HealthDay News — The U.S. Food and Drug Administration is warning consumers about risks of using compounded versions of the drug ketamine, often taken for psychiatric disorders. Compounded products are not evaluated by the FDA for safety and effectiveness. They are also not regulated like approved drugs, so they present a greater risk. “Although compounded drugs can serve an important medical need for certain patients when an FDA-approved drug is not medically appropriate, they also present a risk to patients and should only be used under the care of a health care provider,” the FDA said in a news release. The agency offered an example of a concerning case reported about a patient in April. That person had taken compounded oral ketamine outside of a health care setting for the treatment of posttraumatic stress disorder (PTSD) . The result was slowed breathing and a ketamine blood level that appeared to be twice what a person would typically receive as anesthesia, the FDA said. Patients are increasingly interested in taking compounded ketamine products, including oral formulations, for mental health disorders, such as depression , anxiety , PTSD, and obsessive-compulsive disorder , according to the FDA. Known safety concerns associated with the drug are abuse and misuse, psychiatric events, increases in blood pressure, slowed breathing, and lower urinary tract and bladder symptoms. In the FDA-approved version of ketamine, the expected benefit outweighs these risks when used at appropriate doses. “Despite increased interest in the use of compounded ketamine, we are not aware of evidence to suggest that it is safer, is more effective, or works faster than medications that are FDA-approved for the treatment of certain psychiatric disorders,” the FDA said. The FDA said it understands that getting compounded products through telemedicine platforms and compounders for at-home use may be attractive to some patients, but it reiterated the risk. At-home administration of these products is especially risky because of the lack of monitoring for adverse outcomes, the FDA said. Using compounded products outside a health care setting means there is no monitoring of sleepiness; dissociation or disconnection between a person’s thoughts, feelings, and sense of time, space, and self; as well as changes in vital signs, including blood pressure and heart rate. Related Topic: Study Finds Esketamine Nasal Spray More Likely to Induce Remission in Treatment-Resistant MDD Than Quetiapine Extended Release FDA warns patients and health care providers about potential risks associated with compounded ketamine products, including oral formulations, for the treatment of psychiatric disorders What Patients and Health Care Providers Should Know There is increased interest in compounded ketamine products (including oral formulations) for the treatment of psychiatric disorders. When considering use of compounded ketamine products, patients and health care providers should know: Ketamine is not FDA approved for the treatment of any psychiatric disorder. FDA is aware that compounded ketamine products have been marketed for a wide variety of psychiatric disorders (e.g., depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder); however, FDA has not determined that ketamine is safe and effective for such uses. Compounded drugs, including compounded ketamine products, are not FDA approved, which means FDA has not evaluated their safety, effectiveness, or quality prior to marketing. Therefore, compounded drugs do not have any FDA-approved indications or routes of administration. Although compounded drugs can serve an important medical need for certain patients when an FDA-approved drug is not medically appropriate, they also present a risk to patients and should only be used under the care of a health care provider. Use of compounded ketamine products without monitoring by a health care provider for sedation (sleepiness), dissociation (disconnection between a person’s thoughts, feelings, and sense of space, time, and self), and changes in vital signs (such as blood pressure and heart rate) may put patients at risk for serious adverse events. Known safety concerns associated with the use of ketamine products include abuse and misuse, psychiatric events, increases in blood pressure, respiratory depression (slowed breathing), and lower urinary tract and bladder symptoms. For FDA-approved ketamine ( see Ketalar prescribing information ), the expected benefit outweighs these risks when used at appropriate doses for FDA-approved indications and routes of administration. Despite increased interest in the use of compounded ketamine, we are not aware of evidence to suggest that it is safer, is more effective, or works faster than medications that are FDA approved for the treatment of certain psychiatric disorders. Background Ketamine hydrochloride (referred to here as “ketamine” interchangeably) is a Schedule III controlled substance that is FDA approved as an intravenous or intramuscular injection solution for induction and maintenance of general anesthesia. Ketamine, like many drug products, is a mixture of two mirror-image molecules, R-ketamine and S-ketamine (arketamine and esketamine, respectively). Spravato (which includes only the esketamine molecule), is approved as a nasal spray for treatment-resistant depression in adults and for depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior (in conjunction with an oral antidepressant). On February 16, 2022, FDA published a compounding risk alert describing the potential risks associated with at-home use of compounded ketamine nasal spray and several adverse event reports. The February 2022 compounding risk alert also provided information about Spravato, which is subject to a Risk Evaluation and Mitigation Strategy (REMS) as part of its FDA approval. A REMS is a drug safety program that FDA can require for certain approved medications with serious safety concerns to ensure the benefits of the medication outweigh its risks. The Spravato REMS requires esketamine to be dispensed and administered in medically supervised health care settings that are certified in the REMS and agree to monitor patients for a minimum of two hours following administration because of possible sedation and dissociation and the potential for misuse and abuse. Compounded ketamine products are not FDA approved for any indication, including psychiatric disorders, and are, therefore, not part of a REMS program. This does not mean compounded ketamine products are safer for patients. In fact, because compounded ketamine products are not subject to monitoring requirements under a REMS, they may be less safe. Since the publication of the February 2022 compounding risk alert, FDA has become aware of increasing public interest in the use of sublingual and oral dosage forms of compounded ketamine for the treatment of psychiatric disorders. FDA understands that the ability to obtain such products through telemedicine platforms and compounders for at-home use may be attractive to some patients. However, the lack of monitoring for adverse events, such as sedation and dissociation, by an onsite health care provider may put patients at risk. Additionally, FDA has identified safety concerns associated with compounded ketamine products as discussed below. Furthermore, FDA has not established safe or effective dosing of ketamine for any psychiatric indication because ketamine has not been approved for these uses. These factors may place the patient at risk for serious adverse events, misuse, and abuse. Potential Safety Risks Associated with Compounded Ketamine Products Patients who receive compounded ketamine products from compounders and telemedicine platforms for the treatment of psychiatric disorders may not receive important information about the potential risks associated with the product. As previously noted, safety concerns that may be associated with ketamine products include, but are not limited to, risks of sedation, dissociation, psychiatric events or worsening of psychiatric disorders, abuse and misuse, increases in blood pressure, respiratory depression (breathing becomes slower and shallower and the lungs fail to exchange carbon dioxide and oxygen efficiently), and lower urinary tract and bladder symptoms. At-home administration of compounded ketamine presents additional risks because a health care provider is not available onsite to monitor for serious adverse outcomes resulting from sedation and dissociation. In April 2023, FDA received an adverse event report of a patient who experienced respiratory depression after taking compounded oral ketamine outside of a health care setting for the treatment of PTSD. The patient’s ketamine blood level appeared to be twice the blood level typically obtained for anesthesia. In addition to the potential risks associated with compounded ketamine products, patients and health care providers should be aware that information about use of these products is lacking. For example, FDA has not established safe or effective dosing of ketamine for any psychiatric indication. Furthermore, the dosages of the sublingual and oral compounded ketamine products marketed by compounders and telemedicine platforms may vary, which makes it challenging to predict which potential risks may be associated with these products. In addition to the concerns regarding the short-term use of compounded ketamine, the overall benefit-risk profile of ketamine for treatment of psychiatric disorders is unknown. Conclusions FDA is aware of increased interest in the at-home use of compounded ketamine products, including oral formulations, for the treatment of psychiatric disorders. Patients and health care providers should be aware that FDA has identified potential safety concerns associated with the use of compounded ketamine products from compounders and telemedicine platforms, including abuse and misuse, psychiatric events, increases in blood pressure, respiratory depression, and lower urinary tract and bladder symptoms. Home use of compounded ketamine products presents additional risk because onsite monitoring by a health care provider is not available. Ketamine is not FDA approved for the treatment of any psychiatric disorder, and additional clinical studies are needed to adequately investigate ketamine’s benefit-risk profile and safe-use conditions in the treatment of psychiatric disorders. FDA encourages compounders, patients, and health care providers to report adverse events associated with compounded ketamine products to FDA’s MedWatch Adverse Event Reporting program.

