is also experiencing significant depression or anxiety. Related Disorders Illness anxiety disorder Illness anxiety disorder was previously referred to as "hypochondriasis." The person is preoccupied with having an illness or getting an illness – constantly worrying about their health. They may frequently check themselves for signs of illness and take extreme precautions to avoid health risks. Unlike somatic symptom disorder, a person with illness anxiety disorder generally does not experience symptoms. Conversion disorder Conversion disorder(functional neurological symptom disorder) is a condition in which the symptoms affect a person’s perception, sensation or movement with no evidence of a physical cause. A person may have numbness, blindness or trouble walking. The symptoms tend to come on suddenly. The symptoms may last for a long time or may go away quickly. People with conversion disorder also frequently experience depression or anxiety disorders. Factitious disorder Factitious disorder involves people producing or faking physical or mental illness when they are not really sick, or intentionally making a minor illness worse. A person with factitious disorder may also create an illness or injury in another person (factitious disorder imposed on another), such as faking the symptoms of a child in their care. The person may or may not seem to benefit (such as getting out of school or work) from the situation they create. Reference Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association. (2013).

Every human being has flaws. Every human has insecurities. Every human has vulnerabilities. Forgiveness /Self-Compassion Every human has micro-trauma, sometimes even macro-trauma. Micro-trauma — events in our life that seem insignificant, however remain buried in our subconscious, which alter the way we perceive the world. Ex. breakup with girlfriend/boyfriend, lose of friendship, etc. Macro-trauma is my opinion is abuse, neglect, death, loss of job, loss of identity, etc. Sometimes humans go through their own life…holding on to this trauma…completely altering how they perceive life. Forgiveness /Self-Compassion. Imagine a beautiful sunny day and you are a boat on the water. We are all boats (some yachts, some speed boats, some trolling boats, some kayaks, etc.). We are beautiful in our own way, with our own characteristics or purposes. We have different functions, meanings, and abilities. However, I feel that many are truly yachts on the inside, and depict that are fishing boats on the outside. Vica Versa (to those that are narcissistic and boastful). Ultimately, we all have our anchors to this boat that we call life. Sometimes people with such heavy macro trauma are unable to move much despite a beautiful day, as their toxic experiences are so deeply anchored in their subconscious (sand at the bottom of the ocean floor). One of the most important thing in life is to think about why you act and behave the way that you do. In my humble opinion, our actions are 10–20% conscious, the remaining amount is subconscious. Ex. you meet someone for the first time and they create a deep impression on you….why is that? Baggage or your anchor displaced onto a stranger. I have a pretty decent understanding of subconscious effects and defense mechanisms based on my profession. I like to operate from a very holistic perspective, which is why I truly believe that psychology influences our mood, behavior, exponentially. I dont think that adults are hopeless, I think their need to work on pruning their mind, as neuroplasticity is alive and well. People need to see out doctors that are holistic in nature, helping to coach and develop a tailored lifestyle for someone dealing with mental illness. I truly believe that mental illness is the anchor to many people achieving their dreams and living an abundant life. Limiting beliefs squash anything positive that we could potentially accomplish, as subconscious non-sense got impeded into our mind…As a human, we can achieve many things…we just need a sound mind and life is work its way out. Itruly believe as I dedicated my life to help those going through that journey. Source: Medium: Author: Vilash Reddy, MD

Learning to appreciate life Self Reflection. One of the most important things that I am learning, is to appreciate and reflect on a current moment in life. I feel that throughout the course of my life I have always focused on getting to the next step or chapter in my life, particularly after starting medical school. I feel that over the past 2–3 years, I have become more mindful, something that I was taught during my 4th year of medical school, which I think its very important to help enrich our lives and our existence. I hope to apply that philosophy to all aspects of my life, learning to embrace each and every moment to the fullest with complete awareness. I hope to make make an effort to reflect on a lesson(s) that I may have learned within that day, which could potentially help me be a better person. Source: Medium - Vilash Reddy, MD

