Schopick Psychiatry

Many of us have little behaviors that we repeat for some extra peace of mind–we may double-check that we unplugged the coffee pot before leaving for work, or that the house is locked up for the night. We joke that we are “OCD” or obsessive-compulsive, but for those who truly suffer from obsessive-compulsive disorder, the situation is no laughing matter. It is, however, treatable.

Facts About OCD

What is obsessive-compulsive disorder?

Basically, it is an anxiety disorder characterized by uncontrollable, nagging thoughts and repetitive, ritualized behaviors that a person feels compelled to perform. The thoughts make the person feel afraid, apprehensive or worried. The behaviors may make the person feel less anxious, or he or she may simply be powerless to stop doing them. The most common repetitive behavior is hand washing, but other examples include obsessive cleaning, repeated checking, extreme hoarding, preoccupation with sexual, violent or religious thoughts, dislike of particular numbers, and nervous rituals such as opening and closing doors a certain number of times before entering or leaving a room.

Many people with OCD recognize on an intellectual level that such thoughts and behaviors are irrational, but even so, they cannot break free of them. Their brain gets stuck in a repetitive groove and they find themselves checking the stove 20 times to make sure it’s really turned off, washing their hands until they are scrubbed raw, or spending hours checking the windows over and over to make sure they are truly closed.

OCD is the fourth most common mental disorder and is diagnosed nearly as frequently as asthma and diabetes. In the United States, one in 50 adults suffers from OCD, which affects both children and grownups. In fact, many adult suffers say that they first experienced symptoms during childhood.

Obsessions and Compulsions: What is the difference?

Obsessions: Are involuntary, seemingly uncontrollable thoughts, images, or impulses that occur over and over again in your mind, even though you want them to stop. They are often disturbing and disrupting to your life and relationships.

Compulsions: Are behaviors or rituals that a person with OCD feels he must act out again and again. Usually, compulsions are performed in an attempt to make obsessions go away. For example, a person afraid of germs may develop elaborate cleaning rituals. However, the relief never lasts. In fact, the obsessive thoughts usually return even stronger. Making matters worse, the compulsive behaviors usually end up causing anxiety as they become more demanding and time-consuming. At this point, having a normal life becomes very difficult.

Categories of OCD:

Most people with obsessive-compulsive disorder fall into one of the following categories:

Washers are afraid of contamination. They usually have cleaning or hand-washing compulsions.

Checkers repeatedly check things (oven turned off, door locked, etc.) that they believe could be dangerous.

Doubters and sinners are afraid that if everything isn’t perfect or done exactly right then something terrible will happen or they will be punished.

Counters and arrangers are obsessed with order and symmetry. They may have superstitions about certain numbers, colors, or arrangements.

Hoarders fear that something bad will happen if they throw anything away. They compulsively hoard things that they don’t need or use.

Most people with obsessive-compulsive disorder have both obsessions and compulsions, but some people experience just one or the other.

Just because you have obsessive thoughts or perform compulsive behaviors does NOT mean that you have obsessive-compulsive disorder. With OCD, these thoughts and behaviors cause tremendous distress, take up a lot of time, and interfere with daily life and relationships.

Treatment for OCD

OCD can be successfully treated with cognitive-behavioral therapy, and medication. Cognitive-behavioral therapy for obsessive-compulsive disorder (OCD) involves two components:

1. Exposure and response prevention involves repeated exposure to the source of the obsession. The person suffering from OCD will be asked to refrain from the compulsive behavior they typically perform to reduce anxiety. For example, a compulsive hand washer might be asked to touch the door handle in a public restroom and then be prevented from washing. As time passes, the person’s urge to wash their hands will gradually begin to fade on its own. This shows that the ritual is not necessary in terms of reducing anxiety–the person can control their obsessive thoughts and compulsive behaviors.

2. Cognitive therapy focuses on the catastrophic thoughts and the burden of responsibility that OCD sufferers often feel. With cognitive therapy, those with OCD learn healthy and effective ways of responding to these fears without resorting to compulsive behavior.

1. With help, they learn to recognize obsessive thoughts and tell themselves that this is simply an obsession and there is no need to perform the ritual.
2. They distract themselves from OCD thoughts by engaging in other tasks and redirecting their attention.

Other steps that can also help control OCD include learning relaxation techniques such as deep breathing, yoga, or tai chi. These actions can help reduce anxiety.

Avoiding alcohol and nicotine is wise, as these can also feed feelings of anxiety. Alcohol may seem to relax you, but as it wears off, anxiety increases. Nicotine is a stimulant and can send anxious thoughts into overdrive.

Getting a good night’s sleep is also important, as being fatigued makes it harder to cope with OCD.

Exercise can be very helpful. The endorphins it produces help reduce anxiety, while the activity engages a person’s mind and body.

