To Tweet or Not to Tweet…?

It seems that everyone is a-twitter about Twitter. This social networking site has exploded in recent months leading many to ask the questions: “What is it?” and more importantly, “Why Twitter?” I created an account to experience the phenomenon for myself. Twitter appeals to me on several levels: from the tech/gadget geek side as well as from a psychological perspective—”tapping into the stream of human consciousness”. Fellow psychiatrist Dinah Miller, of ShrinkRap fame, did a similar experiment herself: after one week of Tweeting she posted: “My week is almost up. I still don’t get this. Who is rilescat and why does he have a dead panda on his desk?” There is certainly no shortage of characters in Twitterland. I was impressed with the amount of wit and wisdom being shared in 140 characters. The requisite brevity forcing some to re-discover the art of editing: making every word count. I also observed some incredibly empathetic and compassionate exchanges: including one mother’s life-changing foray into the world of childhood leukemia. Twitter has been described as “a cocktail party” and Facebook as “a dinner party” given the degree of intimacy with ones friends and followers; this seems to be quite accurate. Twitter seems to function best in niches: thus promoted by the use of “Hashtags”.

 

To “get it”–to understand WHY, it is necessary to look at the motivation of each individual. Twitter asks the question: “What are you doing right now?” Differences in motivation lead to diverse responses to this simple question and a variety of Twitter experiences: some individuals are looking for entertainment, some for connection, some for information, and others for self-promotion. The potential for all exist in abundance on Twitter.

 

Many basic emotional needs of individuals can potentially be met through social networking: feeling validated, belonging, being heard… and with minimal risk of emotional trauma and physical effort (as one can happily tweet away in ones pajamas). While this connection for such individuals who may have limited access to other interaction can have certain positive aspects; (ie, a mom who stays home with her children); one must also consider the potential negative consequences of such virtual relationships as well. When needs are met in this superficial way… is the individual kept from developing deeper, albeit more complicated relationships in the world beyond the internet?

 

The potential for constant connectedness leading to the loss of being fully present in one’s “real” life is another concern. When I first began looking for people to follow, I searched for Jon Kabat-Zinn (author & founder of Mindfulness Based Stress Reduction): figuring that he would disseminate some incredibly wise tweets. He’s not on Twitter; the closest I could find was a remark about Twitter being the antithesis of mindfulness. No less concerning is the diversion of time and energy from other “real world” relationships. It is not unheard of for people to spend upwards of 5 hours daily checking their Facebook, MySpace, and Twitter accounts.

 

Perhaps the first question to answer before “What are you doing?” is “What am I doing here?”; consider if the virtual world is the best place to accomplish your goals. As for myself, I remain undecided. While I am absolute junkie for wit and humor, I have found the pace of information to be excessive at times. As with most things in life, it will come down to finding the right Balance… and the determination of how long to stay at the “party.”

Hope… for the economy & in depression

I had the pleasure of watching Dave Ramsey’s Town Hall for Hope last night. I like Dave Ramsey’s approach to money and I often recommend his “Financial Peace” program to my patients who are struggling with financial difficulties. I appreciate his take on the family’s budget as being just that: the outline of the family’s priorities as determined by the entire family together. His focus on personal responsibility resonates with me as well. I thought his presentation was uplifting and encouraging as he reiterated his common sense financial fundamentals to allay the “spirit of fear” that has come over most of America. If you missed it, I would encourage you to check out his website: www.townhallforhope.com .

Mr. Ramsey concluded his presentation with three action steps to combat “fear, panic, and hysteria.” They are: “take action, don’t participate in loser talk, and be giving”. I was struck by the need to apply these same principles in all areas of our life where we experience hopelessness: concern about a down-turned economy, dealing with difficult life situations, and most certainly, dealing with depression. Hopelessness can be one of the most challenging aspects of depression due to its invasive and destructive nature.

Let’s look at each step of the action plan as it pertains to mental health:

Take Action: “Get up, take action, get moving.” My treatment plans almost always include a recommendation for exercise. This type of “action” gets people off the couch and “out of their heads” at least for the moment. The mood enhancing effects of exercise have been well documented: improving levels of mood-enhancing neurotransmitters in the brain, boosting endorphins, releasing muscle tension, reducing stress –hormone cortisol levels, as well as improving sleep, confidence, and potentially reducing isolation. Exercise and music therapy remain some of the best non-pharmacologic steps individuals can take to improve their mental and physical health.

Don’t Participate in Loser Talk: This is one of the basic principles of Cognitive Behavioral Therapy. Specifically, don’t stay stuck in negative thinking. There really is power in positive thinking. Seek to identify and correct any distortions of thought that might be keeping you mired in negativity. Hopelessness is associated with many such “loser thoughts” that lead to poor self-esteem and creating a self-fulfilling negative spiral of thoughts and beliefs. Surround your self with optimistic and encouraging people and avoid those besieged with the “Spirit of Eeyore”.