Sleep disorders (or sleep-wake disorders) involve problems with the quality, timing, and amount of sleep, which result in daytime distress and impairment in functioning. Sleep-wake disorders often occur along with medical conditions or other mental health conditions, such as depression, anxiety, or cognitive disorders. There are several different types of sleep-wake disorders, of which insomnia is the most common. Other sleep-wake disorders include obstructive sleep apnea, parasomnias, narcolepsy, and restless leg syndrome. Sleep difficulties are linked to both physical and emotional problems. Sleep problems can both contribute to or exacerbate mental health conditions and can be a symptom of other mental health conditions. About one-third of adults report insomnia symptoms and 6-10 percent meet the criteria for insomnia disorder.1 Importance of Sleep Sleep is a basic human need and is critical to both physical and mental health. There are two types of sleep that generally occur in a pattern of three-to-five cycles per night: Rapid eye movement (REM) – when most dreaming occurs Non-REM – has three phases, including the deepest sleep When you sleep is also important. Your body typically works on a 24-hour cycle (circadian rhythm) that helps you know when to sleep. How much sleep we need varies depending on age and varies from person to person. According to the National Sleep Foundation most adults need about seven to nine hours of restful sleep each night. The Foundation revised its sleep recommendations in 2015 based on a rigorous review of the scientific literature. Many of us do not get enough sleep. Nearly 30 percent of adults get less than six hours of sleep each night and only about 30 percent of high school students get at least eight hours of sleep on an average school night.2 An estimated 35 percent of Americans report their sleep quality as “poor” or “only fair.”3. More than 50 million Americans have chronic sleep disorders.2 Consequences of Lack of Sleep and Coexisting Conditions Sleep helps your brain function properly. Not getting enough sleep or poor quality sleep has many potential consequences. The most obvious concerns are fatigue and decreased energy, irritability and problems focusing. The ability to make decisions and your mood can also be affected. Sleep problems often coexist with symptoms of depression or anxiety. Sleep problems can exacerbate depression or anxiety, and depression or anxiety can lead to sleep problems. Lack of sleep and too much sleep are linked to many chronic health problems, such as heart disease and diabetes. Sleep disturbances can also be a warning sign for medical and neurological problems, such as congestive heart failure, osteoarthritis and Parkinson’s disease. Insomnia Disorder Insomnia, the most common sleep disorder, involves problems getting to sleep or staying asleep. About one-third of adults report some insomnia symptoms, 10-15 percent report problems with functioning during the daytime and 6-10 percent have symptoms severe enough to meet criteria for insomnia disorder. An estimated 40-50 percent of individuals with insomnia also have another mental disorder.1 Symptoms and Diagnosis To be diagnosed with insomnia disorder, the sleep difficulties must occur at least three nights a week for at least three months and cause significant distress or problems at work, school or other important areas of a person's daily functioning. Not all individuals with sleep disturbances are distressed or have problems functioning. To diagnose insomnia, a physician will rule out other sleep disorders (see Related Conditions below), medication side-effects, substance misuse, depression and other physical and mental illnesses. Some medications and medical conditions can affect sleep. A comprehensive assessment for insomnia or other sleep problems may involve a patient history, a physical exam, a sleep diary and clinical testing (a sleep study). A sleep study allows the physician to identify how long and how well you’re sleeping and to detect specific sleep problems. A sleep diary is a record of your sleep habits to discuss with your physician. It includes information such as when you go to bed, get to sleep, wake up, get out of bed, take naps, exercise, eat and consume alcohol and caffeinated beverages. Sleep problems can occur at any age but most commonly start in young adulthood. The type of insomnia often varies with age. Problems getting to sleep are more common among young adults. Problems staying asleep are more common among middle-age and older adults. Symptoms of insomnia can be: Episodic (with an episode of symptoms lasting one to three months) Persistent (with symptoms lasting three months or more) Recurrent (with two or more episodes within a year) Symptoms of insomnia can also be brought on by a specific life event or situation. Treatment and Self-help Sleep problems can often be improved with regular sleep habits. (See Sleep Hygiene section for tips.) If your sleep problems persist or if they interfere with how you feel or function during the day, you should seek evaluation and treatment by a physician. Sleep disorders should be specifically addressed regardless of mental or other medical problems that may be present. Chronic insomnia is typically treated with a combination of sleep medications and behavioral techniques, such as cognitive behavior therapy. Several types of medications can be used to treat insomnia and to help you fall asleep or stay asleep. Most of these can become habit-forming and should only be used for short periods and under the care of a doctor. Some antidepressants are also used to treat insomnia. Most over-the-counter sleep medicines contain antihistamines, which are commonly used to treat allergies. They are not addictive, but they can become less effective over time. They may also contribute to confusion, blurred vision, urinary retention, and