Medication Therapy

There are psychiatric medications which can help control the obsessions and compulsions of OCD. Antidepressants are usually a first choice. They can be helpful for those with OCD because they can increase levels of serotonin, which may be lacking in those who have the disorder. Commonly prescribed antidepressants include Prozac, Paxil, Celexa, Zoloft, Anafranil, and Luvox.

My goal when working with OCD patients is to effectively control signs and symptoms while using a drug at the lowest possible dosage. Which medication works best in alleviating OCD symptoms depends on the individual. In any case, it can take weeks or sometimes months before a patient notices improvement. It is also not unusual for a patient to have to try several medications before finding the one that is the right “fit.” In some cases, a combination approach works best, with the patient taking both an antidepressant and an anti psychotic medication to help control OCD.

When patients are using medication therapy, it is important for them to remember NOT to stop taking their medication without talking to their doctor first–even if they are feeling better. They may have a relapse of OCD symptoms if they stop the medication, and some medications need to be tapered down rather than stopped abruptly in order to avoid withdrawal symptoms.

It is not uncommon for a patient to require medication for one to two years before I suggest tapering down the dosage. If OCD symptoms return at the lower dosage, this can be an indicator that medication may be needed for a longer period.

For those with OCD, a combination of therapy and medication can often prove to be a very effective combination at restoring them to a normal life.

The tabloids are full of stories about celebrities and politicians caught in scandals due to sexting. The scary thing is that today’s teenagers are also involved in sexting, and the repercussions can be lasting. Sexting is the sending of sexually-oriented messages or photos via text or email messages on Smartphones or other electronic devices. Many of these photos and texts later wind up posted on the Internet for all to see.

Most teenagers have a solid knowledge of technology and any teen with an electronic device–even a gaming device–can potentially engage in sexting. As parents, we cannot take every electronic gadget away from our kids, nor can we completely “unplug” our teens, but we can help protect them from harmful behavior by educating them. Frank talks about the damage that can be done by sexting–and how long that damage can last–are the best defense.

Why is sexting a growing issue among teens?
The short answer is accessibility–78 percent of teens now have a cell phone and nearly half of them own a Smartphone. Twenty-three percent of teens have a tablet and 93 percent of teens have their own computer or have access to one at home. A whopping 95 percent of teens use the Internet. In short, today’s teenagers have easy access to electronic devices and the information superhighway, pretty much around the clock. That puts a lot of temptation at their fingertips, as well as an amazing capacity to spread not just information, but illicit photos and incriminating messages.

How many teens are sexting?
A University of Texas study recorded that 28 percent of teens admitted to sending a sext. Girls (68 percent) were asked to send a sext more often than boys (42 percent).

Why is sexting harmful?
Sexting is harmful in many ways. First, it can easily take the form of cyberbullying. Teens can feel pressured to send a sext–especially girls–for fear of losing their boyfriend. They can also be pushed into sexting by peer pressure. They can be afraid of looking like a prude or not being cool if they don’t indulge in risky behavior such as sexting.

The problem is that sending a sext is not the end of the problem but the beginning. Once a sexually-provocative photo is out there, the person in the photo has lost all control of it. It can be sent to anyone, posted on social media, and from there, literally make its way around the world. Adding to the problem, the image can be out there forever. One lapse in judgment can wreak havoc years down the road. Let’s be honest, the temptation for a teenage boy to share a photo of a nude teenage girl with his friends is huge, and what was initially supposed to be an intimate sharing of images between boyfriend and girlfriend can quickly become something else.

Teens may also feel “blackmailed” to continue to sext even if they don’t want to, as partners or “friends” threaten to share or post images if they do not comply. Ex-boyfriends and girlfriends may use the images in retaliation after a bad breakup. Once you sext you are vulnerable, and peers can quickly become bullies.

Another reason for concern is that a study by an internet watch group found that 88 percent of self-made explicit images are “stolen” from social networking sites to be used on porn sites.

The bottom line is that images used in sexting can be used in ways not intended, and can remain on the Internet long after they were sent. This means that future employers, spouses, neighbors and others can potentially see them. Before you post or send ANYTHING always ask yourself, do I care if the world sees this? If this answer is yes, don’t send it.

Can sexting lead to mental health issues?
Yes, depression is a growing concern and can occur as a result of sexting. Girls especially feel a sense of betrayal when pictures that were supposed to be private are shared. Their self-esteem plummets and many say they feel worthless and ashamed. Girls have seen their reputations shattered as intimate images they shared with a boyfriend have wound up being seen by their entire student body, and even by students at neighboring schools. Those victimized in this way have endured name calling, nasty social media posts and harassing emails. As a result of these attacks, their grades fell and many dropped out of school activities and school itself. Other reactions to sexting have seen teens resort to self-abuse by engaging in cutting, pulling out hair, bulimia, burning themselves with cigarettes, as well as alcohol and drug abuse. It is no exaggeration to say that sexting can destroy young lives. Trust in relationships is shattered and those involved are virtually held up for public ridicule.