Be Giving: Of all the recommendations I make to patients, giving can have the most profound effects on peoples’ lives. Giving is empowering. It improves self-esteem, imparts a sense of connectedness, and can foster an optimistic attitude. Altruism is one of the surest ways to restore hope as well as restoring an individual’s sense of purpose and meaning. Being a part of a cause larger than oneself and the feeling of making a difference in others’ lives are crucial for mental well-being. Giving, especially gifts of time and service, can grant a person perspective thus enabling him to look beyond his problems for a little while.

So no matter what obstacles or challenges you might be facing in your life, I join with Dave Ramsey in encouraging you to choose HOPE now.

World Autism Awareness Day: April 2nd, 2009

This also happens to be my son’s 2^nd Birthday. 

I have neglected my blog over the past six months; a fact kindly brought to my attention by one of my patients.  This neglect has occurred, not due of lack of material or interest- I still have a small pile of clippings on various mental health topics of interest- but because at the end of September 2008 my world changed significantly. 

 I had concerns about my son’s lack of appropriate speech development, but was assured that he was “normal” and that boys just are “late talkers” at his 15-month appointment.  By his 18^th month appointment, he had lost his one word “cat” and all babbling of “mamamama”.   We initially were concerned that he might have a hearing problem, as he didn’t respond to his name or to other communication; but after multiple failed hearing tests (and nightmare scenarios of having to teach a language that I don’t know to a child who won’t make eye contact with me) a sedated ABR revealed his hearing to be normal.  We joked for a few weeks that he didn’t know that we knew he could hear since he slept through the test.  All in all, we are blessed.  Our concerns were heard and we were referred to our state’s program for children 0-3 yielding a whirlwind of evaluations, leading to multiple therapy sessions with some very gifted and dedicated professionals: including a speech pathologist, occupational therapist, child psychologist, and resource coordinator.

 There are so many ways that Autism affects our lives:  from the frustrations of communications challenges; the lack of sufficient research and recommendations for safe & effective treatments; the burden of time and financial commitments for therapies (that insurance companies are not mandated to cover); to the feelings of guilt and helplessness at not knowing…because there are no answers to most of the questions, including “What causes this? What can be done?”  Currently, there are no effective means to prevent autism, no single effective treatment, and no known cure. In the absence of scientifically proven treatment, people turn to “folklore” of anecdotal treatments that may potentially cause more harm than good.  Without proper funding for research, this “folklore” may be all that is available.  

 

So, in honor of my son’s second birthday, I am doing what I can to raise awareness for this condition and the organizations that are working hard on research to find scientifically proven, safe & effective treatments for this devastating condition.  Please join with me in supporting Autism Speaks as we celebrate the second annual World Autism Awareness Day.  Together we can increase the knowledge of the Autism epidemic and convey information regarding the importance of early diagnosis and intervention. By bringing together autism organizations all around the world, we will give a voice to the millions of individuals worldwide who are undiagnosed, misunderstood and looking for help. Please join us in our effort to inspire compassion, inclusion and hope. 

Facts about Autism

Did you know…

• 1 in 150 children is diagnosed with autism

• 1 in 94 boys is on the autism spectrum; Boys are four times more likely than girls to have autism

• 67 children are diagnosed per day; that means a new case is diagnosed almost every 20 minutes

• More children will be diagnosed with autism this year than with AIDS, diabetes & cancer combined

• Autism is the fastest-growing serious developmental disability in the U.S.

• Autism costs the nation over $90 billion per year, a figure expected to double in the next decade

• Autism receives less than 5% of the research funding of many less prevalent childhood diseases

• There is no medical detection or cure for autism, but early intervention improves outcomes

For more information on this condition and how you can help, please visit any of the following website:

www.autismspeaks.com

www.worldautismawarenessday.org

 We will be participating in the Oklahoma City 2009 Walk for Autism Event on June 6th, 2009 at the OKC Bricktown Ballpark.  For more information or to make a tax-deductible donation, please visit us on the web at:

www.walknowforautism.org/oklahoma/evan

8 Lifestyle fixes to help with weight loss

 

Psychiatric patients are at high risk of becoming obese—with rates up to 63% in schizophrenia and 68% in bipolar disorder. Moreover, weight gain from psychotropics is associated with medication non-adherence.

 

The 8 behaviors described below can help individuals become more active and take steps toward a healthier lifestyle.

 

1.  Keep a food diary. Keep a written record of everything you eat or drink in a day. Learn about healthy foods and look up the calories of common foods using food packaging, pocket books listing calorie counts, and online sources.