falls in the elderly and should be used with caution in this population. Many people turn to complementary health approaches to help with sleep problems. According to the National Institutes of Health some may be safe and effective, others lack evidence to support their effectiveness or raise safety concerns. Relaxation techniques, used before bedtime, can be helpful for insomnia. Melatonin supplements may be helpful for people with some types of insomnia. Long-term safety has not been investigated. Mind and body approaches, such as mindfulness, meditation, yoga, massage therapy and acupuncture lack evidence to show their usefulness, but are generally considered safe. Herbs and dietary supplements have not been shown to be effective for insomnia. There are safety concerns about some, including L-tryptophan and Kava. Let your health care provider know about any alternative medicines or supplements you are taking. Sleep Hygiene: Healthy sleep tips to address sleep problems. Stick to a sleep schedule – same bed time and wake up time even on the weekends Allow your body to wind down with a calming activity, such as reading away from bright lights; avoid electronic devices Avoid naps especially in the afternoon Exercise daily Pay attention to bedroom environment (quiet, cool and dark is best) and your mattress and pillow (should be comfortable and supportive) Avoid alcohol, caffeine and heavy meals in the evening Associated Conditions: Sleep Apnea Obstructive sleep apnea involves breathing interruptions during sleep. A person with sleep apnea will have repeated episodes of airway obstruction during sleep causing snoring, snorting/gasping or breathing pauses. This interrupted sleep causes daytime sleepiness and fatigue. Sleep apnea is diagnosed with a clinical sleep study. The sleep study (polysomnography) involves monitoring the number of obstructive apneas (absence of airflow) or hypopneas (reduction in airflow) during sleep. Sleep apnea affects an estimated 2 to 15 percent of middle-age adults and more than 20 percent of older adults.1 Major risk factors for sleep apnea are obesity, male gender and family history of sleep apnea. Lifestyle changes, such as losing weight if needed or sleeping on your side, can improve sleep apnea. In some cases a custom-fit plastic mouthpiece can help keep airways open during sleep. The mouthpiece can be made by a dentist or orthodontist. For moderate to severe sleep apnea, a doctor can prescribe a CPAP (continuous positive airway pressure) device. The CPAP works to keep airways open by gently blowing air through a tube and face mask covering your mouth and nose. Central Sleep Apnea In central sleep apnea, the brain does not properly control breathing during sleep, causing breathing to start and stop. It is diagnosed when a sleep study identifies five or more central apneas (pauses in breathing) per hour of sleep. Central sleep apnea is rare and less prevalent than obstructive sleep apnea. It is more common in older adults, in people with heart disorders or stroke, and in people using opioid pain medications. It can be treated using a CPAP or other device during sleep. Sleep-Related Hypoventilation People with sleep-related hypoventilation have episodes of shallow breathing, elevated blood carbon dioxide levels, and low oxygen levels during sleep. It frequently occurs along with medical conditions, such as chronic obstructive pulmonary disease (COPD), or medication or substance use. Those with sleep-related hypoventilation often have trouble with insomnia or excessive daytime sleepiness. Risk factors for sleep-related hypoventilation include medical conditions, such as obesity and hypothyroidism, and use of certain medications, such as benzodiazepines and opiates. Other Sleep Disorders Non-Rapid Eye Movement Sleep Arousal Disorders Non-rapid eye movement (NREM) sleep arousal disorders involve episodes of incomplete awakening from sleep, usually occurring during the first third of a major sleep episode, and are accompanied by either sleepwalking or sleep terrors. The episodes cause significant distress or problems functioning. NREM sleep arousal disorders are most common among children and become less common with increasing age. Sleepwalking involves repeated episodes of rising from bed and walking around during sleep. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to others; and is difficult to wake up. Nearly 30% of people have experienced sleepwalking at some time in their lives. Sleepwalking disorder, with repeated episodes and distress or problems functioning, affects an estimated 1% to 5% of people. Sleep terrors (also called night terrors) are episodes of waking abruptly from sleep, usually beginning with a panicky scream. During each episode, the person experiences intense fear and associated physical signs such as rapid breathing, accelerated heart rate and sweating. The person typically does not remember much of the dream and is unresponsive to efforts of others to comfort them. Sleep terrors are common among very young children—at 18 months of age about 37% of children experience night terrors and at 30 months about 20% experience them. Only about 2% of adults experience night terrors. Nightmare Disorder Nightmare disorder involves repeated occurrences of lengthy, distressing, and well-remembered dreams that usually involve efforts to avoid threats or danger. They generally occur in the second half of a major sleep episode. The nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem real and cause anxiety, fear or distress. After waking up, people experiencing nightmares are quickly alert and generally remember the dream and can describe it in detail. The nightmares cause significant distress or problems functioning. Nightmares often begin between ages 3 and 6 years but are most prevalent and severe in late adolescence or early adulthood. Rapid Eye Movement Sleep Behavior Disorder Rapid eye movement (REM) sleep behavior disorder involves episodes of arousal during sleep associated with speaking and/or movement. The person’s actions are often responses to events in the dream, such as being attacked or trying to escape a threatening situation. Speech is often loud, emotion-filled, and profane. These behaviors may be a significant problem for the individual and their bed partner and may result in significant injury (such as falling, jumping, or flying out of bed; running, hitting, or kicking). Upon awakening, the person is immediately alert and can often recall the dream. These behaviors arise during REM sleep and usually occur more than 90 minutes after falling asleep. The behaviors cause significant distress and problems functioning and may include injury to self or the bed partner. Embarrassment about the episodes can cause problems in social relationships and can lead to social isolation or work-related problems. The prevalence of REM sleep behavior disorder is less than 1% in the general population and it overwhelmingly affects males older than 50. Hypersomnolence Disorder People with hypersomnolence disorder are excessively sleepy even when getting at least 7 hours sleep. They have at least one of the following symptoms: Recurrent periods of sleep or lapses into sleep within the same day (such as unintentional naps while attending a lecture or watching TV) Sleeping more than nine hours per day and not feeling rested Difficulty being fully awake after abruptly waking up The extreme sleepiness occurs at least three times per week, for at least three months. Individuals with this disorder may have difficulty waking up in the morning, sometimes appearing groggy, confused or combative (often referred to as sleep inertia). The sleepiness causes significant distress and can lead to problems with functioning, such as issues with concentration and memory. The condition typically begins in late teens or early twenties but may not diagnosed until many years later. Among individuals who consult in sleep disorders clinics for complaints of daytime sleepiness, approximately 5%–10% are diagnosed with hypersomnolence disorder. Narcolepsy People with narcolepsy experience periods of an irrepressible need to sleep or lapsing into sleep multiple times within the same day. Sleepiness typically occurs daily but must occur at least three times a week for at least three months for a diagnosis of narcolepsy. People with narcolepsy have episodes of cataplexy, brief sudden loss of muscle tone triggered by laughter or joking. This can result in head bobbing, jaw dropping, or falls. Individuals are awake and aware during cataplexy. Narcolepsy nearly always results from the loss of hypothalamic hypocretin (orexin)-producing cells. This deficiency in hypocretin can be tested through cerebrospinal fluid via a lumbar puncture (spinal tap). Narcolepsy is rare, affecting and estimated 0.02%–0.04% of the general population. It typically begins in childhood, adolescence or young adulthood. Restless Legs Syndrome Restless legs syndrome involves an urge to move one’s legs, usually accompanied by uncomfortable sensations in the legs, typically described as creeping, crawling, tingling, burning, or itching. The urge to move the legs: begins or worsens during periods of rest or inactivity; is partially or totally relieved by movement; and is worse in the evening or at night than during the day or occurs only in the evening or at night. The symptoms occur at least three times per week, continue for at least three months, and cause significant distress or problems in daily functioning. The symptoms of restless legs syndrome can cause difficulty getting to sleep and can frequently awaken the individual from sleep, leading, in turn, to daytime sleepiness. Restless legs syndrome typically begins in a person’s teens or twenties and it affects an estimated 2% to 7.2% of the population. Circadian Rhythm Sleep-Wake Disorders With circadian rhythm sleep-wake disorders, a person’s sleep-wake rhythms (body clock) and the external light-darkness cycle become misaligned. This misalignment causes significant ongoing sleep problems and extreme sleepiness during the day leading to significant distress or problems with functioning. Circadian rhythm disorders can be caused by internal factors (a person’s body clock is different than the light-dark cycle) or external factors (such as shift work or jet lag). Prevalence of delayed sleep phase type (staying up late and getting up late) in the general population is approximately 0.17% but estimated to be greater than 7% in adolescents. The estimated prevalence of advanced sleep phase type (going to sleep early and waking early) is approximately 1% in middle-age adults and it is more common in older adults. References American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013. Centers for Disease Control and Prevention. Insufficient Sleep is a Public Health Problem. Accessed July 2017. National Sleep Foundation. Sleep Health Index. 2014.