The newest class of medications to treat insomnia have many advantages. CONFERENCE REPORTER Dual orexin receptor antagonists (DORAs) , the newest kid on the insomnia treatment block, do not adversely effect sleep architecture, explained Paul P. Doghramji, MD, at the 2023 Annual Psychiatric Times™ World CME Conference. He also explained DORAs do not have rebound insomnia, tolerance issues, or withdrawal symptoms. Doghramji, Senior Family Physician at Collegeville Family Practice, told attendees how orexins work, and then reviewed the currently available DORAs. Suvorexant was the first DORA on the market, approved in 2014 for difficulties with sleep onset and/or maintenance, he said. Available in 5, 10, 15, and 20 mg doses, Doghramji finds most patients do best at the 20 mg dose but suggested starting with the 10 mg dose. It has a half-life of 15 hours and a Tmax of 2 hours. The most common adverse effects in trials were somnolence, headache, abnormal dreams, dry mouth, cough, and upper respiratory infection. Interestingly, the adverse events rate were in a 2 to 1 ratio of women to men, Doghramji explained. There were no differences in psychomotor or morning driving performance when compared with placebo. Doghramji shared highlights of an interesting study, in which there were significant improvements in both total sleep time and wake after sleep for patients with insomnia and mild to moderate Alzheimer in the suvorexant group as compared with the placebo group. Next on the scene was lemborexant, Doghramji said, which was approved for difficulties with sleep onset and/or maintenance. It is available in 5 mg and 10 mg doses; Doghramji noted it is better to start with the 5 mg dose, and if the desired effect is not realized, move to the higher dose. Lemborexant has more effect on orexin 2 than orexin 1, he explained, with a Tmax of 1-3 hours and a half-life of 17-19 hours. Doghramji noted that because it induces CYP2B6, which impacts the area under the curve for bupropion, patients on both drugs will need a higher dose of bupropion. The most common adverse effects in trials were somnolence/fatigue, he said. Doghramji noted research indicates it is safe in mild obstructive sleep apnea, and no difference in middle of the night auditory awakening threshold or morning cognitive performance, body sway, and driving performance when compared with placebo. In one study, lemborexant showed an improvement in sleep latency to persistent sleep almost as good if not better than zolpidem.2 In addition to sustained efficacy, he also explained patients reported improved fatigue during the day, which he said is an important indicator of treatment success. Approved in 2022, daridorexant is the most recent DORA approved for difficulties with sleep onset and/or maintenance, Doghramji said. Daridorexant is available in 25 mg and 50 mg doses. It has a Tmax of 1-2 hours and a half-life of 8h, which he noted is about half that of the other DORAs. Compared to placebo after 4 days of treatment there was no morning driving impairment, and he said safety as been demonstrated in mild obstructive sleep apnea and moderate chronic obstructive pulmonary disease. Interestingly, the most common adverse effects are nasopharyngitis and headache, he said, but somnolence and fatigue were also reported. In addition to improving latency to persistent sleep and wake after sleep onset, Deradoorian was found to improve daytime function, Doghramji told attendees. He explained the Insomnia Daytime Symptoms and Impacts Questionnaire was created and validated according to FDA guidelines to assess and evaluate daytime functioning in individuals with insomnia disorder. At the 50 mg dose daridorexant improved the IDSIQ sleepiness domain at months 1 and 3, with clinically meaningful at month 3. Doghramji told attendees there are 2 emerging DORAs: seltorexant and vornorexant. Seltorexant is a selective orexin-2 receptor antagonist and is currently in phase 3 trials as an adjunctive therapy to antidepressants for patients with major depressive disorder and insomnia symptoms, he said. On the other hand, vornorexant is a balanced dual orexin antagonist that showed significant improvement in sleep latency to persistent sleep and wake after sleep onset. Related Topic: Orexin Receptor 2 Agonist Improves Sleepiness in Narcolepsy References 1. Herring WJ, Ceesay P, Snyder E, et al. Polysomnographic assessment of suvorexant in patients with probable Alzheimer's disease dementia and insomnia: a randomized trial. Alzheimers Dement . 2020;16(3):541-551. 2. Rosenberg R, Murphy P, Zammit G, et al. Comparison of Lemborexant With Placebo and Zolpidem Tartrate Extended Release for the Treatment of Older Adults With Insomnia Disorder: A Phase 3 Randomized Clinical Trial JAMA Netw Open . 2019;2(12):e1918254. Published 2019 Dec 2. 3. Kärppä M, Yardley J, Pinner K, et al. Long-term efficacy and tolerability of lemborexant compared with placebo in adults with insomnia disorder: results from the phase 3 randomized clinical trial SUNRISE 2. Sleep . 2020;43(9):zsaa123. 4. Chepke C, Jain R, Rosenberg R, et al. Improvement in fatigue and sleep measures with the dual orexin receptor antagonist lemborexant in adults with insomnia disorder. Postgrad Med . 2022;134(3):316-325. 5. Mignot E, Mayleben D, Fietze I, et al. Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials .L ancet Neurol . 2022;21(2):125-139. 6. Hudgens S, Phillips-Beyer A, Newton L, Seboek Kinter D, Benes H. Development and Validation of the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ). Patient . 2021;14(2):249-268.

Key Takeaways Sleep disturbances exacerbate psychiatric symptoms and are common in psychiatric disorders, complicating treatment and increasing the risk of depression and suicidal behaviors. Insomnia is predictive of psychiatric disorders and can be effectively managed with cognitive behavioral therapy, improving psychiatric outcomes. Comorbid primary sleep disorders, such as obstructive sleep apnea and circadian rhythm disorders, overlap with psychiatric symptoms and require careful management. Sleep issues are often under-evaluated in psychiatric patients, necessitating improved identification and treatment strategies to enhance psychiatric care. SPECIAL REPORT: SLEEP DISORDERS Sleep and rhythm disturbances are prevalent in individuals with psychiatric disorders, and sleep complaints are part of the diagnostic criteria or related features in most disorders. Not only are sleep problems worsened by psychiatric illnesses, but sleep disturbances also exacerbate psychiatric symptomatology. This Special Report highlights these important interactions and the need to better identify and treat sleep disturbances and disorders in psychiatric patients. Insomnia is frequently reported, and objective sleep recordings in groups of individuals with acute episodes of most major psychiatric illnesses tend to show reductions in total sleep amount and sleep efficiency, as well as increased latency to sleep onset. Not only does insomnia frequently occur in psychiatric disorders, but it is also predictive of new onset or exacerbation of psychiatric disorders, particularly depression. Both insomnia and reduced sleep time are also predictive of increased risk of suicidal behaviors. Treatment of insomnia with cognitive behavioral therapy for insomnia has been shown to reduce depressive symptoms or hasten the antidepressant response in individuals with depression. Individuals with psychiatric disorders may also have sleep complaints related to comorbid primary sleep disorders. Obstructive sleep apnea (OSA), which is characterized by episodes of upper airway obstruction, commonly occurs in patients with psychiatric disorders. Furthermore, symptoms of OSA overlap with symptoms of many psychiatric disorders, including depressed mood, irritability, sleep disturbance, cognitive impairment, and lack of motivation.9 Psychiatric medications that lead to muscle relaxation, decreased upper airway muscle tone, or increase arousal threshold, can worsen OSA; these include benzodiazepines, nonbenzodiazepine hypnotics, and barbiturates. Circadian rhythm disorders—particularly delayed sleep-wake phase disorder, in which individuals fall asleep and wake up much later than desired—are also seen in individuals with psychiatric disorders, particularly bipolar disorder, and are associated with increased risk of developing bipolar disorder. Parasomnias, or abnormal behaviors arising from sleep, are also more frequent in individuals with psychiatric disorders. Restless legs syndrome (RLS), in which individuals feel an urge to move their legs in the evening or at rest, is also more commonly seen in individuals with psychiatric disorders in comparison with the general population, and both parasomnias and RLS may be triggered by some psychopharmacologic agents. The articles in this Special Report review topics related to sleep in psychiatry that are relevant for the practicing clinician. “Beyond the Night: Unraveling the Psychiatric Impact of Sleep Disorders” points out the strong associations between various primary sleep disorders and psychiatric disorders. The importance of addressing insomnia in people with psychiatric disorders and an overview of its management are covered in “Promoting Insomnia Management in the Context of Psychiatric Symptoms” and “Cognitive Behavior Therapy for Insomnia and Hypnotic Deprescribing.” Sleep problems are common in individuals with T, but unfortunately, patients are not routinely evaluated for sleep or rhythm disorders. Given the overlap in symptoms between the 2 groups of disorders, a treatment-resistant psychiatric disorder may be a treatment-responsive sleep disorder, and treating sleep problems often leads to improvement in psychiatric symptoms and quality of life. Note: This article originally appeared on Psychiatric Times .