 

2.  Start walking. Pedometers could motivate individuals to exercise regularly and reach goals of taking a certain number of steps each day. A physically healthy individual should walk approximately 10,000 steps per day. Scheduling daily walks also provides structure and increases the likelihood of compliance.

 

3.  Plan meals and eat mindfully. Schedule meals and eat mindfully. This means keeping your full attention on eating by noticing the smell, taste, and texture of food. Eat slowly, enjoy every bite, and avoid eating while watching television or when occupied by another activity.

 

4.  Have a healthy snack before a meal. Eating a serving of boiled vegetables or a piece of fruit such as an apple before a meal can satisfy hunger and reduce food intake.

 

5.  Increase fluid intake. Feeling hungry might be a signal that the body needs more fluid.  Drink water, avoid beverages that contain sugar, and limit fruit juice to 4 to 8 ounces per day.

 

6.  Obtain support from family and friends. Loved ones can reinforce a patient’s weight loss efforts by not eating high-calorie food in front of the patient and buying only healthy snacks such as fruits and vegetables.

 

7.  Improve nutrition.   Specifically:

* eat at least 3 meals and 2 to 3 healthy snacks per day

*  choose lean meats and whole grains

*  eat 5 servings of fruits and vegetables daily

*  avoid eating after 7 Pm or 3 to 4 hours before bedtime.

8.  Monitor weight regularly. Digital scales give more precise measurements, which can prompt individuals to reduce food intake when they notice weight gain. Frequent feedback can help facilitate behavior changes necessary for weight loss.  Weigh-ins should occur between once-a-day and once-a-week.  

People often need help setting appropriate weight loss goals because achieving their ideal weight may not be possible. Losing 10% of body weight usually is a realistic goal that can improve their health.

(Summarized from Current Psychiatry, Vol 7, No. 9: article by Imran S. Khawaja, MBBS)

Mind-Body Medicine Used to treat PTSD in Kosovo Teens

Traumatized children living in Kosovo experienced significant reductions in post-traumatic stress disorder (PTSD) symptoms when treated with a mind-body program according to a new study published in Journal of Clinical Psychiatry (8/12/08. PTSD is an anxiety disorder that can occur in response to traumatic events. Common symptoms include flashbacks, nightmares or difficulty sleeping, feeling emotionally numb, being easily startled and difficulty concentrating.

The mind-body techniques used in the study were developed by the Center for Mind-Body Medicine (CMBM) and included meditation, biofeedback, breathing techniques, guided imagery and self expression. Eighty-two high school students diagnosed with PTSD were included in the three-month long study. Instructors trained in the CMBM program provided 12 sessions, in small educational settings.

Patients in the mind-body group experienced a significant improvement in PTSD symptoms compared to the control group. The number of children with PTSD symptoms decreased from 100 percent to 18 percent by the end of the study. The techniques reduced stress and symptoms of withdrawal, as well as decreased the frequency of flashbacks and nightmares. The effects were maintained three months after the study.

This mind-body technique is currently being used to treat people in Israel and Gaza who are traumatized by war, as well as those traumatized by Hurricane Katrina in southern Louisiana. It is also used to treat depression in the United States and has been added to a stress reduction program in several U.S. medical schools.

The study, published in the Journal of Clinical Psychiatry represents the first randomized controlled trial of any intervention in war-traumatized children.

RX data used as health “credit report”

An article in the August 4th, 2008 Washington Post describes how health and life insurance companies are now accessing databases of individuals’ personal prescription records to rate their relative risk.

They note that consumers authorize the data release and that the services can save insurance companies millions of dollars and benefit consumers anxious for a decision. 

Why are we so focused on saving the insurance companies millions of dollars?  I frequently encounter requests from certain pharmaceutical benefit plans requesting that I change a patient from a medication, that they are usually doing well on, to one that is truly not a generic equivalent, for the sole purpose of saving money.  However, when examined more closely, it only serves to save the insurance plan money.  

 

More and more, I find myself concerned about the future of for-profit, insurance-driven medicine.  It seems too problematic to have such divergent interests working together:  serving the health care needs of the individual (providing quality care) and the business goals of the insurance company (minimizing costs).  We have already experienced the deterioration of the doctor-patient relationship due to time constraints that exist (de-facto) due to the insurance paradigm.  Now we are seemingly at the edge of a more efficient means of maximizing profits for the insurers by mitigating risk:  unfortunately, the risk that is avoided is providing healthcare to those who might actually need it.  What types of conditions will be considered too high a risk: diabetes, depression?  What happens to those individuals when they are excluded or have to pay rates that are cost prohibitive?  It is an unfortunate, and perhaps unforeseen by-product of the move to computerize our health records.  I am entirely in favor of information, but not at the expense of privacy violations or corporate profiteering.