Excoriation (Skin-Picking) Disorder A person with excoriation (skin-picking) disorder, also known as dermatillomania, repeatedly picks at one’s own skin enough to cause lesions. The skin-picking behavior causes significant distress or problems in work, social interactions, or other activities. It can cause feelings of a loss of control, embarrassment, and shame and can lead to avoiding social situations. Individuals with excoriation disorder have usually made repeated attempts to decrease or stop skin picking. The behavior may be triggered by feelings of anxiety or boredom. It may be preceded by an increasing sense of tension and may lead to a sense of relief after, or it may be a more automatic behavior. It sometimes involves a compulsion to try to fix perceived “blemishes.” In the general population, the lifetime prevalence of excoriation disorder in adults is estimated at less than 2% and it is much more common among women than men. It most often begins in adolescence, and it may come and go over time Treatment for skin picking disorder typically involves cognitive behavioral therapy, including a technique called habit reversal therapy, which can help identify stressors and triggers, tolerate and reduce urges, and replace the behavior with one that is less harmful. People with excoriation disorder often have other psychiatric disorders, such as depression or obsessive-compulsive disorder. Source: International OCD Foundation

“She would never hurt her baby.” These are words commonly uttered by the partners and family members of women presenting to our facilities with postpartum psychosis (PPP) symptoms. In their reluctance to accept the presence of a mental illness and its related risks, and in their desire to get their loved one out of a psychiatric facility and back home with her baby, partners and family members of patients with PPP often minimize the severity of symptoms they have observed and place themselves at odds with the inpatient psychiatric team seeking to hold and treat the patient. Their reasons for doing so are myriad, but often rooted in a lack of understanding of the course of PPP episodes and the potential for devastating outcomes of not providing treatment. At Connections Health Solutions psychiatric crisis centers in Arizona, where I serve as medical director, we typically have at least 1 patient with PPP. By contrast, many psychiatrists in the community encounter PPP rarely, or not at all. Despite this, it is vital that we are all prepared to recognize the risk factors and early signs of a developing episode, and to provide education and guidance to patients and their supports. Given the co-occurrence of massive hormone fluctuations, sleep deprivation, and the acute psychological stress of being wholly responsible for keeping a newborn alive, it is no wonder that the postpartum period is fraught with vulnerability for the development of mood disturbances, anxiety disorders, and psychosis. Findings from some studies have shown that a woman’s risk of hospitalization for psychosis is higher in the first postpartum month than it is at any other time in her life. Helping expectant mothers and their supports prepare for these possibilities, whether it is as common and relatively benign as the so-called “baby blues” or as rare and potentially life-threatening as PPP, is the first step to improving clinical outcomes. As with most psychiatric disorders, early intervention is key to improving clinical outcomes for PPP, and this becomes more feasible when mental health clinicians, patients, and their supports are familiar with risk factors and early warning signs. A Brief Summary of the Clinical Aspects of PPP Table. Identified Risk Factors for Developing PPP3-5 PPP is relatively rare, occurring in 1 to 2 per 1000 live births, with at least half of sufferers having no psychiatric history.1,2 Identified risk factors for developing PPP are listed in the Table.3-5 Psychiatrists should take careful family histories when caring for pregnant and postpartum patients, inquiring about any history of psychiatric hospitalization, mania, psychosis, depression, and suicide. The onset of PPP is rapid and severe, with hallucinations, delusions, emotional distress, and bizarre behaviors seen as early as 2 days after, and typically within 2 weeks of, delivery.2,6 The patients whom I have encountered, presenting with their first episodes of psychosis during the postpartum period, have typically exhibited delusions that are persecutory, religious, and/or grandiose in nature and usually involve the baby (for example, believing that something “evil” is happening to the baby). This differs from patients with a history of psychosis presenting with relapse of symptoms during the postpartum period, who tend