Key Takeaways The BPD-I™ is a 25-item questionnaire designed to screen for core features of BPD, reflecting a psychodynamic understanding. It serves as a quick assessment tool for clinicians, aligning with psychodynamic theory, but does not replace a full diagnostic evaluation. Developed with input from international mental health professionals, the BPD-I™ is freely available for clinical use, education, and research. The tool is practical, easy to administer, and intended to complement existing assessment practices, encouraging further evaluation and research. Borderline personality disorder (BPD) remains one of the most commonly misunderstood and challenging diagnoses in mental health. Despite its clinical significance, few assessment tools exist that reflect the complex intrapsychic reality of borderline pathology as it presents in everyday practice. Most instruments are grounded in behavioral checklists or symptom counts, often missing the deeper dynamics that psychodynamic clinicians recognize in their work. To help bridge this gap, I am pleased to introduce the Borderline Personality Disorder Inventory (BPD-I™)—a brief, clinically-derived, psychodynamically-informed screening tool designed for use by psychiatrists, psychologists, and psychotherapists in evaluating the possible presence of BPD. What Is the BPD-I™? The BPD-I™ is a 25-item yes/no questionnaire that screens for core features of BPD. It was developed in response to the growing need for a brief tool that reflects a deeper, psychodynamic understanding of borderline personality—one that goes beyond surface behaviors to capture themes such as identity diffusion, splitting, and interpersonal hypersensitivity. While it is not a diagnostic test and cannot replace a full diagnostic evaluation, the BPD-I™ offers clinicians a way to quickly assess for borderline symptoms in a manner that aligns with psychodynamic theory and practice. It is particularly useful as an adjunct to clinical interviews or when deciding whether to pursue a more in-depth personality assessment. A Tool for the Clinician's Desk Unlike many tools that are rooted solely in DSM symptom clusters or factor-analytic models, the BPD-I™ was constructed from a clinical standpoint, drawing upon the extensive psychodynamic literature on BPD. Its development was informed by ongoing consultation with an international group of mental health professionals, including psychoanalysts, psychiatrists, clinical psychologists, and psychometricians. Although empirical validation is forthcoming, the BPD-I™ was designed with clinical sensibility in mind, and its utility lies in its ability to flag potential cases of BPD for further evaluation—not to provide formal diagnosis. Practical, Free, and Open Access The BPD-I™ is freely available for clinical use, education, and research, with appropriate attribution. Instructions for administration, scoring, and interpretation are provided on the inventory. The format is simple, the language accessible, and its brevity makes it easy to incorporate into routine assessments. I invite you to explore the BPD-I™ and consider how it might complement your existing assessment practices. As with any tool, its results are best understood within the broader context of a comprehensive evaluation, clinical judgment, and therapeutic work. You can download the BPD-I™ here. Feedback from clinicians and researchers is welcome as I continue to refine and validate the instrument. Note: This article originally appeared on Psychiatric Times .

It’s well known that medications used to treat attention-deficit hyperactivity disorder (ADHD) do more than address the core symptoms of inattention, hyperactivity, and impulsivity. They have also been associated with significant reductions in the risk for serious real-world outcomes such as self-harm, unintentional injury, car crashes, and crime. However, a large-scale Swedish study has found that the magnitude of associations between ADHD medication use and these real-world outcomes appears to have weakened, in parallel with rising prescription rates. “The declining strength of the associations of ADHD medication and real-world outcomes could be attributed to the expansion of prescriptions to a broader group of individuals having fewer symptoms or impairments,” first author Lin Li, PhD, Karolinska Institutet, Stockholm, Sweden, and colleagues wrote. The findings were published online on June 25 in JAMA Psychiatry. Waning Real-World Impact? The rate of ADHD medication use has risen substantially in many countries over the past two decades. With treatment now reaching a broader population of individuals who may have less severe symptoms, an emerging question is whether there remains a meaningful reduction in real-world harm. To investigate, Li and colleagues analyzed health data from Swedish national registers for 247,420 individuals aged 4-64 years who were prescribed ADHD medications between 2006 and 2020. They employed a self-controlled case series design, which allowed individuals to serve as their own controls. Outcomes included rates of self-harm, unintentional injury, traffic crashes, and crime measured during medicated vs nonmedicated periods. Over the 14-year study period, ADHD medication use rose sharply in Sweden — from 0.6% to 2.8% in children and from 0.1% to 1.3% in adults. ADHD medication use was consistently linked to reduced risks for self-harm (incidence rate ratio [IRR] range, 0.77-0.85), unintentional injury (IRR range, 0.87-0.93), traffic crashes (IRR range, 0.71-0.87) and crime (IRR range, 0.73-0.84) across all analyzed time periods, age groups, and sexes. However, the magnitude of risk reduction for these real-world outcomes diminished significantly over time (P < .01) and was not fully explained by the age and sex distribution of people taking ADHD medication . The study team noted that the strongest associations between ADHD medication and reduced risk for real-world outcomes were consistently observed in women during the earliest study period (2006-2010), a time when only the most severe ADHD cases in women were being diagnosed and treated. Over time, as more women were prescribed ADHD medication, the sex differences on the various real-world outcomes narrowed, investigators said. In an accompanying editorial in JAMA Psychiatry , Ryan S. Sultan, MD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University and the New York State Psychiatric Institute, New York City, and colleagues said it’s “critically” important to remember that the purpose of ADHD treatment is not primarily to prevent arrests, car crashes, or self-harm crises but to improve patients’ daily functioning and quality of life. “The accumulation of evidence makes one thing clear: When used appropriately, ADHD medications can help affected people not just feel better but live safer, more productive lives. This message is important as many individuals with ADHD still do not receive medication as their first-line treatment, despite medications having the most robust evidence for ADHD,” the editorialists wrote. Note: This article originally appeared on Medscape .

TOPLINE: Among women under mental health care in the UK who died by suicide between 2015 and 2021, 26% had experienced domestic violence, with higher rates of posttraumatic stress disorder (PTSD), self-harm, and alcohol or drug misuse, a new study reported. These women were more likely to be younger and unemployed and had multiple adversities including serious financial problems and housing issues. METHODOLOGY: Researchers conducted a cross-sectional study including 2416 women who died by suicide within 12 months of being under the care of UK mental health services between 2015 and 2021. Characteristics were compared between women who experienced domestic violence (including physical or sexual assault) and those with no known history of it. Data collection involved detailed questionnaires completed by supervising clinicians, primarily consultant psychiatrists. TAKEAWAY: A total of 630 women reported experiencing domestic violence, 26% of all women with mental disorders who died by suicide while being under the care of mental health services. Women who experienced domestic violence had higher rates of PTSD (13% vs 4%), previous self-harm (83% vs 62%), alcohol misuse (63% vs 27%), drug misuse (48% vs 18%), violence as a perpetrator (22% vs 5%), and personality disorder (33% vs 16%; P < .001 for all) than those who did not. Women who experienced domestic violence were more likely to be younger (median age, 42 vs 47 years), living alone (51% vs 39%; P < .001), and unemployed (64% vs 39%; P < .001) than those who did not. Adverse life events were more common among women with domestic violence experience than among those without (66% vs 50%), with the most often being serious financial problems (23% vs 10%) and/or loss of job, benefits, or housing (20% vs 13%; P < .001 for all). IN PRACTICE: "Mental health services need to acknowledge the impact of domestic violence among many of their female patients and jointly work with domestic violence services to offer appropriate clinical and societal support," the authors wrote. SOURCE: This study was led by Pauline Turnbull, School of Health Sciences, University of Manchester, Manchester, England. It was published online on June 17 in The Lancet Regional Health - Europe. LIMITATIONS: This study was limited by incomplete data collection, with information about domestic violence available for only 62% of women under the care of mental health services. The questionnaire's specific phrasing restricted responses to sexual and physical violence, potentially underestimating the overall prevalence of domestic violence by not including psychological, emotional, or financial abuse. DISCLOSURES: This study was supported by the Healthcare Quality Improvement Partnership. Some authors reported having various ties with various sources. Details are provided in the original article. Note: This article originally appeared on Medscape .