Self-Disclosure in Therapy

One area that is sometimes contentious in therapy is that of self-disclosure. In traditional psychoanalysis, analysts deliberately refrain from revealing anything about themselves.  However, my therapeutic approach is that of Cognitive Behavioral Therapy (CBT).  There is no such prohibition in CBT and I find that I tend to do a lot of self-disclosure with patients whom I think will benefit from it.  I do, however, think it is important to differentiate between self-disclosure for the therapeutic benefit of the patient verses the burdening of the patient by unloading the therapist’s own baggage.  As one of my mentors, Dr. Murali Krisha once shared, “Never share things with patients that would add to their sorrow or cause them to worry about us.”

 

Examples of therapeutic self-disclosure may range from addressing issues that patients may have with unrealistic, perfectionistic standards through relating the standards and expectations I have of my own life to helping those who are struggling with feeling of frustration or low self-esteem by sharing how I motivate myself by “giving credit” or other such techniques I have used in my own life with success.

 

I don’t use self-disclosure with every patient but it does happen frequently. Self-disclosure is a way to give people a different perspective—a different way of thinking about their problems.   I have also found that it goes a long way in strengthening the therapeutic relationship when patients recognize that I am a human being who is willing to share something of myself to help them.  

Does this mean I can get a “pedi” with my FSA?

A small study in Japan (n=13) looked at the autonomic, neuro-immunological and psychological responses to wrapped warm footbaths.   “Warm wrapped footbaths” were associated with an increase in parasympathetic activity and decrease in sympathetic activity as measured by serum cortisol levels and salivary igA levels.  Hmmmm…. so footbaths are relaxing…..  

I actually do recommend bodywork, whether massages or pedicures, to patients to help manage and mitigate the effects of stress.  How much better to get a pedicure than to pop an extra benzo.

Why do I do what I do?

At the simplest level, it is because I love what I do.  A colleague/ mentor encouraged me a few years ago, to imagine what my practice would be like if I were free to practice medicine the way I wanted to.  So I did…then I made it happen…and it has made all the difference.

 

I was originally drawn to medicine through my love of science… and the observation that nothing “grossed me out”.  In junior high, I contemplated psychiatry…as I enjoyed helping my friends work out their problems.  In med school I was drawn to OB and ER, but quickly realized that I do not function well in the middle of the night.  After a few weeks on my psychiatry rotation, the decision was clear.  I signed a residency contract before the start of my fourth year of medical school. 

 

Psychiatry embodies several aspects that I loved from ER and OB/Gyn rotations:  an ongoing relationship with patients, the opportunity to really listen and hear people, and the fact that it is never boring.  I have always loved stories… I may not be the greatest with names, but I generally remember all of the stories.

 

I often discuss with my patients the concept of basic human needs:  obviously food and shelter… but also intimacy, joy, and a sense of “purpose”.   My medical practice fills many of those needs in myself.  I sometimes question why being a wife and mother isn’t “good enough”, although I do believe that they are most noble and important roles… it seems to come back to the thought, “…because I know I’m supposed to be doing something more.”

 

A therapist who offices with me, has a verse from Galatians 6:2 on his business cards… “Bear each other’s burdens, and in this way you will fulfill the law of Christ”.  I do consider my practice as my ministry.  I am blessed and honored by these people who trust me with their wounded souls and chaotic lives.  I do not take my responsibility lightly; I continually look for ways that I can facilitate relief from their suffering.

 

My patients sometimes remark, “How can you do this?  How can you listen to these stories all day?” I guess it comes to down to my steadfast and stubborn belief that things can get better.  I was once afraid to share this optimism with patients. Now I realize that giving someone hope and the assurance that they don’t have to go down the path alone, can be very powerful medicine.

Bipolar Voices

One of the frustrations that I hear voiced from my patients with bipolar disorder is the feeling of isolation and of being an outcast.  “How can I talk with someone who will think I’m crazy if I tell them I’m bipolar.”  Add this loneliness to an existing depressed mood and you have a downward spiral of negativity and hopelessness.  One of the few positive outcomes of direct to consumer advertising by drug companies has been the subtle move towards mainstream acceptance of mental health disorders.  Unfortunately, there are miles to go before one can admit with the same nonchalance that one has bipolar (or any other mental disorder) as one would with high cholesterol.  While a few support groups exist, they do not meet the needs of all patients and tend to be utilized by those who are not functioning well.  “Where are the bipolar patients who aren’t on disability and on five different meds?”  Most likely, they are working, spending time with their family….but probably not attending a support group; at least, not while they are doing well.  It’s a shame too:  it would be nice for those who have had success in managing their condition to share some of their strategies and tips with others.  Until then, there is a wonderful multimedia collection of stories on the New York Times website from patients living with bipolar disorder:

http://tinyurl.com/bipolarvoices