After hours: If urgent, life threatening (please call 988, 911, or go to nearest ER. Otherwise, for side effects to medications, please text 816-766-0119. For all other non-urgent issues, please contact us Practice Q messaging portal or contact us during clinic hours at 888-855-0947.




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- 988 Lifeline
On July 16, 2022, the Lifeline transitioned away from the National Suicide Prevention Line reached through a 10-digit number to the three-digit 988 Lifeline. Psychiatric Times provides a year end review of their progress below: A year ago, the National Suicide Prevention Lifeline switched to its new 3-digit number, 988. Since its launch, the Lifeline has received a startling number of contacts: over 5 million, including more than 1.43 million calls, 416,000 chats, and 281,000 texts.1 But is it effective in saving lives? “The transition to the 988 Suicide & Crisis Lifeline has sparked a transformational moment in behavioral health care in this country. For the first time in my 26-year career history, every state and territory is talking about improving their behavioral health crisis systems,” said Monica Johnson, MA, director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration (SAMHSA). “While we know that there is still much work to do to achieve a robust response system for mental health and substance use crisis care across the country, we have accomplished a lot in the past year. The data show that, since the transition to 988, more people are reaching out for help, and they are getting a response much faster than ever before to get the help that they need in a time of crisis.” Figure 1. May 2023 Contacts According to SAMHSA, the Lifeline receives an average of approximately 350,000 contacts per month. During May 2023 alone, contacts increased by more than 40% in calls, chats, and texts alike compared with the previous year (Figure 1).2 “We are seeing this increase in contacts, and I do not think that is a failure of the system; I think that’s showing it’s a success. Increasing numbers means that we might be catching some folks before they get to that terrible stage,” said Scott Zeller, MD, vice president of acute psychiatry at Vituity, assistant clinical professor of psychiatry at the University of California, Riverside School of Medicine, and Psychiatric Times editorial board member. “Anything we can do to reduce suicide is a win.” Let’s take a look at the Lifeline, still in its infancy, and evaluate the current benefits and potential areas for improvement. Decreased Wait Times Figure 2. Monthly Comparison of Average Answer Speeds2 National overall answer rates have increased to 91% as of December 2022, compared with 64% from December 2021, meaning—no matter the outcome—more individuals in need of help are being connected to a counselor. Additionally, individuals who contact 988 are spending much less time waiting for a counselor; the average overall wait time decreased from 2 minutes and 52 seconds to just 44 seconds.1 Monthly average wait times are even shorter in 2023 (Figure 2).2 “Seconds count when somebody is in crisis. If someone finds themselves on a long hold, waiting for an answer, that could lead to frustration or hanging up the phone, and that is when bad things start to happen. The more quickly we can get them access, the better,” said Zeller. According to research, 24% of suicide survivors aged 13 to 24 years said it took them less than 5 minutes between deciding to attempt suicide and trying.3 Data from another study showed that of 82 patients referred to a psychiatry department post suicide attempt, nearly half (47.6%) reported their suicidal deliberation lasted 10 minutes or less.4 Better Text Response Prior to 988’s launch, the Lifeline could only sufficiently process 56% of the text messages and 30% of the chats received. In contrast, although text volume has now increased by over 700%,1 the text answer rate in May 2023 was an impressive 99%.2 Connecting via text may be more important to youth who contact the Lifeline. With the average teenager sending and receiving 5 times more text messages a day than a typical adult, this may be their preferred method of communication.5 “One of the biggest impacts that 988 is having, when you look at the data, is the dramatic increase of texting services,” said Margie Balfour, MD, PhD, chief of quality and clinical innovation at Connections Health Solutions and an associate professor of psychiatry at the University of Arizona. “You should be able to provide services in ways that people like to communicate, and it really shows that there was an unmet need in this area.” Target Group Specificity Figure 3. Lifeline Specialized Services The Lifeline also now offers specialized services for various populations (Figure 3). Other pilot programs are expected to follow, with potential Lifeline subnetworks for individuals who are hearing impaired and for American Indian/Alaska Natives.6 Area Code Issues Ideally, 988 calls should be answered as locally as possible. A national backup crisis center handles any calls that local crisis centers cannot answer, but how exactly is an individual’s local center determined? Unlike 911, 988 does not geolocate those who contact the Lifeline. Instead, 988 uses their area code to determine the closest call center.7 Unfortunately, this means if an individual living in New York has a Texas area code, the call center will be directed to the closest center in Texas, which will not be able to deploy a mobile team to a New York location. More on 988 Inside 988 Lifeline: Conversations with a Crisis Counselor Leah Kuntz; Jennifer Lang 988: The 1-Year Anniversary Bob GebbiaTherein lies the problem. Although geolocation would help in providing localized services, some callers may not want their location to be known. “I think there is a really good argument from the advocate side, saying ‘We do not want to be tracked.’ What if I just want to call and talk to you and say that I feel hopeless? It does not mean that I want you to know where I am to send cops, which is really what this all comes down to. There is not an easy solution here. Ethically and philosophically, this is one of the most interesting components of the 988 rollout so far,” said Tony Thrasher, DO, MBA, DFAPA, medical director of crisis services at Milwaukee County Behavioral Health Division, Wisconsin. Lack of Quality Consistency Every 988 call center is unique in how it responds to crisis callers. Some states had robust crisis lines prior to 988. Arizona, for example, is being looked at as an example model, Balfour told Psychiatric Times. Built on the backbone of Medicaid rather than telecommunication fees, this preexisting system has established trust in the community over the past 2 to 3 decades. However, some call centers do not have the privilege of a preexisting system. “When you ask what happens when you call 988, in Arizona, you are going to get a crisis line that has been active for years. They have the infrastructure and resources to be able to dispatch 24/7 clinician mobile crisis teams, who can do interventions in the field and then resolve many of those crises. If needed, they can bring individuals to crisis stabilization centers, or crisis receiving centers that can then provide crisis care,” said Balfour. “If you call 988 in a community that does not have that… What actually happens is very local resource dependent. Different communities carry much different loads and are at different stages of development.” Another example is Montgomery County, Ohio. Before the launch of 988, the county created Crisis Now, a 3-pronged approach to delivering crisis services that included a hotline and mobile response teams. In the initial 6 months of Crisis Now, 89% of calls to the hotline were resolved over the phone and 77% of the mobile crisis responses were resolved in the community. Upon 988’s launch in July, the already-in-place hotline also began taking local 988 calls, and felt better prepared to handle the switchover.8 Compare this with Hanover in York County, Pennsylvania. Prior to 988’s launch, the rural center, TrueNorth Wellness Services, reported difficulty hiring counselors and were uncertain they would be able to handle an influx of contacts.9 Uncertain Expectations When you call 911, you know exactly what you are getting: an ambulance, a firetruck, or police, or maybe a combination depending on the situation. What do callers get when they call 988? “It comes down to supply and demand,” said Thrasher. “What type of workers can each area find to respond to calls? There is a large push for less law enforcement presence and higher mental health presence. The hard part is, from a supply and demand focus, there are markedly more law enforcement workers, and they are paid significantly better than mental health workers. That is no knock on law enforcement—I think they earn what they get. But if we as a culture want to bring the mental health after-hours response 24/7, 365 days, on holidays, we need to pay them. One reason law enforcement and fire do that is because they are compensated to do so.” To build these expectations, we must know: Who is running that response team? What is their supply and demand? What is their funding? Do they have enough funds to have a 24/7 mental health work? The Need for More Funding The federal government has invested close to $1 billion into the 988 Lifeline, including a little more than $500 million in the federal spending bill.10 In May 2023, the US Department of Health and Human Services announced an additional $200 million in new funding for states, territories, and tribes to build local capacity for the 988 Suicide & Crisis Lifeline and related crisis services.11 Figure 4. States With Enacted