Distraction (A.C.C.E.P.T.S.) Negative feelings will usually pass, or at least lessen in intensity over time. It can be valuable to distract yourself until the emotions subside. The acronym "A.C.C.E.P.T.S." serves as a reminder of this idea. a blue circles with white text Distress Tolerance Skills DBT Activities Engage in activities that require thought and Activities concentration. This could be a hobby, a project, work, or school. Contributing Focus on someone or something other than yourself. You can volunteer, do a good deed, or do anything else that will contribute to a cause or person. Comparisons Look at your situation in comparison to something worse. Remember a time you were in more pain, or when someone else was going through something more difficult. ​ Emotions Do something that will create a competing emotion. Feeling sad? Watch a funny movie. Feeling nervous? Listen to soothing music. Pushing Away Do away with negative thoughts by pushing them out of your mind. Imagine writing your problem on a piece of paper, crumbling it up, and throwing it away. Refuse to think about the situation until a better time. Thoughts ​When your emotions take over, try to focus on your thoughts. Count to 10, recite a poem in your head, or read a book. Sensations Find safe physical sensations to distract you from intense negative emotions. Wear a rubber band and snap it on your wrist, hold an ice cube in your hand, or eat something sour like a lime. Radical Acceptance Sometimes you'll run into a problem that's simply out of your control. It can be easy to think "This isn't fair" or "I shouldn't have this problem", even though those ways of thinking only make the pain worse. Radical acceptance refers to a healthier way of thinking during these situations. Instead of focusing on how you would like something to be different, you will recognize and accept the problem or situation as it is. Remember, accepting is not the same as liking or condoning something. Learning to accept the problems that are out of your control will lead to less anxiety, anger, and sadness when dealing with them. Situation You find out that you were not selected for a job where you felt that you were the best candidate. **Shift in way of thinking** Typical Thinking "This isn't fair - I did everything right! was the best one there. They can't do this to me." Radical Acceptance "It's frustrating that I didn't get the job, but I accept that they felt someone else would be a better fit." Self-Soothe with Senses Find a pleasurable way to engage each of your five senses. Doing so will help to soothe your negative emotions. 1) Vision - Go for a walk somewhere nice and pay attention to the sights. 2) Hearing - Listen to something enjoyable such as music or nature. 3) Touch - Take a warm bath or get a massage. 4) Taste - Have a small treat-it doesn't have to be a full meal. 5) Smell - Find some flowers or spray a perfume or cologne you like.

A single dose of psilocybin combined with psychological support can provide lasting relief from depression and anxiety in patients with cancer. In a phase 2 clinical trial, more than half of patients reported sustained reductions in depression, and nearly half reported significant reductions in anxiety 2 years after treatment. Psilocybin is a “potentially paradigm-shifting alternative to traditional antidepressants,” wrote the investigators, led by Manish Agrawal, MD, Sunstone Therapies, Rockville, Maryland. Sandeep Nayak, MD, medical director, Johns Hopkins Center for Psychedelic and Consciousness Research, Baltimore, who wasn’t involved in the study, said that the antidepressant effects of psilocybin in patients with cancer are “consistent” with those found in larger studies of people with depression. “If psilocybin works for major depression in general, it’s likely to work for major depression in people with cancer, even though there are, of course, unique aspects of psychological suffering with cancer,” Nayak told Medscape Medical News. He cautioned, however, that more study is needed. “Ultimately, this data is encouraging but not a game changer,” said Nayak. “We do need bigger studies, which are coming.” Limited Success Treating Cancer Depression Depression remains common in patients with cancer, and the typical treatment approaches — antidepressants and psychotherapy — have demonstrated limited success. Agrawal and colleagues explored the safety, feasibility, and efficacy of psilocybin-assisted group therapy in 30 patients (mean age, 58 years; 70% women; 80% White individuals) with major depressive disorder and curable or noncurable cancer. Participants received one-on-one and group therapy sessions before, during, and after receiving a single 25-mg psilocybin dose. No patients were taking an antidepressant or antipsychotic medications or using medical cannabis. Earlier results from this trial showed that, at 8 weeks posttreatment, 25 of 30 patients (80%) had a lasting response to psilocybin, with half demonstrating full remission of depressive symptoms by week 1, which lasted for at least 8 weeks. The latest findings explore depression after 2 years in the 28 patients available for follow-up (two patients died). The new 2-year data, published June 16 in the journal Cancer, highlight the durability of these effects. At 2 years, 15 patients (54%) demonstrated ongoing benefit, with a significant 15-point reduction in Montgomery-Åsberg Depression Rating Scale scores, 14 of which had full remission of depressive symptoms. Psilocybin also helped relieve anxiety. At 2 months, 22 patients (79%) had a significant 17-point reduction from baseline in Hamilton Anxiety Rating Scale, with 13 (46%) having a sustained reduction in anxiety at 2 years (average, 13.9-point reduction from baseline). ‘Impressive’ Data With Caveats Nayak said the fact that 50% of patients with cancer were in remission from their depression at 2 years is “impressive and consistent with a long-lasting antidepressant effect of psilocybin.” “However, the study had no control group, which is a limitation in that we can’t tell how much of the benefit was from the intervention vs other causes (placebo effect, depression improving on its own, social support following the trial),” he noted. “If psilocybin receives approval for major depressive disorders, studies like this will I think spur clinical work with psilocybin and cancer,” Nayak said. So why does psilocybin relieve depression ? “There are a lot of theories,” F. Perry Wilson, MD, Yale School of Medicine, New Haven, Connecticut, and Medscape’s Impact Factor commentator, said in a recent post. Wilson noted that some researchers are using a new term — psychoplastogens — to describe drugs like psilocybin. “The science suggests that one-time use of these agents can allow for a sudden increase in neural plasticity, allowing new neuronal connections to form where they wouldn’t in other conditions, and for older connections to break down and restructure,” Wilson explained. “If our brains are etched with the stories of our lives, if our behaviors deepen and reinforce those psychological ruts, psychoplastogens like psilocybin may loosen the soil, so to speak.” This also suggests that concomitant psychotherapy could be a critical component of psilocybin treatment for depression, he added. “Perhaps the psilocybin shakes loose some maladaptive pathways, but putting them together in a healthy way still takes work.” Wilson said it wouldn’t surprise him if this is the case, “and it’s a good reminder to those of you reading this that these drugs are not a panacea for mental health.” Note: This article originally appeared on Medscape .