to present with psychotic symptoms similar to those exhibited during their previous episodes. Episodes of PPP can last for months, and subsequent psychotic episodes outside of the postpartum period are common.7 The association between PPP and bipolar I disorder is well established, with onset of psychosis in the immediate postpartum period being a significant predictor of a later diagnosis of bipolar I disorder, although some women do present with an isolated episode of PPP that does not develop into a chronic psychiatric disorder following the postpartum period.6,8,9 There is a significant risk of death by suicide in patients presenting with first-episode PPP, with study data demonstrating rates as high as 4% to 11%, as well as a risk of homicide, with 4% of women with PPP committing infanticide.7,10 PPP should be considered a medical emergency that necessitates rapid identification and intervention, which should always begin by ensuring the safety of the patient and her child(ren). It is recommended that patients with PPP be psychiatrically hospitalized and that they not be left alone with their child(ren) prior to stabilization. With appropriate pharmacotherapy and support, patients can make a full recovery. Tragic Outcomes of Untreated PPP Andrea Yates. Kimberlynn Bolanos. Carol Coronado. We are likely all familiar with at least 1 of these names. All 3 women live in infamy after having murdered their children while in the throes of PPP. All 3 also had romantic partners who had observed signs of mental illness in them but were not able to prevent the murder of their children. And of course, all 3 women have faced the vitriol of the US public and criminal justice system. If you have not viewed the 2019 documentary Not Carol, I suggest you do so. It tells the story of Carol Coronado, a loving and devoted mother who murdered her 3 young children and then stabbed herself in the chest during a PPP episode in 2014. Prosecutors sought the death penalty, but she ultimately received 3 life sentences. The documentary features psychiatrist Torie Sepah, MD, who treated Carol at the Twin Towers Correctional Facility in Los Angeles, California, following her arrest and testified in her criminal trial. Sepah speaks and writes passionately about the tragic loss of life that can result from untreated PPP—a tragedy that is too often compounded by a justice system that often seeks to punish rather than to treat these patients, each of whom will suffer until her last breath knowing that her child(ren) died at her hands. But the greatest tragedy of all is that PPP is treatable and these horrific outcomes are preventable when intervention is swift. Concluding Thoughts PPP is a serious psychiatric disorder with a significant risk of morbidity and mortality for the patient and her child(ren). Early and aggressive treatment is vital to improving outcomes, and we must find ways to reduce the barriers to achieving them. This starts with psychiatrists gaining expertise on PPP and sharing that knowledge with others. When it comes to the woman experiencing PPP, it may be true that she would never hurt her baby, but she is not herself. Fortunately, there is treatment and there is hope. Dr Costales serves as Arizona medical director at Connections Health Solutions, overseeing all clinical operations for Connections crisis response centers in Phoenix and Tucson. Prior to joining Connections, she spent time working with individuals designated as being seriously mentally ill in outpatient settings. References 1. Terp IM, Mortensen PB. Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry. 1998;172:521-526. 2. Blackmore ER, Rubinow DR, O’Connor TG, et al. Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis. Bipolar Disord. 2013;15(4):394-404. 3. Videbech P, Gouliaev G. First admission with puerperal psychosis: 7-14 years of follow-up. Acta Psychiatr Scand. 1995;91(3):167-173. 4. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry. 1998;59(suppl 2):34-40. 5. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry. 2001;158(6):913-917. 6. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384(9956):1789-1799. 7. Gilden J, Kamperman AM, Munk-Olsen T, et al. Long-term outcomes of postpartum psychosis: a systematic review and meta-analysis. J Clin Psychiatry. 2020;81(2):19r12906. 8. Munk-Olsen T, Laursen TM, Meltzer-Brody S, et al. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry. 2012;69(4):428-434. 9. Wesseloo R, Kamperman AM, Munk-Olsen T, et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry. 2016;173(2):117-127. 10. Parry BL. Postpartum psychiatric syndromes. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 6th ed. Williams & Wilkins; 1995 Source: Psychiatric Times: Volume 40, Issue 7; Theresa Costales, MD