Legislation to Sustain 98812 However, as contacts continue to pour in, some local Lifeline call centers may not be able to maintain their coverage when federal funding decreases. As of early June 2023, just 26 states had enacted legislation to maintain 988, and only 5 of those states had enacted legislation to sustainably fund 988 through telecommunications fees, as enabled by the National Suicide Hotline Designation Act of 2020 (Figure 4).12 “I think we need to have parity of these 4 services: fire, EMS, law enforcement, and mental health. To do so, they should all be in the same room and should all have the same sort of requirements of staffing and quality of care. But then we also must get the same degree of funding,” said Thrasher. “Mental health is not near those other 3 in anything resembling sustainable funding. The public does not see a mental health call like a fire or a police call.” Looking Ahead Comparisons are often made between 988 and 911. Notably, 911 took 13 years to reach a modicum of stability; the first 911 call was placed in 1986, but 911 was not designated the nationwide emergency telephone number until 1999.13Furthermore, there are more than 5700 primary and secondary Public Safety Answering Points to answer 911 calls, as compared with approximately 200 988 centers.1,14 911’s success was not built in a year, and to expect otherwise for 988 is irrational. Our experts agreed: “Emergency psychiatry is all about taking care of people in their most vulnerable moments on their worst days. 988 has now led to more access to services to help them with that, including services that do not necessarily culminate in the emergency department,” Thrasher told Psychiatric Times. “It is not to the scale that I think we want to see it yet, but it is a really good start.” “It is a first step in what I think is a longer journey. It has been a catalyst for both the federal government and for communities to start to look at what we need,” said Balfour. “The promise of 988 is not there yet, but I think it is effective in getting us closer.” In a Psychiatric Times online poll, 70% of responders said they had discussed 988 with their patients.15 Have you discussed 988 with patients or their families? Source: Psychiatric Times Updated 7/13/23 to reflect new statistics. References 1. Saunders H. Taking a look at 988 suicide & crisis lifeline implementation. KFF. February 23, 2023. Accessed May 31, 2023. https://www.kff.org/other/issue-brief/taking-a-look-at-988-suicide-crisis-lifeline-implementation/ 2. 988 Lifeline performance metrics. SAMHSA. Accessed May 31, 2023. https://www.samhsa.gov/find-help/988/performance-metrics 3. Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(suppl 1):49-59. 4. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19-24. 5. Lenhart A. Part four: a comparison of cell phone attitudes & use between teens and adults. Pew Research Center. September 2, 2010. Accessed June 14, 2023. https://www.pewresearch.org/internet/2010/09/02/part-four-a-comparison-of-cell-phone-attitudes-use-between-teens-and-adults/ 6. Stracqualursi V, Howard J. Forthcoming 988 suicide prevention hotline plans pilot program specifically for LGBTQ community. CNN. July 9, 2022. Accessed June 14, 2023. https://www.cnn.com/2022/07/09/politics/988-national-suicide-prevention-lifeline-lgbtq-subnetwork-wellness/index.html 7. 988 Geolocation Report — National Suicide Hotline Designation Act of 2020. Federal Communications Commission. April 15, 2021. Accessed June 14, 2023. https://docs.fcc.gov/public/attachments/DOC-371709A1.pdf 8. Six months after launch, how is 988 doing? National Association of Counties. January 13, 2023. Accessed June 14, 2023. https://www.naco.org/articles/six-months-after-launch-how-988-doing 9. Mencia A. Pennsylvania gears up for launch of new 988 mental health hotline. Axios Philadelphia. July 13, 2022. Accessed June 14, 2023. https://www.axios.com/local/philadelphia/2022/07/13/988-mental-health-hotline-pennsylvania 10. Chatterjee R. 988 Lifeline sees boost in use and funding in first months. GBH. January 16, 2023. Accessed June 14, 2023. https://www.wgbh.org/news/national-news/2023/01/16/988-lifeline-sees-boost-in-use-and-funding-in-first-months 11. HHS announces additional $200 million in funding for 988 Suicide & Crisis Lifeline. US Department of Health and Human Services. May 17, 2023. Accessed June 14, 2023. https://www.hhs.gov/about/news/2023/05/17/hhs-announces-additional-200-million-funding-988-suicide-crisis-lifeline.html 12. State legislation to fund and implement the 988 Suicide and Crisis Lifeline. National Academy for State Health Policy. Updated June 6, 2023. Accessed June 14, 2023. https://nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/ 13. 911 and E911 Services. Federal Communications Commission. Accessed June 14, 2023. https://www.fcc.gov/general/9-1-1-and-e9-1-1-services#:~:text=The%20official%20emergency%20number%20in,States%20for%20all%20telephone%20services 14. 10 things you might not know about the United States’ 911 emergency telephone number. Walden University. Accessed June 14, 2023. https://www.waldenu.edu/online-masters-programs/ms-in-criminal-justice/resource/ten-things-you-might-not-know-about-the-united-states-911-emergency-telephone-number 15. What have you heard about 988? Psychiatric Times. May 25, 2023. https://www.psychiatrictimes.com/view/what-have-you-heard-about-988
- Are Alternative Remedies Safe?
"Dietary supplements", aka herbal remedies are not stringently regulated as medicines. Despite the regulation by the FDA, various medications have strong side effect profile so it is always important to advocate for yourself when seeing a physician (such as primary care or psychiatrist) about how your body is reacting to the medication, as various mood stabilizers and anti-psychotic medications have horrible side effects. It was very surprising that the FDA approved Abilify and Risperdal for the treatment of irritability for children with Autism Spectrum Disorder. Both of these medications having side effects such as weight gain, blunting the dopamine receptor (the happy neurotransmittor) - one potential cause of overeating as you receive dopamine responses with food. Risperdal was originally developed to treat patients with schizophrenia, which is odd how it would reduce the irritability of patients with ASD. Personally, I think there are many agents that can help control the symptoms of irritability if you understand the root cause of where it is coming from. Sorry that was a tangent, as I tend to be very cautious about use of mood stabilizers/anti-psychotics, as it seems that everyone is on it these days. I have added a link below so you can read and identify that you are not having severe or moderate side effects to your medications, as I could imagine it would be a frustrating experience. You are trying to get rid of one problem, while adding on one or more. Regardless, consumers are left in an unregulated industry, unprotected by watchdogs like the FDA there is very hard to predict which manufacturer, products, and forms would we good for our consumption. Also, there is a lot of misinformation and erroneous information on the internet so it is important to know the source of information. It is always important to use these supplements under the guidance of a clinician, as sometimes herbal remedies are not potent enough for the underlying condition or may need to be augment with a medication and/or therapy. Self-diagnosis is always frowned upon as we innately have our own biases and lack objectivity. Also, it is important to understand and recognize that there is no such thing as a "fully safe treatment", even herbal remedies. It is important to recognize that the source of herb is just as important, as there are many ways of mass producing products that are not high grade with fillers/preventatives/contaminants. A majority of the content that I use is from Herbs of the Mind, which I feel is a well written book that helps a person understand and integrate mental health from a holistic model, is from two experienced psychiatrist from Duke University Medical Center, Johnathan Davidson, MD and Kathryn Connor, MD. There is various studies that reflect simple herbs, which should be taken under the care of a physician, such as St. John's Wort (which can induce mania in patients) or 5-HTP can reduce symptoms of depression, Kava can alleviate stress and anxiety, valerian root can help with sleep issues, or ginkgo can help slow the rate of declining memory. Now, each response in on a case by case basis, again as mentioned is not full safe, therefore I would not recommend purchase these products without a physician's supervision. Did you know that Gingko Biloba can reverse the sexual side effects of SSRIs? St. John's Wort can long been used to help reduce the symptoms of depression (with caution based on concerns of inducing mania). Kava bars exist around the world, particularly in the Polynesia, but more recently into the US. The advantage of kava is can potential improve cognitive acuity unlike other anxiolytics that have a dulling effect. Valerian root is an alternative for people suffering with insomnia or mild anxiety (particular at night), compared to sleep aid (which cause sedation, which typically disrupt REM sleep). Most of data for herbal remedies comes from Europe, however there is limited long term data present in the US, as it is not typically studied as it is seen a non-lucrative, that is open to a lot of competition as it is hard to patient natural remedies, as they are hundreds, if not thousands of years old. One herb Ashwaganda has been used for thousands of years in India for anxiety, with minimal side effects. Source: Herbs of the Mind
- What are Alternative Medical Treatments?