TOPLINE: In a randomised trial of adolescents with mental health issues, the use of a 6-week online emotion-regulation therapy was found to be feasible and acceptable. Compared with an active control therapy, this online therapy significantly alleviated symptoms of anxiety, depression, and maladaptive coping. METHODOLOGY: This single-blind randomised clinical trial conducted between 2022 and 2023 in Swedish primary care included 30 adolescents aged 12-17 years (93% girls) with mental health problems and their parents. Participants were randomly assigned to receive 6 weeks of either therapist-guided primary care online emotion-regulation treatment (POET; n = 15) or supportive treatment (n = 15) as an active control. Primary outcomes included feasibility and acceptability; secondary outcomes included symptom severity and improvement (measured using the Clinical Global Impressions-Severity Scale [CGI-S] and CGI-Improvement Scale), symptoms of anxiety and depression (measured using the Revised Child Anxiety and Depression Scale [RCADS-47]), global functioning (measured using the Children's Global Assessment Scale [CGAS]), and emotion regulation (measured using the Cognitive Emotion Regulation Questionnaire [CERQ]). Outcomes were self-reported online or obtained via telephonic interviews immediately after treatment and at a 3-month follow-up. TAKEAWAY: The study had a consent rate of 81%, with 93% of participants completed at least one assessment immediately after treatment and 87% completed 3-month follow-up assessments. Treatment satisfaction was high among both adolescents (mean Client Satisfaction Questionnaire-8 [CSQ-8] score: POET, 20.6; supportive treatment, 22.8) and parents (mean CSQ-8 score: POET, 24.8; supportive treatment, 23.1). When comparing before and immediately after treatment, the POET group showed significant reductions in symptom severity (CGI-S: effect size, 1.30; 95% CI, 0.73-1.86), symptoms of anxiety and depression (RCADS-47: Cohen d, 1.07; 95% CI, 0.37-1.84), and maladaptive cognitive coping (CERQ: Cohen d, 1.10; 95% CI, 0.52-1.70), as well as improvement in global functioning (CGAS: Cohen d, 1.26; 95% CI, 0.66-1.85). The control group showed no significant differences. When comparing before treatment and at 3 months post-treatment, the POET group maintained reductions in symptom severity (CGI-S: effect size, 1.32; 95% CI, 0.76-1.88), symptoms of anxiety and depression (RCADS-47: Cohen d, 1.28; 95% CI, 0.51-2.08), and maladaptive cognitive coping (CERQ: Cohen d, 0.82; 95% CI, 0.22-1.40), as well as improvement in global functioning (CGAS: Cohen d, 1.54; 95% CI, 0.95-2.14). The control group showed no significant differences. IN PRACTICE: "Given that adolescents represent a large patient group with limited access to psychological treatment, these findings suggest that POET is a promising treatment in primary care, with the potential for broad outreach and improved accessibility for adolescents with mental health problems," the authors wrote. SOURCE: This study was led by Katja Sjöblom, MSc, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden. It was published online on June 11 in JAMA Network Open . LIMITATIONS: A small sample size and lack of stratification in the randomisation procedure prevented the between-group analysis of effectiveness. Most participants were self-referred, potentially introducing selection bias. The active control study design limited clinical interpretation compared with a control group using treatment as usual or gold standard treatment. DISCLOSURES: This study was supported by grants from the Kavli Trust, Region Stockholm, and the Swedish Research Council. Several authors reported receiving grants, royalties, and personal fees from various academic, governmental, and private sources, and one author reported holding shares in companies outside the submitted work. Details are provided in the original article. Note: This article originally appeared on Medscape .

Self-awareness is the ability to see yourself clearly and objectively through reflection and introspection. While it may not be possible to attain total objectivity about oneself (that’s a debate that has continued to rage throughout the history of philosophy), there are certainly degrees of self-awareness. It exists on a spectrum. Although everyone has a fundamental idea of what self-awareness is, we don’t know exactly where it comes from, what its precursors are, or why some of us seem to have more or less than others. This is where the self-awareness theory comes in, offering some potential answers to questions like these. These detailed, science-based exercises will not only help you increase the compassion and kindness you show yourself but will also give you the tools to help your clients, students, or employees show more compassion to themselves. What Is Self-Awareness Theory? Self-awareness theory is based on the idea that you are not your thoughts, but the entity observing your thoughts; you are the thinker, separate and apart from your thoughts (Duval & Wicklund, 1972). We can go about our day without giving our inner self any extra thought, merely thinking and feeling and acting as we will; however, we also can focus our attention on that inner self, an ability that Duval and Wicklund (1972) termed “self-evaluation.” When we engage in self-evaluation, we can give some thought to whether we are thinking and feeling and acting as we “should” or following our standards and values. This is referred to as comparing against our standards of correctness. We do this daily, using these standards as a way to judge the rightness of our thoughts and behaviors. Using these standards is a major component of practicing self-control, as we evaluate and determine whether we are making the right choices to achieve our goals. Research on the Topic This theory has been around for several decades, giving researchers plenty of time to test its soundness. The depth of knowledge on self-awareness, its correlates, and its benefits can provide us with a healthy foundation for enhancing self-awareness in ourselves and others. According to the theory, there are two primary outcomes of comparing ourselves against our standards of correctness: We “pass,” or find alignment between ourselves and our standards. We “fail,” or find a discrepancy between ourselves and our standards (Silvia & Duval, 2001). When we find a discrepancy between the two, we find ourselves with two choices: to work toward reducing the discrepancy or avoid it entirely. Self-awareness theory (and subsequent research) suggests that there are a couple of different factors that influence how we choose to respond. Basically, it comes down to how we think it will turn out. If we believe there’s little chance of actually changing this discrepancy, we tend to avoid it. If we believe it’s likely that we can improve our alignment with our standards of correctness, we take action. Our actions will also depend on how much time and effort we believe that realignment will take; the slower progress will be, the less likely we are to take on the realignment efforts, especially if the perceived discrepancy between ourselves and our standards is large (Silvia & Duval, 2001). Essentially, this means that when faced with a significant discrepancy that will take a lot of consistent and focused work, we often simply don’t bother and stick to avoiding self-evaluation on this particular discrepancy. Further, our level of self-awareness interacts with the likelihood of success in realigning ourselves and our standards to determine how we think about the outcome. When we are self-aware and believe there is a high chance of success, we are generally quick to attribute that success or failure to our efforts. Conversely, when we are self-aware but believe there is a low chance of success, we tend to think that the outcome is more influenced by external factors than our efforts (Silvia & Duval, 2001). Of course, sometimes our success in realignment with our standards is driven in part by external factors, but we always have a role to play in our successes and failures. Interestingly, we also have some control over our standards, such that we may alter our standards if we find that we don’t measure up to them (Dana, Lalwani, & Duval, 1997). This is more likely to happen if we’re focused more on the standards than on ourselves; if we fail when we are focused on the standards more than our performance, we are more likely to blame the standards and alter them to fit our performance (Dana et al., 1997). Although it may sound like merely shifting the blame to standards and, therefore, letting yourself off the hook for a real discrepancy, there are many situations in which the standards are overly strict. Therapists’ offices are filled with people who hold themselves to impossibly high standards, effectively giving themselves no chance of success when comparing themselves to their internal standards. It’s clear from the research on self-awareness that it is an important factor in how we think, feel, act, and react to our thoughts, feelings, and actions. 4 Proven Benefits of Self-Awareness Now, let’s shift our attention to research on the outcomes of being self-aware. As you might imagine, there are many benefits to practicing self-awareness: It can make us more proactive, boost our acceptance, and encourage positive self-development (Sutton, 2016). Self-awareness allows us to see things from the perspective of others, practice self-control , work creatively and productively, and experience pride in ourselves and our work as well as general self-esteem (Silvia & O’Brien, 2004). It leads to better decision making (Ridley, Schutz, Glanz, & Weinstein, 1992). It can make us better at our jobs, better communicators in the workplace, and enhance our self-confidence and job-related wellbeing (Sutton, Williams, & Allinson, 2015). These benefits are reason enough to work on improving self-awareness, but this list is by no means exhaustive. Self-awareness has the potential to enhance virtually every experience you have, as it’s a tool and a practice that can be used anywhere, anytime, to ground yourself in the moment, realistically evaluate yourself and the situation, and help you make good choices. 