It's no secret that alternative medical treatment is not so alternative anymore. Due to various side effects, natural ways of living it is estimated that approximately 40% of Americans are opting to try to use or augment their medical or mental health medications. Each year approximately $20 billion per year on these choices. Traditional medicine, can have its limitations, as there has been epidemic of inappropriate dispensing leading to epidemics like the opioid crisis or overuse of "benzos". Stricter regulations should have been enforced by the FDA at the time clinicians would careless prescribe such medications though it was out of their scope of practice. A lot of research is not dedicated to alternative medicine, as it is hard to patent a substance that grows from the ground, compared to prescription medications that can be patented for 10 years, priced at 30-40x times the cost of a generic medication. One question that comes to mind - how does someone without insurance or limited coverage able to pay for medication that is only name brand name. As example of such is the medication, Latuda is an expensive drug. The out-of-pocket cash price for a 30-day supply of 40 mg tablets is $1,776. That’s nearly $60 per pill, but 40 mg is on the lower end of Latuda dosages. There is a epidemic growth of popularity of herbs for mind to treat conditions, such as depression, anxiety, insomnia, memory deficits. "He that will not apply new remedies must expect new evils; for time in the great inventor" - Sir Francis Bacon. One factor that contributes to this shift in use of remedies, is ongoing issues with side effects of newly involving psychotrophic medications, despite millions, if not billions of dollars in research. Now the hard part is the internet is flood with various products that claim certain properties. I will discuss some simple well studied remedies. I will also include the supplement(s) that I would recommend based on high potency (not related to side effects) but maximum effect, but also maximum absorption and bioavailability. I think that it is important to be selective when purchasing items as a local grocery store, as it is unclear if your body is properly processing the ingredients labeled on the bottle. I have exclusive researched and created a list of supplements, which I think will be beneficial, which I recommend for my patients as well. In writing this article, I wanted to provide a disclaimer that this is only a suggestion that I am providing, as this is not a medication, it is your choice to try to supplement. I would highly recommend you do additional research to see if this is the right fit, however alternative medical treatment tend to have minimal side effects, if any at all. Regardless, if you don't feel that you are having a positive experience I would highly recommend discontinuing it. In this article and other article, I will provide an in-depth description of each herbal remedy and even discuss areas that I would be concerned about, before attempting to start the supplement. You can find more details about many herbal remedies in the book I would highly recommend. Herbal supplement(s) can be benign, however no one can truly know how it interacts with your body leading to potential allergic reaction, though a low probability. What is interesting is ask the average herbal shopper what is the actual remedy that is found in the product, often you are looked at with a blank stare, unless well read in the fundamental of herbal science. The irony of medicine in general is it has been a series of trial and errors, to this day. One interesting example, as an observation in the 1800's form a Viennese physician who was austerized to the point of having an emotional breakdown when he pointed out that women were dying during child birth because their doctors were not washing their hands. Now, it seems like a no-brainer that germs cause infection spread through unhygiene practices. Unfortunately, excessive handwashing based on this preoccupation with germs can be seen with OCD. It is important to recognize that every human being wants relief and wants to feel good and have a quality life. Depression hurts, stress kills, anxiety is unnerving, and insomnia is dangerous and unnerving, therefore it is not a mysterious that everyone is trying to find a solution that is in alignment with their values. Medication and/or therapy is not for everyone, however it should be an option to consider in the right situation. It is important to be open minded and feel free to discuss potential treatment options with your doctor, as herbal remedies can be helpful, but really dependent on your response. Check out this book that such the benefit of herbs, nutrients, and yoga in mental health care.
- What is a Gambling Disorder?
Gambling disorder involves repeated, problem gambling behavior. The behavior leads to problems for the individual, families, and society. Adults and adolescents with gambling disorder have trouble controlling their gambling. They will continue even when it causes significant problems. Diagnosis A diagnosis of gambling disorder requires at least four of the following during the past year: Need to gamble with increasing amounts to achieve the desired excitement. Restless or irritable when trying to cut down or stop gambling. Repeated unsuccessful efforts to control, cut back on or stop gambling. Frequent thoughts about gambling (such as reliving past gambling or planning future gambling). Often gambling when feeling distressed. After losing money gambling, often returning to get even. (This is referred to as "chasing" one's losses.) Lying to hide gambling activity. Risking or losing a close relationship, a job, or a school or job opportunity because of gambling. Relying on others to help with money problems caused by gambling People with gambling disorder can have periods where symptoms subside. The gambling may not seem a problem in between periods of more severe symptoms. Gambling disorder tends to run in families. Factors such as trauma and social inequality, particularly in women, can be risk factors. Symptoms can begin as early as adolescence or as late as older adulthood. Men are more likely to start at a younger age. Women are more likely to start later in life. Gambling Disorder Treatment Some people can stop gambling on their own. But many people need help to address their gambling problems. Only one in ten people with gambling disorder seek treatment. Gambling affects people in different ways. Different approaches may work better for different people. Several types of therapy are used to treat gambling disorders, including cognitive behavioral therapy (CBT), psychodynamic therapy, group therapy, and family therapy. Counseling can help people understand gambling and think about how gambling affects them and their family. It can also help people consider options and solve problems. There are no FDA-approved medications to treat gambling disorders. Some medications may help treat co-occurring conditions like depression or anxiety. Support from family and friends can be critical to a person's recovery from gambling. However, only the individual can decide to stop the behaviors. Counseling can help: Gain control over your gambling. Heal family relationships. Deal with your urge to gamble. Handle stress and other problems. Find other things to do with your time. Put your finances in order. Maintain recovery and avoid triggers. Support Groups and Self-Help Support groups, such as Gamblers Anonymous and Alcoholics Anonymous, use peer support to help others stop gambling. Some research has shown physical activity can help those with gambling disorder. Many states have gambling helplines and other assistance. A National Helpline is available at 1-800-662-HELP (4357). Strategies to Deal with Cravings Reach out for support. Call a trusted friend or family member. Go to a Gamblers Anonymous meeting. Distract yourself with other activities. Postpone gambling. Giving yourself time may allow the urge to pass or weaken. Stop for a moment and consider what will happen when you gamble. Avoid isolation. "Dos" and "Don'ts" for Partners, Friends, or Family Members Do Seek the support of others with similar problems; attend a self-help group for families such as Gam-Anon. Recognize your partner's good qualities. Remain calm when speaking to the person with a gambling disorder. Let them know that you are seeking help for yourself; the gambling is affecting you (and possibly children). Explain problem gambling to children. Understand the need for treatment of problem gambling and that it may take time. Set boundaries in managing money; take control of family finances; review bank and credit card statements. Don't Preach, lecture, or allow yourself to lose control of your anger Exclude the gambler from family life and activities Expect immediate recovery, or that all problems will be resolved when the gambling stops Bailout the gambler Preventing Suicide Problem gamblers are at increased risk of suicide. It’s very important to take any thoughts or talk of suicide seriously. For immediate attention, call 988, text 988, or chat at 988lifeline.org. Source: Yale Medicine - Gambling Disorder
- What is Body Dysphoric Disorder?
Body Dysphoric Disorder Individuals with body dysmorphic disorder are preoccupied with what they perceive as flaws in their physical appearance. The perceived flaws are not noticeable or appear only slight to others but are seen as ugly or abnormal to the person with body dysmorphic disorder. It is not the same as the typical concerns many people have about their appearance. Body dysmorphic disorder also involves repetitive behaviors (such as checking a mirror or seeking reassurance) or repetitive thinking (such as comparing one’s appearance with others). The preoccupations can focus on one or many body areas, most commonly the skin, hair or nose. The preoccupations and behaviors are intrusive, unwanted, and time-consuming (occurring, on average, three to eight hours per day). The individual feels driven to perform them and usually has difficulty resisting or controlling them. The preoccupation causes significant distress or problems in daily activities such as work or social interactions. This can range from avoiding some social situations to being completely isolated and housebound. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood and low self-esteem. Many individuals seek and too often receive cosmetic treatment, such as skin treatments or surgery, to try to fix their perceived defects. People with body dysmorphic disorder may or may not understand that their concerns about their appearance are distorted. Many individuals with body dysmorphic disorder believe that other people take special notice of them or mock them because of how they look. It affects an estimated 2% of people. It typically begins before age 18 and affects both men and women. Body dysmorphic disorder is usually treated with a combination of cognitive behavior therapy and medication, such as selective serotonin reuptake inhibitors (SSRIs). Muscle Dysphoria - subcategory of Body Dysphoria Muscle dysmorphia, a form of body dysmorphic disorder, more common in males, consists of preoccupation with the idea that one’s body is too small or too heavy, or not muscular enough. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. A majority (but not all) diet, exercise, and/or lift weights excessively. Source: Mayo Clinic - Body Dysphoric Disorder
- What Is Obsessive-Compulsive Disorder?
Obsessive-compulsive disorder (OCD) is a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions). To get rid of the thoughts, they feel driven to do something repetitively (compulsions). The repetitive behaviors, such as hand washing/cleaning, checking on things, and mental acts like (counting) or other activities, can significantly interfere with a person’s daily activities and social interactions. Many people without OCD have distressing thoughts or repetitive behaviors. However, these do not typically disrupt daily life. For people with OCD, thoughts are persistent and intrusive, and behaviors are rigid. Not performing the behaviors commonly causes great distress, often attached to a specific fear of dire consequences (to self or loved ones) if the behaviors are not completed. Many people with OCD know or suspect their obsessional thoughts are not realistic; others may think they could be true. Even if they know their intrusive thoughts are not realistic, people with OCD have difficulty disengaging from the obsessive thoughts or stopping the compulsive actions. A diagnosis of OCD requires the presence of obsessional thoughts and/or compulsions that are time-consuming (more than one hour a day), cause significant distress, and impair work or social functioning. OCD affects 2-3% of people in the United States, and among adults, slightly more women than men are affected. OCD often begins in childhood, adolescence, or early adulthood. Some people may have some symptoms of OCD but not meet full criteria for this disorder. Obsessive-compulsive disorder Obsessions Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety, fear or disgust. Many people with OCD recognize that these are a product of their mind and that they are excessive or unreasonable. However, the distress caused by these intrusive thoughts cannot be resolved by logic or reasoning. Most people with OCD try to ease the distress of the obsessional thinking, or to undo the perceived threats, by using compulsions. They may also try to ignore or suppress the obsessions or distract themselves with other activities. Examples of common content of obsessional thoughts: Fear of contamination by people or the environment Disturbing sexual thoughts or images Religious, often blasphemous, thoughts or fears Fear of perpetrating aggression or being harmed (self or loved ones) Extreme worry something is not complete Extreme concern with order, symmetry, or precision Fear of losing or discarding something important Can also be seemingly meaningless thoughts, images, sounds, words or music Compulsions Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession. The behaviors typically prevent or reduce a person's distress related to an obsession temporarily, and they are then more likely to do the same in the future. Compulsions may be excessive responses that are directly related to an obsession (such as excessive hand washing due to the fear of contamination) or actions that are completely unrelated to the obsession. In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible. Examples of compulsions: Excessive or ritualized hand washing, showering, brushing teeth, or toileting Repeated cleaning of household objects Ordering or arranging things in a particular way Repeatedly checking locks, switches, appliances, doors, etc. Constantly seeking approval or reassurance Rituals related to numbers, such as counting, repeating, excessively preferencing or avoiding certain numbers People with OCD may also avoid certain people, places, or situations that cause them distress and trigger obsessions and/or compulsions. Avoiding these things may further impair their ability to function in life and may be detrimental to other areas of mental or physical health. Treatment Patients with OCD who receive appropriate treatment commonly experience increased quality of life and improved functioning. Treatment may improve an individual's ability to function at school and work, develop and enjoy relationships, and pursue leisure activities. Cognitive Behavioral Therapy One effective treatment is a type of cognitive-behavioral therapy (CBT) known as exposure and response prevention (ERP). During treatment sessions, patients are exposed to feared situations or images that focus on their obsessions. Although it is standard to start with those that only lead to mild or moderate symptoms, initially the treatment often causes increased anxiety. Patients are instructed to avoid performing their usual compulsive behaviors (known as response prevention). By staying in a feared situation without anything terrible happening, patients learn that their fearful thoughts are just thoughts. People learn that they can cope with their thoughts without relying on ritualistic behaviors, and their anxiety decreases over time. Using evidence-based guidelines, therapists and patients typically collaborate to develop an exposure plan that gradually moves from lower anxiety situations to higher anxiety situations. Exposures are performed both in treatment sessions and at home. Some people with OCD may not agree to participate in CBT because of the initial anxiety it evokes, but it is the most powerful tool available for treating many types of OCD. Medication A class of medications known as selective serotonin reuptake inhibitors (SSRIs), typically used to treat depression, can also be effective in the treatment of OCD. The SSRI dosage used to treat OCD is often higher than that used to treat depression. Patients who do not respond to one SSRI medication sometimes respond to another. The maximum benefit usually takes six to twelve weeks or longer to be fully visible. Patients with mild to moderate OCD symptoms are typically treated with either CBT or medication depending on patient preference, the patient’s cognitive abilities and level of insight, the presence or absence of associated psychiatric conditions, and treatment availability. The best treatment of OCD is a combination of CBT and SSRIs, especially if OCD symptoms are severe. Neurosurgical treatment Some newer studies show that gamma ventral capsulotomy, a surgical procedure, can be very effective for patients who do not respond to typical treatments and are very impaired, but it is underused due to historical prejudice and its invasiveness. Deep brain stimulation, which involves an implanted device in the brain, has data to support efficacy and does not permanently destroy brain tissue as done in a capsulotomy. However, it is still highly invasive and complex to manage, and there are limited providers and hospital systems trained to offer this treatment and, able to provide the long-term support needed by DBS patients. How to Support a Loved One Struggling with OCD In people with OCD who live with family, friends, or caregivers, enlisting their support to help with exposure practice at home is recommended. In fact, the participation of family and friends is a predictor of treatment success. Self-care Maintaining a healthy lifestyle can help in coping with OCD. Getting enough good quality sleep, eating healthy food, exercising, and spending time with others can help with overall mental health. Also, using basic relaxation techniques (when not doing exposure exercises) such as meditation, yoga, visualization, and massage can help ease the stress and anxiety. Source: International OCD foundation
- What are Disruptive, Impulse Control and Conduct Disorders?
These are a group of disorders that are linked by varying difficulties in controlling aggressive behaviors, self-control, and impulses. Typically, the resulting behaviors or actions are considered a threat primarily to others’ safety and/or to societal norms. Some examples of these issues include fighting, destroying property, defiance, stealing, lying, and rule breaking. These disorders are: Oppositional defiant disorder Intermittent explosive disorder Conduct disorder Pyromania Kleptomania Other specified disruptive, impulse-control and conduct disorder Unspecified disruptive, impulse-control, and conduct disorder Problematic behaviors and issues with self-control associated with these disorders are typically first observed in childhood and can persist into adulthood. In general, disruptive, impulse-control, and conduct disorders tend to be more common in males than females, with the exception of kleptomania. Behavioral issues are a common reason for referral to psychiatrists or other mental health providers. It is important to note that it can be developmentally appropriate for kids to become disruptive or defiant at times. However, disruptive, impulse, and conduct disorders involve a pattern of much more severe and longer-lasting behaviors then what is developmentally appropriate. For instance, these behaviors are frequent, occur in various settings, and can have significant consequences (including legal repercussions). It is also important to consider that anger and defiance can be manifestations of other disorders. One difference between disruptive behavioral disorders and many other mental health conditions is that with behavioral disorders, a person's distress is focused outward and directly affects other people. With most other mental health conditions, such as depression and anxiety, a person's distress is generally directed inward toward themselves. Types of Disorders Oppositional Defiant Disorder Oppositional defiant disorder is a common disorder in children and adolescents who are referred to mental health providers for behavioral issues. Individuals with this disorder experience varying levels of dysfunction secondary to oppositionality, vindictiveness, arguments, and aggression. Symptoms of oppositional defiant disorder include a pattern of: Angry/irritable mood—often loses temper, easily annoyed, often angry and resentful. Argumentative/defiant behavior—often argues with authority figures or adults, often refuses to comply with requests or rules, deliberately annoys others, blames others for mistakes or misbehavior. Vindictiveness—spiteful or vindictive. These behaviors are distressing to the individual and alarming to others. Anger, threatening behaviors, and spitefulness cause disruption at school or work and affect relationships with others. Of note, these behaviors do not include aggression towards animals or people, destruction, or theft. In other words, there are no violations to others or societal norms. Individuals with oppositional defiant disorder, will likely experience conflict with adults and authority figures. To be diagnosed with Oppositional defiant disorder, the behaviors must occur with at least one individual who is not the person's sibling. Signs of the disorder typically develop during preschool or early elementary school but can also begin in adolescence. For children under age 5, the behaviors occur on most days for at least six months. For people 5 and older, the behaviors occur at least once per week for at least six months. The severity of this illness is based on the number of settings in which these behaviors are observed. The cause of oppositional defiant disorder is not fully understood. However, it is believed that ODD might be secondary to several biological, psychological, and social factors. There are several risks associated with the development of oppositional defiant disorder: having poor frustration tolerance, high levels of emotional reactivity, neglect during childhood, and inconsistent parenting.ODD tends to be more common in children who live in poverty and is more common in boys than girls prior to adolescence. The prevalence of oppositional defiant disorder is about 3.3%. Many, but not all, children and adolescents who have been diagnosed with oppositional defiant disorder will later be diagnosed with Conduct Disorder, which is typically considered a more severe behavioral disorder. More information on Conduct Disorder to follow. However, oppositional defiant disorder is not necessarily a chronic condition. About 70% of individuals with oppositional defiant disorder will have resolution of the symptoms by the time they turn 18 years old. Furthermore, about 67% of children diagnosed with oppositional defiant disorder will no longer meet diagnostic criteria within a 3 year follow up. Of note, adults and adolescents who have been diagnosed with oppositional defiant disorder have a 90% chance of being diagnosed with another mental illness in their lifetime3 - especially anxiety disorders, mood disorders, substance abuse, conduct disorder, antisocial personality disorder, and other personality disorders. Individuals with oppositional defiant disorder, have higher risk of dying by suicide then the general population. Oppositional defiant disorder is diagnosed by a psychiatrist or other mental health professional based on information from the individual (child, adolescent, adult) and, for children/adolescents, from parents, teachers and other caregivers. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that it's important for a child to have a comprehensive evaluation to identify any other conditions which may be contributing to problems, such as ADHD, learning disabilities, depression or anxiety. Treatment of oppositional defiant disorder often involves a combination of therapy and training for the child, and training for the parents. For children and adolescents, cognitive problem-solving training can teach positive ways to respond to stressful situations. Social skills training helps children and youth learn to interact with other children and adults in a more appropriate, positive way. In some cases, medications might be necessary. Parent management training can help parents learn skills and techniques to respond to challenging behavior and help their children with positive behavior. The training focuses on providing supportive supervision and immediate, consistent discipline for problem behavior. According to ACAAP, one-time or short programs that try to scare or coerce children and adolescents into behaving, such as tough-love or boot camps, are not effective and may even be harmful.1 If you're concerned about your child's behavior, talk to your child's doctor or a mental health professional, such as a child psychiatrist or psychologist or a child behavioral specialist. Disruptive, Impulse Control and Conduct Disorders Adapted from Understanding Mental Disorders: Your Guide to DSM-5 Conduct Disorder Conduct disorder involves severe behaviors that violate the rights of others or societal norms. Behaviors may involve aggression towards others, animals, and/or destruction of property all of which could result in legal consequences.4 As stated in the oppositional defiant disorder section, many (but not all) children and adolescents with oppositional defiant disorder will eventually meet diagnostic criteria for conduct disorder. However, not all individuals who are diagnosed with Conduct Disorder were first diagnosed with ODD.5 Symptoms of conduct disorder include varying patterns of: Aggression to people and animals (bullies, intimidates others, initiates fights, use of weapons, cruelty to others, cruelty to animals, stolen while confronting a victim, raped others). Destruction of property (deliberate fire setting, vandalization). Deceitfulness or theft (broken into properties, manipulates others, stolen). Serious violations of rules (runs away from home, truant from school, stays out at night). Per the DSM-5, these behaviors can first be observed in pre-school. However, the more significant symptoms tend to appear between middle childhood and middle adolescents. It is rare for these symptoms to first appear after the age of 16. Conduct disorder is only diagnosed in children and youth up to 18 years of age. Adults with similar symptoms may be diagnosed with antisocial personality disorder. Early treatment can help prevent problems from continuing into adulthood. There are multiple risk factors for the development of conduct disorder, including: harsh parenting styles, exposure to physical or sexual abuse during childhood, unstable upbringing, maternal substance use during pregnancy, parental substance use and criminal activity, and poverty.5 These behaviors cause significant dysfunction in multiple settings such as at home, in school, in relationships, and in occupational settings. However, people with conduct disorder may deny or downplay their behaviors. Conduct disorder is generally considered more serious than ODD. It can be associated with criminal behaviors, dropping out of high school, and substance abuse. About 40% of individuals who meet diagnostic criteria for conduct disorder, will later meet diagnostic criteria for antisocial personality disorder. The prevalence of conduct disorder is between 1.5% and 3.4%. It tends to be more common in males. About 16-20% of youth with conduct disorder also have ADHD.5 Of note, youth that have both ADHD and Conduct Disorder have higher risk of substance use. Therapy can help children learn to change their thinking and control angry feelings. Treatment may include parent management training and family therapy, such as Functional Family Therapy. Functional Family Therapy helps families understand the disorder and related problems, teaches positive parenting skills and helps build family relationships. It can help families apply positive changes to other problem areas and situations. Intermittent Explosive Disorder Intermittent explosive disorder is a disorder associated with frequent impulsive anger outbursts or aggression—such as temper tantrums, verbal arguments, and fights.2 The observed behaviors result in physical assaults towards others or animals, property destruction, or verbal assaults.6 The aggressive outbursts: Are out of proportion to the event or incident that triggered them. Are impulsive. Cause much distress for the person. Cause problems at work or home. It is important to note that these aggressive behaviors are not planned, they are impulsive and anger based.7 They happen rapidly after being provoked and typically do not last longer than 30 minutes.2 These outbursts must be associated with subjective distress or social or occupational dysfunction.7 Affected individuals tend to have poor life satisfaction and lower quality of life.7 In order to meet diagnostic criteria, affected individuals must be at least 6 years old or the developmental equivalent.2 However, this disorder is usually first observed in late childhood or adolescence.2 The one-year prevalence is 2.7% and lifetime prevalence is 7%.8 Many risk factors have been identified with the development of Intermittent Explosive Disorder, such as: being male, young, unemployed, single, having lower levels of education, and being victim of physical or sexual violence.6 Intermittent explosive disorder is associated with anxiety and bipolar disorders.6 Individuals with this disorder have higher risks of developing substance use disorders than those without it.7 Treatment typically involves cognitive behavioral therapy focusing on changing thoughts related to anger and aggression and developing relaxation and coping skills. Sometimes, depending on a person's age and symptoms, medication may be helpful. Pyromania While fire setting can be a common issue among young individuals and a cause of significant destruction in the United States, it is different from pyromania which is a rare disorder that involves repeated impulses or strong desires to set intentional fires.9 Fire setting is typically motivated by curiosity and tends to occur in unsupervised children with access to lighters and matches.9 Individuals with pyromania, on the other hand, are fascinated by fire and its uses. Affected individuals engage in repeated and deliberate fire setting that is not motivated by external reasons.10 They experience strong urges to engage in dangerous fire setting. They also experience internal tension prior to setting fires that is followed by pleasure after fires are lit. These individuals set fires to release built-up inner emotional tension, not for any type of material gain or revenge. Some known risk factors for pyromania are male gender, substance use, victim of abuse, being fascinated with fires, and having mental illness.11 The prevalence of pyromania is about 1% in the United States.9 It is associated with personality disorders or traits (especially antisocial personality disorder or antisocial behaviors), conduct disorder, and substance use disorders.9 Treatment of pyromania usually involves cognitive behavioral therapy and education. The therapy can help people become more aware of the feelings of tension and find ways to cope. Every child should be taught about the dangers of playing with fire and possible consequences.9 Kleptomania Kleptomania is a rare disorder that involves involuntary, impulsive, and irresistible stealing of objects that are not needed for personal or other forms of use. This is different from shoplifting in that shoplifters steal for some form of gain and often plan out their actions.21 However, individuals with Kleptomania do not need what they have stolen. They often give away, return, hide, or hoard the stolen objects.13 People with kleptomania know what they are doing is wrong but cannot control the impulse to steal, leading to hasty and poorly thought-out stealing.12 They experience internal tension before stealing that is then relieved after the theft. While they experience pleasure or gratification from stealing, they tend to have guilt or sadness afterwards.13 Many people with this disorder may try to stop stealing but feel guilt and shame about their inability to do so.13 Unfortunately, many may be apprehended or jailed for these behaviors.13 This disorder tends to appear in adolescence. However, its onset can vary significantly between childhood and old age.13 The prevalence of this disorder is not known, but it is believed to be a generally uncommon diagnosis12 that may be more common in females and psychiatric patients.13 Many with this disorder also have substance use disorders, mood disorders, and first-degree relatives with substance use disorders and OCD.13 Symptoms tend to be more severe when patients also experience anorexia nervosa, bulimia nervosa, and obsessive-compulsive disorder.12 The disorder can be chronic if not treated.13 Treatment for this disorder varies between medications and therapy. Related Conditions Attention-deficit/hyperactivity disorder Autism spectrum disorder Disruptive mood dysregulation disorder Source: American Psychiatric Association
- What is Schizophrenia?
Schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation. However, with treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished. While there is no cure for schizophrenia, research is leading to innovative and safer treatments. Experts also are unraveling the causes of the disease by studying genetics, conducting behavioral research, and using advanced imaging to look at the brain’s structure and function. These approaches hold the promise of new, and more effective therapies. The complexity of schizophrenia may help explain why there are misconceptions about the disease. Schizophrenia does not mean split personality or multiple-personality. Most people with schizophrenia are not any more dangerous or violent than people in the general population. While limited mental health resources in the community may lead to homelessness and frequent hospitalizations, it is a misconception that people with schizophrenia end up homeless or living in hospitals. Most people with schizophrenia live with their family, in group homes or on their own. Research has shown that schizophrenia affects men and women fairly equally but may have an earlier onset in males. Rates are similar around the world. People with schizophrenia are more likely to die younger than the general population, largely because of high rates of co-occurring medical conditions, such as heart disease and diabetes. Definitions Psychosis refers to a set of symptoms characterized by a loss of touch with reality due to a disruption in the way that the brain processes information. When someone experiences a psychotic episode, the person’s thoughts and perceptions are disturbed, and the individual may have difficulty understanding what is real and what is not. Delusions are fixed false beliefs held despite clear or reasonable evidence that they are not true. Persecutory (or paranoid) delusions, when a person believes they are being harmed or harassed by another person or group, are the most common. Hallucinations are the experience of hearing, seeing, smelling, tasting, or feeling things that are not there. They are vivid and clear with an impression similar to normal perceptions. Auditory hallucinations, “hearing voices,” are the most common in schizophrenia and related disorders. Disorganized thinking and speech refer to thoughts and speech that are jumbled and/or do not make sense. For example, the person may switch from one topic to another or respond with an unrelated topic in conversation. The symptoms are severe enough to cause substantial problems with normal communication. Disorganized or abnormal motor behavior are movements that can range from childlike silliness to unpredictable agitation or can manifest as repeated movements without purpose. When the behavior is severe, it can cause problems in the performance of activities of daily life. It includes catatonia, when a person appears as if in a daze with little movement or response to the surrounding environment. Negative symptoms refer to what is abnormally lacking or absent in the person with a psychotic disorder. Examples include impaired emotional expression, decreased speech output, reduced desire to have social contact or to engage in daily activities, and decreased experience of pleasure. Symptoms When the disease is active, it can be characterized by episodes in which the person is unable to distinguish between real and unreal experiences. As with any illness, the severity, duration and frequency of symptoms can vary; however, in persons with schizophrenia, the incidence of severe psychotic symptoms often decreases as the person becomes older. Not taking medications as prescribed, the use of alcohol or illicit drugs, and stressful situations tend to increase symptoms. Symptoms fall into three major categories: Positive symptoms: (those abnormally present) Hallucinations, such as hearing voices or seeing things that do not exist, paranoia and exaggerated or distorted perceptions, beliefs and behaviors. Negative symptoms: (those abnormally absent) A loss or a decrease in the ability to initiate plans, speak, express emotion or find pleasure. Disorganized symptoms: Confused and disordered thinking and speech, trouble with logical thinking and sometimes bizarre behavior or abnormal movements. Cognition is another area of functioning that is affected in schizophrenia leading to problems with attention, concentration and memory, and to declining educational performance. Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made. Men often experience initial symptoms in their late teens or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More subtle signs may be present earlier, including troubled relationships, poor school performance and reduced motivation. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms mimic schizophrenia. Risk Factors Researchers believe that a number of genetic and environmental factors contribute to causation, and life stressors may play a role in the start of symptoms and their course. Since multiple factors may contribute, scientists cannot yet be specific about the exact cause in each individual case. Treatment Though there is no cure for schizophrenia, many patients do well with minimal symptoms. A variety of antipsychotic medications are effective in reducing the psychotic symptoms present in the acute phase of the illness, and they also help reduce the potential for future acute episodes and their severity. Psychological treatments such as cognitive behavioral therapy or supportive psychotherapy may reduce symptoms and enhance function, and other treatments are aimed at reducing stress, supporting employment or improving social skills. Diagnosis and treatment can be complicated by substance misuse. People with schizophrenia are at greater risk of misusing drugs than the general population. If a person shows signs of addiction, treatment for the addiction should occur along with treatment for schizophrenia. Rehabilitation and Living With Schizophrenia Treatment can help many people with schizophrenia lead highly productive and rewarding lives. As with other chronic illnesses, some patients do extremely well while others continue to be symptomatic and need support and assistance. After the symptoms of schizophrenia are controlled, various types of therapy can continue to help people manage the illness and improve their lives. Therapy and psychosocial supports can help people learn social skills, cope with stress, identify early warning signs of relapse and prolong periods of remission. Because schizophrenia typically strikes in early adulthood, individuals with the disorder often benefit from rehabilitation to help develop life-management skills, complete vocational or educational training, and hold a job. For example, supported-employment programs have been found to help people with schizophrenia obtain self-sufficiency. These programs provide people with severe mental illness competitive jobs in the community. For many people living with schizophrenia family support is particularly important to their health and well-being. It is also essential for families to be informed and supported themselves. Organizations such as the Schizophrenia and Related Disorders Alliance of America (SARDAA), Mental Health America (MHA) and the National Alliance on Mental Illness (NAMI) offer resources and support to individuals with schizophrenia and other mental illnesses and their families (see Additional Resources). Optimism is important and patients, family members and mental health professionals need to be mindful that many patients have a favorable course of illness, that challenges can often be addressed, and that patients have many personal strengths that must be recognized and supported. Related Conditions Delusional Disorder Delusional disorder involves a person having false beliefs (delusions) that persist for at least one month. The delusions can be bizarre (about things that cannot possibly occur) or non-bizarre (things that are possible but not likely, such as a belief about being followed or poisoned). Apart from the delusion(s), it does not involve other symptoms. The person may not appear to have any problems with functioning and behavior except when they talk about or act on the delusion.Delusional beliefs can lead to problems with relationships or at work, and to legal troubles. Delusional disorder is rare: around 0.2% of people will have it in their lifetime. Delusional disorder is treated with individual psychotherapy, although people rarely seek treatment as they often do not feel they need treatment. Brief Psychotic Disorder Brief psychotic disorder occurs when a person experiences a sudden short period of psychotic behavior. This episode lasts between one day and one month and then the symptoms completely disappear, and the person returns to normal. Brief psychotic disorder involves one (or more) of the following symptoms: Delusions, Hallucinations, Disorganized speech Grossly disorganized or catatonic behavior. Although the disturbance is short, individuals with brief psychotic disorder typically experience emotional turmoil or overwhelming confusion. Brief psychotic disorder can occur at any age, though the average age at onset is the mid-30s. It is twice as common in females than in males. It is important to distinguish symptoms of brief psychotic disorder from culturally appropriate responses. For example, in some religious ceremonies, an individual may report hearing voices, but these do not generally persist and are not perceived as abnormal by most members of the individual’s community. Schizophreniform Disorder The symptoms of schizophreniform disorder are similar to those of schizophrenia, but the symptoms only last a short time—at least one month but less than six months. If the symptoms last longer than six months, then the diagnosis changes to schizophrenia. Schizophreniform disorder involves two or more of the following symptoms, each present for a significant portion of time during a one-month period (or less if successfully treated):: Delusions, Hallucinations Disorganized speech, Grossly disorganized behavior or catatonic behavior, and/or Negative symptoms. A diagnosis of schizophreniform disorder does not require problems in functioning (as schizophrenia does). In the U.S., schizophreniform disorder is significantly less common than schizophrenia. About one-third of individuals with an initial diagnosis of schizophreniform disorder recover within the 6-month period and schizophreniform disorder is their final diagnosis. Most of the remaining two-thirds of individuals will eventually receive a diagnosis of schizophrenia or schizoaffective disorder. Schizoaffective Disorder People with schizoaffective disorder experience symptoms a major mood episode of depression or bipolar disorder (major depression or mania) at the same time as symptoms of schizophrenia (delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative symptoms). Symptoms of a major mood episode must be present for the majority of the duration of the active illness and there must be a period of at least two weeks when delusions or hallucinations are present in the absence of a mood episode. Schizoaffective disorder is about one-third as common as schizophrenia, affecting about 0.3% of people at some time in their lives. The typical age at onset of schizoaffective disorder is early adulthood, although it can begin anywhere from adolescence to late in life. A significant number of individuals initially diagnosed with another psychotic illness later receive the diagnosis schizoaffective disorder when the pattern of mood episodes becomes apparent. Source: American Psychiatric Association
- What is Intellectual Disability?