3 Examples of Self-Awareness Skills So we know that self-awareness is good, but what does it look like? How does one practice self-awareness? Below are three examples of someone practicing self-awareness skills: Bob at work Bob struggles with creating a quarterly report at work, and he frequently produces subpar results. He notices the discrepancy between his standards and performance and engages in self-evaluation to determine where it comes from and how to improve. He asks himself what makes the task so hard for him, and he realizes that he never seems to have trouble doing the work that goes into the report, but rather, writing it up cohesively and clearly. Bob decides to fix the discrepancy by taking a course to improve his writing ability, having a colleague review his report before submitting it, and creating a reusable template for future reports so he is sure to include all relevant information. Monique at home Monique is having relationship problems with her boyfriend, Luis. She thinks Luis takes her for granted and doesn’t tell her he loves her or share affection enough. They fight about this frequently. Suddenly, she realizes that she may be contributing to the problem. She looks inward and sees that she doesn’t show Luis appreciation very often, overlooking the nice things he does around the house for her and little physical touches that show his affection. Monique considers her thought processes when Luis misses an opportunity to make her feel loved and notes that she assumes he purposely avoids doing things that she likes. She spends time thinking and talking with Luis about how they want to show and receive love, and they begin to work on improving their relationship. Bridget on her own Bridget struggles with low self-esteem , which causes depressive symptoms. She doesn’t feel good enough, and she doesn’t accept opportunities that come her way because of it. She begins working with a therapist to help her build self-awareness. The next time an opportunity comes her way, she thinks she doesn’t want to do it and initially decides to turn it down. Later, with the help of some self-awareness techniques, Bridget realizes that she is only telling herself she doesn’t want to do it because of her fear that she won’t be good enough. Bridget reminds herself that she is good enough and redirects her thoughts to “what if I succeed?” instead of “what if I fail?” She accepts the opportunity and continues to use self-awareness and self-love to improve her chances of success. These three stories exemplify what self-awareness can look like and what it can do for you when you tap into it. Without self-awareness, Bob would have kept turning in bad reports, Monique would have continued in an unsatisfying relationship or broken things off, and Bridget would never have taken the opportunity that helped her grow. If you look for them, you can find these stories everywhere. 5 Ways to Increase Your Self-Awareness Now we have some clearcut examples of self-awareness in mind. We know what it looks like to embrace self-awareness and grow. But how do you do it? What did our leading characters do to practice self-awareness? There are many ways to build and practice self-awareness, but here are some of the most effective: 1. Practice mindfulness and meditation Mindfulness refers to being present in the moment and paying attention to yourself and your surroundings rather than getting lost in thought or ruminating or daydreaming. Meditation is the practice of focusing your attention on one thing, such as your breath, a mantra, or a feeling, and letting your thoughts drift by instead of holding on to them. Both practices can help you become more aware of your internal state and your reactions to things. They can also help you identify your thoughts and feelings and keep from getting so caught up in them that you lose your hold on your “self.” 2. Practice yoga Yoga is a physical practice, but it’s just as much a mental practice. While your body is stretching and bending and flexing, your mind is learning discipline, self-acceptance, and awareness. You become more aware of your body and all the feelings that manifest, and you become more aware of your mind and the thoughts that crop up. You can even pair yoga with mindfulness or meditation to boost your self-awareness. 3. Make time to reflect Reflecting can be done in multiple ways (including journaling; see the next tip) and is customizable to the person reflecting, but the important thing is to go over your thoughts, feelings, and behaviors to see where you met your standards, where you failed them, and where you could improve. You can also reflect on your standards themselves to see if they are good ones for you to hold yourself to. You can try writing in a journal, talking out loud, or simply sitting quietly and thinking, whatever helps you to reflect on yourself. 4. Journal The benefit of journaling is that it allows you to identify, clarify, and accept your thoughts and feelings. It helps you discover what you want, what you value, and what works for you. It can also help you find out what you don’t want, what is not important to you, and what doesn’t work for you. Both are equally important to learn. Whether you like to write free-flowing entries, bulleted lists, or poems, writing down your thoughts and feelings helps you to become more aware and intentional. 5. Ask the people you love It’s vital to feel we know ourselves from the inside, but external feedback helps too. Ask your family and close friends about what they think about you. Have them describe you and see what rings true with you and what surprises you. Carefully consider what they say and think about it when you journal or otherwise reflect. Of course, don’t take any one person’s word as gospel; you need to talk to a variety of people to get a comprehensive view of yourself. And remember that at the end of the day, it’s your self-beliefs and feelings that matter the most to you! Importance in Counseling and Coaching Self-awareness is a powerful tool that, when practiced regularly, can do more good for coachees and clients than anything else a professional can share with them. To make real, impactful, and lasting change, people need to be able to look inward and become familiar with that internal environment. Building self-awareness should be a top priority for virtually all clients, after which the more traditional coaching and counseling work can begin. For example, you can counsel someone on their bad habits and give 1,000 ways to break their habits. Still, if they don’t understand why they tend toward these bad habits in the first place, it’s almost a guarantee that they will either never break those habits or will quit for a while and simply pick up where they left off when things get tough. Self-awareness is not only vital for the coachee or client; it is also important for the coach or counselor. In fact, self-awareness is prioritized as a core standard in the Council for Accreditation of Counseling and Related Educational Programs Standards (2017) for the profession, as both a requirement for counselors and a necessary skill to build in clients. It takes a good amount of self-awareness to give competent counsel and provide actionable advice. Plus, self-awareness will help the caring counselor from getting too wrapped up in their client’s problems or seeing the issues through their own skewed lens. To truly help someone, it’s essential to see things from their perspective, and that requires being self-aware enough to put our thoughts and feelings aside sometimes. Meditation, Mindfulness, and Self-Awareness The link between meditation, mindfulness, and self-awareness is clear, meaning it’s no surprise that practicing the first two will naturally lead to more of the third. When we meditate or practice mindfulness, we are paying attention to the things that can often get ignored in our busy day-to-day: the present moment and our own internal experience. Those who get to know their thought processes and patterns are more able to adapt and improve them, both by simply being aware of their processes and patterns and by giving themselves a mechanism for practicing and improving. Indeed, a program intended to enhance self-awareness (among other things) through yoga and meditation resulted in a range of improvements, including more positive affect, less stress, greater mindfulness, enhanced resilience, and even greater job satisfaction (Trent et al., 2019). Self-Awareness & Emotional Intelligence Emotional intelligence can be defined as the cluster of abilities that allow us to recognize and regulate emotions in ourselves and others (Goleman, 2001). According to the most popular theory of emotional intelligence from psychologist and author Daniel Goleman (2001), self-awareness is not only crucial for emotional intelligence; it’s one of the five components. These five components are: Self-awareness Self-regulation Social skills Empathy Motivation Other popular theories of emotional intelligence also include self-awareness as a core component, making it one of the factors that virtually all researchers and experts agree on (Goleman, 2001). Self-awareness is a necessary building block of emotional intelligence; it is the building block upon which the rest of the components are built. One must have self-awareness to self-regulate, and social skills will be weak and of little use if you are not aware enough about when and how to use them. If you’re looking to build your emotional intelligence, self-awareness is the first step. Make sure you have developed strong skills in self-awareness before giving the other elements your all. ONION METAPHOR OF IDENTITIES Individuals do not want to be too similar or too dissimilar to others. They search for optimal distinctiveness (Brewer, 1991). Being too different and unaccepted can lead to stigmatization, prejudice, and isolation (Lynn & Snyder, 2002). But being too similar can make you lose your sense of self. All humans have these competing needs to belong (Baumeister & Leary, 1995) yet stand out from others. People may vary in their need for uniqueness. Still, most people adjust their behaviors to set them apart when they feel too similar to others (Mengers, 2014). In that respect, you can compare a person to an onion. Personal identities are at the core, with social identities building the different outward layers. Imagine, for example, you are traveling and asked where you are from. Answering the specific district you are from won’t relate to a person from a different continent, but telling your home country won’t differentiate you from others of the same nationality. Other common social identities are race, ethnicity, religion, gender, sexual orientation, or age. Given the context, people can call their social identity to action, depending on their need to belong to or differ from a group (Brewer, 1991). Individuals can fulfill their needs simultaneously by activating social identities associated with distinct groups, resulting in greater levels of wellbeing (Mengers, 2014). Apart from benefits for personal wellbeing and life satisfaction, societies can benefit from encouraging distinctiveness (Lynn & Snyder, 2002). Open and accepting environments allow people to assert their uniqueness, engage in their interests and pursuits and fear negative consequences less (Mengers, 2014). To know who you are and live authentically, you must also understand what you are not. Distinctiveness is an essential tool to help differentiate you from others. Openness and approval must be encouraged to enable individuals, especially teenagers, to thrive. 