Intellectual disability involves problems with general mental abilities that affect functioning in two areas: Intellectual functioning (such as learning, problem solving, judgement). Adaptive functioning (activities of daily life such as communication and independent living). Additionally, the intellectual and adaptive deficit begin early in the developmental period. Intellectual disability affects about 1% of the population, and of those about 85% have mild intellectual disability. Males are more likely than females to be diagnosed with intellectual disability. Diagnosing Intellectual Disability Intellectual disability is identified by problems in both intellectual and adaptive functioning. Intellectual functioning is measured with individually administered and psychometrically valid, comprehensive, culturally appropriate, psychometrically sound tests of intelligence. While a specific full-scale IQ test score is no longer required for diagnosis, standardized testing is used as part of diagnosing the condition. A full-scale IQ score of around 70 to 75 indicates a significant limitation in intellectual functioning. However, the IQ score must be interpreted in the context of the person’s difficulties in general mental abilities. Moreover, scores on subtests can vary considerably so that the full-scale IQ score may not accurately reflect overall intellectual functioning. Therefore, clinical judgment is needed in interpreting the results of IQ tests. Three areas of adaptive functioning are considered: Conceptual – language, reading, writing, math, reasoning, knowledge, memory. Social – empathy, social judgment, communication skills, the ability to follow rules and the ability to make and keep friendships. Practical – independence in areas such as personal care, job responsibilities, managing money, recreation, and organizing school and work tasks. Adaptive functioning is assessed through standardized measures with the individual and interviews with others, such as family members, teachers and caregivers. Intellectual disability is identified as mild (most people with intellectual disability are in this category), moderate or severe. The symptoms of intellectual disability begin during childhood. Delays in language or motor skills may be seen by age two. However, mild levels of intellectual disability may not be identified until school age when a child has difficulty with academics. Causes There are many different causes of intellectual disability. It can be associated with a genetic syndrome, such as Down syndrome or Fragile X syndrome. It may develop following an illness such as meningitis, whooping cough or measles; may result from head trauma during childhood; or may result from exposure to toxins such as lead or mercury. Other factors that may contribute to intellectual disability include brain malformation, maternal disease and environmental influences (alcohol, drugs or other toxins). A variety of labor- and delivery-related events, infection during pregnancy and problems at birth, such as not getting enough oxygen, can also contribute. Treatment Intellectual disability is a life-long condition. However, early and ongoing intervention may improve functioning and enable the person to thrive throughout their lifetime. Underlying medical or genetic conditions and co-occurring conditions frequently add to the complex lives of people with intellectual disability. Once a diagnosis is made, help for individuals with intellectual disability is focused on looking at the individual’s strengths and needs, and the supports he or she needs to function at home, in school/work and in the community. Services for people with intellectual disabilities and their families can provide support to allow full inclusion in the community. Many different types of supports and services can help, such as: Early intervention (infants and toddlers). Special education. Family support (for example, respite care support groups for families). Transition services from childhood to adulthood. Vocational programs. Day programs for adults. Housing and residential options. Case management. Under federal law (Individuals with Disabilities Education Act, IDEA, 1990), early intervention services work to identify and help infants and toddlers with disabilities. Federal law also requires that special education and related services are available free to every eligible child with a disability, including intellectual disability. In addition, supports can come from family, friends, co-workers, community members, school, a physician team, or from a service system. Job coaching is one example of a support that can be provided by a service system. With proper support, people with intellectual disabilities are capable of successful, productive roles in society. A diagnosis often determines eligibility for services and protection of rights, such as special education services and home and community services. The American Association of Intellectual and Developmental Disabilities (AAIDD) stresses that the main reason for evaluating individuals with intellectual disabilities is to be able to identify and put in place the supports and services that will help them thrive in the community throughout their lives. Related and Co-occurring Conditions Some mental health, neurodevelopmental, medical and physical conditions frequently co-occur in individuals with intellectual disability, including autism spectrum disorder, cerebral palsy, epilepsy, attention-deficit hyperactivity disorder, impulse control disorder, and depression and anxiety disorders. Identifying and diagnosing co-occurring conditions can be challenging, for example recognizing depression in an individual with limited verbal ability. Family caregivers are very important in identifying subtle changes. An accurate diagnosis and treatment are important for a healthy and fulfilling life for any individual. Autism spectrum disorder Attention-deficit hyperactivity disorder Impulse control disorder Depression Anxiety disorders. Tips for Parents Ask for help, learn about your child’s disability. Connect with other parents of children with disabilities. Be patient; learning may come slower for your child. Encourage independence and responsibility. Educate yourself on the educational services your child deserves. Learn the laws that are written to help your child live their best life. Look for opportunities in your community for social, recreational and sports activities (such as Best Buddies or Special Olympics). References The term intellectual disability used in DSM-5 replaces “mental retardation” used previously. The majority of people, 68%, have IQ scores between 85 and 115. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA APA Publishing. 2013.
- What is Gender Dysphoria?
The term “transgender” refers to a person whose sex assigned at birth (i.e. the sex assigned at birth, usually based on external genitalia) does not align their gender identity (i.e., one’s psychological sense of their gender). Some people who are transgender will experience “gender dysphoria,” which refers to psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later. Gender Dysphoria People who are transgender may pursue multiple domains of gender affirmation, including social affirmation (e.g., changing one’s name and pronouns), legal affirmation (e.g., changing gender markers on one’s government-issued documents), medical affirmation (e.g., pubertal suppression or gender-affirming hormones), and/or surgical affirmation (e.g., vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, etc.). Of note, not all people who are transgender will desire all domains of gender affirmation, as these are highly personal and individual decisions. It is important to note that gender identity is different from gender expression. Whereas gender identity refers to one’s psychological sense of their gender, gender expression refers to the way in which one presents to the world in a gendered way. For example, in much of the U.S., wearing a dress is considered a “feminine” gender expression, and wearing a tuxedo is considered a “masculine” gender expression. Such expectations are culturally defined and vary across time and culture. One’s gender expression does not necessarily align with their gender identity. Diverse gender expressions, much like diverse gender identities, are not indications of a mental disorder. Gender identity is also different from sexual orientation. Sexual orientation refers to the types of people towards which one is sexually attracted. As with people who are cisgender (people whose sex assigned at birth aligns with their gender identity), people who are transgender have a diverse range of sexual orientations. Diagnosis The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)1 provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults. The DSM-5-TR defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following: A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender) A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender) A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender) In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. The DSM-5-TR defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion): A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing A strong preference for cross-gender roles in make-believe play or fantasy play A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender A strong preference for playmates of the other gender In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities A strong dislike of one’s sexual anatomy A strong desire for the physical sex characteristics that match one’s experienced gender As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Treatment Support for people with gender dysphoria may include open-ended exploration of their feelings and experiences of gender identity and expression, without the therapist having any pre-defined gender identity or expression outcome defined as preferable to another.2 Psychological attempts to force a transgender person to be cisgender (sometimes referred to as gender identity conversion efforts or so-called “gender identity conversion therapy”) are considered unethical and have been linked to adverse mental health outcomes.2,3 Support may also include affirmation in various domains. Social affirmation may include an individual adopting pronouns, names, and various aspects of gender expression that match their gender identity.4,5 Legal affirmation may involve changing name and gender markers on various forms of government identification.6 Medical affirmation may include pubertal suppression for adolescents with gender dysphoria and gender-affirming hormones like estrogen and testosterone for older adolescents and adults. Medical affirmation is not recommended for prepubertal children. Some adults (and less often adolescents) may undergo various aspects of surgical affirmation. Family and societal rejection of gender identity are some of the strongest predictors of mental health difficulties among people who are transgender.14 Family and couples’ therapy can be important for creating a supportive environment that will allow a person’s mental health to thrive. Parents of children and adolescents who are transgender may benefit from support groups. Peer support groups for transgender people themselves are often helpful for validating and sharing experiences. Challenges/Complications Transgender people suffer from high levels of stigmatization, discrimination and victimization, contributing to negative self-image and increased rates of other mental health disorders.15 Transgender individuals are at higher risk of victimization and hate crimes than the general public. Suicide rates among transgender people are markedly higher than the general population.16 Transgender children and adolescents are often victims of bullying and discrimination at school, which can contribute to serious adverse mental health outcomes.17 Interventions are often needed to create safe and affirming school environments. Transgender individuals may also face challenges in accessing appropriate health care and insurance coverage of related services. Terminology Important terms related to Gender Dysphoria: Cisgender: Describes a person whose gender identity aligns in a traditional sense with the sex assigned to them at birth. Gender diverse: An umbrella term describing individuals with gender identities and/or expressions and includes people who identify as multiple genders or with no gender at all. Gender dysphoria: A concept designated in the DSM-5-TR as clinically significant distress or impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics. Not all transgender or gender diverse people experience gender dysphoria. Gender expression: The outward manifestation of a person’s gender, which may or may not reflect their inner gender identity based on traditional expectations. Gender expression incorporates how a person carries themselves, their dress, accessories, grooming, voice/speech patterns and conversational mannerisms, and physical characteristics. Gender identity: A person’s inner sense of being a girl/woman, boy/man, some combination of both, or something else, including having no gender at all. This may or may not correspond to one's sex assigned at birth. Nonbinary: A term used by some individuals whose gender identity is neither girl/woman nor boy/man. Sex/gender assigned at birth: Traditional designation of a person as “female,” “male,” or “intersex” based on anatomy (e.g., external genitalia and/ or internal reproductive organs) and/or other biological factors (e.g., sex chromosomes). “Sex” and “gender” are often used interchangeably, but they are distinct entities. It is best to distinguish between sex, gender identity, and gender expression and to avoid making assumptions about a person regarding one of these characteristics based on knowledge of the others. This is sometimes abbreviated as AFAB (assigned female at birth) or AMAB (assigned male at birth). Sexual orientation: Describes the types of individuals toward whom a person has emotional, physical, and/or romantic attraction. Transgender: An umbrella term describing individuals whose gender identity does not align in a traditional sense with the gender they were assigned at birth. It may also be used to refer to a person whose gender identity is binary and not traditionally associated with that assigned at birth. References Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association. 2022 The American Academy of Child & Adolescent Psychiatry. (2018). Conversion Therapy. https://www.aacap.org/AACAP/Policy_Statements/ 2018/Conversion_Therapy.aspx. Accessed November 7, 2020. Turban, J. L., Beckwith, N., Reisner, S. L., & Keuroghlian, A. S. (2020). Association between recalled exposure to gender identity convers
- What Are Bipolar Disorders?