4 Tips for Improving Self-Awareness in Relationships If you want to be more like post-reflection Monique than pre-reflection Monique (referring to examples of self-awareness skills in action above), or if you’re going to help your clients with their relationship woes, here are some excellent tips for introducing more self-awareness within the context of a relationship: 1. Be mindful Practice mindfulness, especially when interacting with your loved ones. Pay attention to the words they say, their tone, their body language, and their facial expressions. We often communicate far more information with the latter three than we do with our words alone. Give your loved ones your full attention. 2. Talk Have regular discussions about the relationship. It’s important to keep things in perspective and ensure that nothing is falling between the cracks. When you have regular conversations about your relationship with your loved ones, it’s much harder to avoid or ignore things that can turn into problems. It also helps you reflect on your part and come prepared to discuss your thoughts, feelings, and behaviors with your loved ones. 3. Quality time Spend quality time together and apart. This is especially important for romantic relationships, as we often find ourselves spending most or even all of our free time with our spouse or partner. However much you love and enjoy spending time with your partner, everyone needs some quality time alone. Make sure you and your partner are both getting some quality “me” time to think about what you want, what you need, and what your goals are. This will help you keep yourself from merging too much into your partner and maintaining your independence and stability. Then, since there will be two independent, stable, and healthy adults in the relationship, it will be even more fulfilling and satisfying to both partners when they spend quality time together. 4. Be considerate Share your perspective and consider theirs. It’s easy to get too caught up in our own perspective on things; however, healthy relationships require that we consider others’ needs in addition to our own. To know what our loved ones need and to deliver on those needs, we must first identify and understand them. We do this by practicing our self-awareness and sharing that awareness with our friends and family. If you never check in with your loved ones on their views or feelings, it can cause you to drift apart and inhibit real, satisfying intimacy. Ask your loved ones for their perspective on things and share your perspective with them. Role in the Workplace and Leadership As noted earlier, self-awareness improves our communication, confidence, and job performance (Sutton et al., 2015). It’s easy to see how self-awareness can lead to these outcomes in the workplace, as better self-evaluation naturally leads to improving the alignment between our actions and our standards, resulting in better performance. According to Tasha Eurich (2018), self-awareness can be divided into two categories or types: internal self-awareness and external self-awareness. Internal self-awareness is about how well we see ourselves and our strengths, weaknesses, values, etc., while external self-awareness is understanding how others view us with those same factors (Eurich, 2018). Good managers and leaders need both to perform well in their roles. Although you might think that more experience as a leader and greater power in one’s role lead to better self-awareness, that may not be the case. Experience can be positive or negative in terms of learning and improving the self. Even positive experiences can lead one to attribute success to themselves when it may have had more to do with the circumstances, leading to false confidence. In fact, only 10–15% of those in Eurich’s (2018) study displayed self-awareness, although most of us believe we are self-aware. To improve self-awareness, Eurich (2018) recommends introspection , but with a focus on asking oneself the right questions. She notes that asking “why” might not always be effective, as many of our internal processes remain shrouded in our subconscious or unconscious minds; insteadFor example, instead of asking, “ Why do I fail at this task so often? ” you might ask yourself, “ What are the circumstances in which I fail at this task, and what can I do to change them? ” It’s not a foolproof method, but it can aid you in improving your self-awareness and increasing your alignment with your standards on certain activities., asking “what” may lead to better introspection. Self-Awareness in Students and Children Self-awareness isn’t just for managers and employees; it can also substantially benefit students, children, and adolescents. The same benefits that make us more productive in the workplace can make students more productive in the classroom and at home: better communication with teachers and peers, more confidence, and more satisfaction with performance can all lead to happier, healthier students. These benefits also apply to advanced students. Increased self-awareness leads to more self-care in medical students (Saunders et al., 2007) and a better understanding of one’s strengths and capabilities along with a boost to emotional intelligence in law students (James, 2011). A Take-Home Message In short, a little extra self-awareness can be of great benefit to anyone with the will to improve. This piece includes a description of self-awareness, an exploration of the theory of self-awareness, examples, and tips and tools you can use to boost your self-awareness. We hope you find this information helpful in increasing your self-awareness or that of your clients. What exercises do you use to help build self-awareness? What are some other benefits you’ve noticed? Let us know in the comments section below. If you liked this post, head on over to our post about self-awareness books to further help you increase reflection. We hope you enjoyed reading this article. 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Despite most strokes being preventable, someone in the US experiences a stroke every 40 seconds. Could a new risk score focused on the brain help change that? The McCance Brain Care Score (BCS) aims to empower patients and practitioners to better care for their brains. We already have the American Heart Association’s (AHA) PREVENT online calculator for predicting the 10- and 30-year risk for heart attack, stroke, and heart failure, as well as the Framingham Risk Calculator that estimates 10-year risk for atherosclerotic cardiovascular disease, including strokes and heart attacks. While they incorporate variations of the known modifiable risk factors, the BCS takes a more holistic, patient-forward approach and addresses dementia and late-life depression. Here are some aspects that make it stand out to me. 1. Intuitive scoring system. The BCS incorporates well-known modifiable risk factors (eg, hypertension, hyperlipidemia, smoking, alcohol use) into a 21-point score rather than a risk percentage. Each risk factor gets a number. For hypertension, the biggest modifiable contributor to stroke risk, this ranges from 0 to 3, with more points for better blood pressure control. 2. Gamification of health. Adding the points across several modifiable risk factors yields a score of up to 21, with higher scores linked to better neurologic outcomes. A 5-point higher BCS was associated with an approximate 50% lower risk for stroke in those under 60 years of age. This scoring system capitalizes on the gamification of health, a concept that is increasingly popular because of health apps and wearables such as the Apple Watch and FitBit. Nearly 1 in 3 US adults use health wearables that may nudge them toward health-promoting behaviors such as hitting benchmarks for daily steps or weekly physical activity. Gamification tactics have been shown to improve medication adherence; whether they can lead to sustained behavioral changes remains to be seen. I like the idea of improving people’s health while making it a fun challenge to get a “high” score. 3. Practicality. The BCS presents the modifiable risk factors as opportunities for change and capitalizes on this by giving people goals. For example, the score provides multiple ways to get points for a healthier diet, such as eating 4.5 servings of fruit and vegetables per day or less than 36 oz of sweetened beverages (such as juice and soda) per week. The targets are specific, measurable, and realistic. 4. Widespread applicability and generalizability. Another highlight of the BCS is that it can be used by anyone, even those who have already had a stroke. The score also incorporates risk factors tied to dementia and late-life depression. Given that dementia cases are expected to double by 2060, this has broad application. The BCS shares risk factors with cardiovascular disease and multiple cancers, allowing people to use it to reduce their chances of multiple diseases. For example, in UK adults aged 40-69 years, a 5-point higher BCS was associated with a 43% lower risk of developing cardiovascular disease and a 31% lower risk for leading cancers (specifically, a 66% lower risk for lung cancer, 21% lower risk for colorectal cancer, and 16% lower risk for breast cancer). 5. Increasing popularity. The score is very new. The first validation study was published less than 2 years ago. But since then, there have been at least five other papers on the score’s utility, and the questionnaire has even been adapted by The New York Times. Have you or any of your patients taken the BCS? It might be a fun poster to have in your doctor’s office or waiting room, and it could serve as a focal point to discuss positive habits and opportunities for change. With these strategies, we can empower our patients to proactively reduce their risk for stroke, heart disease, and cancer, and help them live longer, healthier lives. Note: This article originally appeared on Medscape .

Key Takeaways TD is often underreported and misdiagnosed, despite being a well-known adverse effect of antipsychotic medications, leading to inadequate treatment. VMAT2 inhibitors, approved in 2017, represent a significant advancement in the treatment of TD, offering evidence-based options for managing symptoms. The AIMS exam is essential for monitoring TD, but individual experiences and functional impacts vary, requiring personalized treatment approaches. The Impact-TD scale assesses TD's functional impact across social, psychological, physical, and vocational domains, highlighting the need for comprehensive assessments. According to a new study published in BMC Psychiatry, only 4.9% of patients who were prescribed antipsychotics for their psychiatric illness and had evidence of tardive dyskinesia (TD) had TD recorded properly in their electronic health records, supporting the idea that TD is often underreported and misdiagnosed and, therefore, not treated appropriately.1 Yet, TD is a well-established adverse effect of antipsychotic medications and is often irreversible. The well-described hyperkinetic and often dramatic involuntary movements can involve any of the estimated 650 skeletal muscles of the human body, including the diaphragm and pharynx. As well as causing noticeable and often dramatic involuntary movements, these movements often cause significant functional impairment, which varies significantly from patient to patient. Sometimes the patient is unaware of these movements, and it is not uncommon for a patient’s friend, family member, coworker, or even a stranger to bring these movements to the patient’s attention. TD was first described in the medical literature in 1957,2,3 just a few years after the very first antipsychotic medication, chlorpromazine, was introduced in the United States. Despite tireless medical research, it wasn’t until 2017 that 2 vesicular monoamine transporter 2 (VMAT2) inhibitors—deutetrabenazine4 and valbenazine5—were approved by the US Food and Drug Administration as the first evidence-based effective treatments. This 60-year gap likely contributed to the progressive decrease in screening, documenting, and discussing the cause and course of TD with patients. The presumed pathophysiological mechanism of TD by antipsychotics is the antagonism of dopamine-2 receptors (D2Rs) in the dorsal striatum of the human brain, whereas antagonism of these same receptors in the ventral striatum is believed to improve psychotic symptoms, hence the term antipsychotic. Nonpsychiatric medications such as metoclopramide (Reglan; used for the treatment of gastroesophageal reflux disease, gastroparesis, and as an antiemetic) and prochlorperazine (Compazine; used as an antiemetic) share this property of D2R antagonism and exhibit similar risks for TD. The VMAT2 Inhibitors It was a big deal when VMAT2 inhibitors were approved for the treatment of TD. The American Psychiatric Association updated their practice guidelines for the treatment of schizophrenia in 2020 and recommended “that patients who have moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy be treated with a reversible inhibitor of the vesicular monoamine transporter 2.” There has been much to learn about TD and its subtleties since its approval. To complicate matters, the field of medicine, the FDA lumped at least 24 different movement disorders into the category of extrapyramidal symptoms (EPS) with no differentiation regarding etiology and diverse treatments. Even today, the term EPS is ubiquitously used to define the presence of any medication-induced movement disorder. (I suggested the term EPS is antiquated and needs to be retired in a previous editorial, but it remains very much entrenched in our nosology.) Curiously, anticholinergic medications, including benztropine, diphenhydramine, and trihexyphenidyl, are commonly used to treat all antipsychotic-induced movement disorders despite the fact that they make TD worse and have no benefit for akathisia. Similarly, the VMAT2 inhibitors can bring out a vulnerability to Parkinson disease (PD) , or if PD is already present, they can make it worse. The AIMS Exam Establishing a pre-antipsychotic motor system baseline, ongoing screening for TD, and monitoring TD once it appears are essential components of good evidence-based practice. The Abnormal Involuntary Movement Scale (AIMS) exam is currently the gold standard monitoring scale that is used to establish a baseline before initiating an antipsychotic medication, as well as to detect the onset of any TD and track its worsening or improvement. Initially developed by the National Institute of Mental Health for use in research, clinicians rapidly adopted the AIMS, and it is the most utilized scale for evaluating and managing TD in the US as well as in clinical trials and research.8 The AIMS includes 12 items, but only the first 7 questions rate movement severity in various muscle groups. Each of these groups is rated from 0 (no movements) to 4 (severe movements), giving a total numeric range from 0 (no movements) to 28 (severe movements in all 7 muscle areas). The collective rating of these 7 items is the AIMS dyskinesia total score (AIMS DTS). Importantly, an individual may have an AIMS DTS of 5 yet meet the standard for treatment with a VMAT2 inhibitor, whereas another individual’s score may be 10, yet no treatment is indicated. How can this be? Let’s review a few case examples. Case 1 “Ms Robbins” is 49 years old and works as a bank teller. She has been on an antipsychotic medication to treat her bipolar disorder for 10 years, resulting in stability of mood symptoms that were previously poorly controlled. Ms Robbins presents to your office for a follow-up visit. She had a recent encounter with her supervisor after several bank customers reported that they observed frequent eye blinking and some lip movements during their bank transactions with her. Later at home, she asked her husband and adult children whether they noticed any movements. They confirmed these types of movements, noting they seemed to be increasing over the past several months. After performing an AIMS exam, Ms Robbins scores a 3 (moderate) on the item for muscles of facial expression due to notable eye blinking, and a 2 (mild) on the item for lip movements, giving her an AIMS DTS of 5. Upon further discussion, Ms Robbins reports increased anxiety and sadness about these movements, and she is worried about her job. Additionally, she reports she is attending fewer social events out of embarrassment. She becomes tearful and is visibly distressed during the conversation. She does not want to change any of her current medications and asks what treatment options are available. Case 2 “Mr Jones” is 45 years old and works the night shift as a security guard at a large office complex. He has been on an antipsychotic medication to treat schizoaffective disorder, bipolar type , for 12 years. He had multiple hospitalizations for psychotic and manic decompensations in his 20s, but he has done well over the past 10 years, which you attribute both to his medication adherence and minimal psychosocial stressors. Mr Jones is in a long-term relationship and enjoys the quietude and financial stability of his job. You perform his annual AIMS exam, and Mr Jones scores a 2 (mild) on tongue, lips, jaw, fingers, and feet, resulting in an AIMS DTS of 10. Upon further discussion, Mr Jones denies distress from these movements. Although both he and his partner have noticed some of these movements, he prefers to leave treatment as is and simply increase monitoring with more frequent AIMS exams. Impact of Movements These 2 cases highlight the importance of balancing the relative objective AIMS DTS score with the individual’s experience and how movements impact their day-to-day life. Looking at AIMS DTS, Mr Jones’ score was twice as high as Ms Robbins’ score on the objective scale, suggesting he should receive treatment with a VMAT2. However, all 5 of Mr Jones’ scores were 2s, putting them all in the mild range. In addition, he expressed no distress or concerns about the movements. After reviewing the possible impact of the current movements on various aspects of his daily functioning, he preferred to simply increase monitoring. On the other hand, Ms Robbins had a much lower score. Yet, she expressed that the moderate eye blinking and mild lip movements were impacting her job, emotions, self-esteem, and social functioning, causing significant distress, so she readily agreed to initiate VMAT2 inhibitor treatment to minimize these movements to the greatest degree possible. Domains of Impairment These past 8 years have shown us that TD is a much larger bucket of symptoms than we originally thought. Although patients with severe TD are readily recognizable, our challenge is identifying patients with moderate to mild impairment. This requires the vigilance of a systematic AIMS exam. The clinician should ensure the patient is relaxed and should be aware of various activating maneuvers, such as tapping each finger to the thumb of one hand while looking for movements everywhere else. Once movements are identified, the real detective work begins. Because each person is unique, movements that bother one person may be hardly noticeable in another, as in the cases of Ms Robbins and Mr Jones. Thus, as clinicians, we should ask questions to uncover any degree of functional impairment. Spouses, partners, family, friends, and care providers can be imperative to capturing the full range of impairments. Importantly, some patients with anosognosia will innocently deny any movements despite dramatic TD with significant impairments. In 2022, a panel of TD experts developed a standardized tool that could be utilized easily in a clinical setting to assess TD’s impact on functioning in various domains. The resulting Impact-TD scale measures the degree of functional impact on 4 categories: social, psychological/psychiatric, physical, vocational/educational/recreational.9 Through my years of assessing and treating TD, I developed an acronym—MEASO—that has been helpful in reminding me to ask the many questions to capture functional impairment resulting from TD, regardless of the AIMS score or my impression of the likely consequences of the dyskinetic movements. Concluding Thoughts Antipsychotic medications have proven to be worthy tools in addressing psychiatric illness, yet they put our patients at risk for developing TD. In retrospect, it is not surprising that psychiatry has overlooked, or even become complacent, in completing motor assessments, functional assessments, informed consent discussions, psychoeducation, and comprehensive treatment of TD. The first task is to master the differential diagnoses of any movement-related symptom, then assess functional impact. When facing uncertainty, consider consulting with a psychiatric colleague or a neurologist to aid in the differential diagnosis and treatment. Importantly, once the diagnosis of TD has been made, perform a thorough assessment of the resulting functional impairment and work with your patient to find the outcomes that are most appropriate for them. Note: This article originally appeared on Psychiatric Times .