Bipolar disorder is a brain disorder that causes changes in a person's mood, energy, and ability to function. People with bipolar disorder experience intense emotional states that typically occur during distinct periods of days to weeks, called mood episodes. These mood episodes are categorized as manic/hypomanic (abnormally happy or irritable mood) or depressive (sad mood). People with bipolar disorder generally have periods of neutral mood as well. When treated, people with bipolar disorder can lead full and productive lives. People without bipolar disorder experience mood fluctuations as well. However, these mood changes typically last hours rather than days. Also, these changes are not usually accompanied by the extreme degree of behavior change or difficulty with daily routines and social interactions that people with bipolar disorder demonstrate during mood episodes. Bipolar disorder can disrupt a person’s relationships with loved ones and cause difficulty in working or going to school. Bipolar disorder is a category that includes three different diagnoses: Bipolar I, Bipolar II, and Cyclothymic disorder. Risk Factors: Bipolar disorder commonly runs in families: 80 to 90 percent of individuals with bipolar disorder have a relative with bipolar disorder or depression. Environmental factors such as stress, sleep disruption, and drugs and alcohol may trigger mood episodes in vulnerable people. Though the specific causes of bipolar disorder within the brain are unclear, an imbalance of brain chemicals is believed to lead to dys-regulated brain activity. The average age of onset is 25 years old. People with bipolar I disorder frequently have other mental disorders such as anxiety disorders, substance use disorders, and/or attention-deficit/hyperactivity disorder (ADHD). The risk of suicide is significantly higher among people with bipolar I disorder than among the general population. Bipolar I Disorder Bipolar I disorder is diagnosed when a person experiences a manic episode. During a manic episode, people with bipolar I disorder experience an extreme increase in energy and may feel on top of the world or uncomfortably irritable in mood. Some people with bipolar I disorder also experience depressive or hypomanic episodes, and most people with bipolar I disorder also have periods of neutral mood. Symptoms of Bipolar I Disorder Manic Episode A manic episode is a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior: Decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual Increased or faster speech Uncontrollable racing thoughts or quickly changing ideas or topics when speaking Distractibility Increased activity (e.g., restlessness, working on several projects at once) Increased risky behavior (e.g., reckless driving, spending sprees These behaviors must represent a change from the person’s usual behavior and be clear to friends and family. Symptoms must be severe enough to cause dysfunction in work, family, or social activities and responsibilities. Symptoms of a manic episode commonly require a person to receive hospital care to stay safe.Some people experiencing manic episodes also experience disorganized thinking, false beliefs, and/or hallucinations, known as psychotic features. Hypomanic Episode A hypomanic episode is characterized by less severe manic symptoms that need to last only four days in a row rather than a week. Hypomanic symptoms do not lead to the major problems in daily functioning that manic symptoms commonly cause. Major Depressive Episode A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms): Intense sadness or despair Loss of interest in activities the person once enjoyed Feelings of worthlessness or guilt Fatigue Increased or decreased sleep Increased or decreased appetite Restlessness (e.g., pacing) or slowed speech or movement Difficulty concentrating Frequent thoughts of death or suicide Treatment and Management Bipolar disorder symptoms commonly improve with treatment. Medication is the cornerstone of bipolar disorder treatment, though talk therapy (psychotherapy) can help many patients learn about their illness and adhere to medications, preventing future mood episodes. Medications known as “mood stabilizers” (e.g., lithium) are the most commonly prescribed type of medications for bipolar disorder. These medications are believed to correct imbalanced brain signaling. Because bipolar disorder is a chronic illness in which mood episodes typically recur, ongoing preventive treatment is recommended. Bipolar disorder treatment is individualized; people with bipolar disorder may need to try different medications before finding what works best for them. In some cases, when medication and psychotherapy have not helped, an effective treatment known as electroconvulsive therapy (ECT) may be used. However, there can be short-term or long-term effects on memory, therefore it should be used as a last resort as based on the severity of symptoms. It is typically recommended to have 10-12 sessions spread out over 3 weeks, otherwise there is increase risk of memory impairment. ECT involves several rounds of a brief electrical current applied to the scalp while the patient is under anesthesia, leading to a short, controlled seizure. ECT-induced seizures are believed to remodel brain signaling pathways. Since bipolar disorder can cause serious disruptions in a person’s daily life and create a stressful family situation, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies for coping, participating actively in the treatment, and obtaining support. Bipolar II Disorder A diagnosis of bipolar II disorder requires someone to have at least one major depressive episode and at least one hypomanic episode (see above). People return to their usual functioning between episodes. People with bipolar II disorder often first seek treatment as a result of their first depressive episode, since hypomanic episodes often feel pleasurable and can even increase performance at work or school. People with bipolar II disorder frequently have other mental illnesses such as an anxiety disorder or substance use disorder, the latter of which can exacerbate symptoms of depression or hypomania. Treatment Treatments for bipolar II are similar to those for bipolar I: medication and psychotherapy. The most commonly used medications are mood stabilizers and antidepressants, depending on the specific symptoms. If depressive symptoms are severe and medication is not effective, ECT (see above) may be used. Each person's treatment is individualized. Cyclothymic Disorder Cyclothymic disorder is a milder form of bipolar disorder involving many "mood swings," with hypomania and depressive symptoms that occur frequently. People with cyclothymia experience emotional ups and downs but with less severe symptoms than bipolar I or II disorder. Cyclothymic disorder symptoms include the following: For at least two years, many periods of hypomanic and depressive symptoms, but the symptoms do not meet the criteria for hypomanic or depressive episode. During the two-year period, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months. Treatment Treatment for cyclothymic disorder can involve medication and talk therapy. For many people, talk therapy can help with the stresses of mood swings. Keeping a mood journal can be an effective way to observe patterns in mood fluctuation. People with cyclothymia may start and stop treatment over time.
- Mental Health Parity at a Crossroads
More than 25 years after the first federal mental health parity protections were put in place, adequate coverage for behavioral health (BH) care – including both mental health and substance use conditions –remains elusive for many consumers with health insurance.1 Federal BH parity rules require health plans that offer BH coverage to ensure that financial requirements (such as deductibles, copayments, coinsurance, and out-of-pocket limits) and treatment limits (such as day and visit limits as well as nonquantitative limits on benefits such as prior authorization) on these benefits are no more restrictive than those on medical and surgical benefits. Mental Health Parity at a Crossroads The COVID-19 pandemic has heightened awareness and exacerbated existing challenges in BH. Strengthening BH parity protections is just one part of a larger policy discussion that includes addressing the BH workforce shortage, rising BH treatment needs among children and youth, an inadequate health care infrastructure to address those in crisis, and the need for improved coordination and integration of primary care and BH care in the health care delivery system. All of these issues contribute to the access and coverage challenges in health insurance that BH parity was supposed to address. The stakes are high for coverage protection, as nearly 90% of nonelderly individuals with a BH condition have some form of health coverage. Despite having coverage, many insured adults (36%) with moderate to severe symptoms of anxiety and depression did not receive care in 2019. There have been consistent calls for more federal guidance on the specific protections in the federal BH parity law, as well as for increased enforcement. As Congress2 debates reforms to address these concerns in BH care, and as federal agencies plan to update parity regulations, this brief explains the federal BH parity requirements – including who they apply to and how they’re enforced — and sets out key policy issues. Federal BH Parity Protections Federal protections for BH coverage sought to correct historical differences in how health insurance covered this care when compared to medical/surgical benefits. The focal point of these protections has evolved over the years from the narrow initial federal law, the Mental Health Parity Act of 1996 (MHPA), to the broader protections in the current law, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (Appendix Figure 1). With MHPAEA, an initial focus on ensuring that consumers were not subject to higher cost sharing and more restrictive day and visit limits for BH shifted to looking at disparities in treatments limits in coverage that are not expressed numerically. These so-called “nonquantitative treatment limits” or NQTLs include plan features that limit the scope or duration of care such as prior authorization requirements and medical necessity reviews, standards for provider admission to a network, and provider reimbursement rates. Federal regulations implementing parity for commercial plans and for Medicaid and the Children’s Health Insurance Program (CHIP) have set out substantially similar protections (See Appendix Table 1 for major differences between commercial parity and Medicaid). These are detailed and complex standards making it a challenge for consumers with coverage to know what practices violate the law. Federal agencies have issued FAQs and other guidance for both commercial and Medicaid/CHIP to explain how these standards work. The basic protections are described below. Who does the law apply to? Federal BH parity rules apply to most health coverage, public and private, but do not apply to Medicare. Table 1 summarizes the basic rules and exceptions. Parity applies to all health coverage in the individual, small and large group insurance markets, as well as to all private employer-sponsored plans (insured and self-insured) with the exception of self-insured employer plans covering groups of no more than 50 employees, “retiree only” plans, short-term limited duration coverage and coverage considered “excepted benefits.”3 It also applies to self-insured state and local governmental plans (called nonfederal governmental plans), though these plans have the ability to opt out of MHPAEA protections, as hundreds of plans across 31 states currently do. Source: Kaiser Family Foundation