Can sexting lead to legal issues?
Yes, many teens do not realize that if you send or keep a nude or sexually provocative photo of a minor you can run the risk of porn trafficking charges. If your emails or texts show that you are coercing someone into sending sexts, then that can also be considered a crime. Teens engaged in this behavior can face jail time under the current laws in some states, and as a result, forever have a blot on their records.

What can parents do?
The most important thing is to have a calm conversation about sexting and its implications. Don’t rant or threaten, simply introduce the topic and first ask if they are aware of what sexting is. You might bring up a case that has been in the media, either with a celebrity or regular teen, and use that as a place to start. Ask them if they think sexting is an issue at their school or with their friends. Explain that true friends do not ask for sexts, and that as a friend they should never share or post one if a sext is sent to them. Give them plenty of time to ask their own questions and LISTEN. It is important to understand what is going on in their lives. Then you can get a sense of whether they are in potentially harmful relationships or being pressured in any way–both of these scenarios can lead to sexting and other issues.

Another thing to consider is a house rule about access to electronic devices. Studies have shown that most sexting is done between midnight and early morning when most family members are asleep. Some parents control access to devices during these hours.

What if my teen has been sexting?
Again, the most important thing is to not over-react. Yes, it is upsetting but your teen needs your support and help in getting out of a damaging situation, not a lecture. Have a conversation and try to understand what led to this behavior. Is it peer pressure? Boyfriend pressure? Are they lonely and trying to fit in? Once there is some understanding as to why, then stress the ramifications and why this behavior must stop. Next, try to undo the damage by deleting all photos. If you fear a relapse, limiting access to technology may come into play. Your phone provider can also provide programs to limit sexting.

What can teens do?
If someone sends you a sext, tell them to stop. If they are a friend, explain the dangers–they may be unaware. If the person persists in sexting, tell your parents and have them contact the authorities. Keep copies of all of your message requests asking them to stop.

If you have been sexting, stop and delete as many pictures from your phone, computer and social media as possible. Ask anyone whom you sent sexts to to delete them. Send your requests in electronic form so you have proof of your request. Report the issue to the authorities if pictures are not taken down or removed. Google yourself to see if any photos show up on other sites. Local law enforcement cyber units can also advise you on how to restore your online image.

Teens are naturally curious about sex, and that’s normal. However, sexting can lead to real emotional damage and mark young lives for years to come. That’s the real message that needs to be sent.

About Dr. David Schopick:
Dr. David Schopick is a psychiatrist in private practice in Portsmouth, NH. He is Board Certified by the American Board of Psychiatry and Neurology in adult, adolescent and child psychiatry and has been serving patients in the Greater Seacoast area and beyond for more than 22 years.

For more information, call (603) 431-5411 or visit www.schopickpsychiatry.com

Many people suffer from varying degrees of depression. For most, successful treatment can be found using medication. However, some sufferers cannot tolerate medication well, or find that the medication does not fully relieve their symptoms. Now, there is a treatment available that can possibly bring relief to those who previously could not find help. The treatment is called Transcranial Magnetic Stimulation (TMS) and it appears very promising.

What is Transcranial Magnetic Stimulation?

Transcranial magnetic stimulation uses magnetic fields to stimulate nerve cells in the brain in order to treat depression. During the procedure, a large magnetic coil is placed on the patient’s scalp near the forehead. The electromagnet within the coil creates electric currents which are believed to stimulate the areas of the brain involved in mood control and depression.

When is TMS used?

Doctors may recommend TMS when other traditional methods of treatment for depression, such as medication and psychotherapy, have not worked, or if patients have experienced significant side effects from multiple medication trials.

How does it work?

How TMS relieves depression is not completely understood at this point. TMS is relatively new — only approved by the Food & Drug Administration in 2008, so more studies are still being done and data is still being evaluated. As research continues, doctors will have a better understanding as to why this procedure may be helpful. It is believed that the magnetic impulses affect the brain cells involved in mood control, causing improvement. Electric stimulation of areas of the brain to treat mental illness is not new, such as Electroconvulsive Therapy (ECT). Though highly effective in treating severe depression, ECT can be associated with substantial side effects, such as memory loss.

Does TMS work right away?

TMS usually requires a series of treatment sessions to be effective. These are usually scheduled on a daily basis, five times per week for four to six weeks.

How do I know if I am a candidate for TMS?

Your mental health provider will conduct an interview with you to determine if you meet the criteria for possible treatment. If you are going to ask your insurance carrier to help with payment for TMS, they generally require proof of failed treatment on multiple anti-depressants along with “adjunctive” medication trials for treatment-resistant depression. They will also require patients to have had past efforts with psychotherapy. If you have already been approved for ECT treatment by your insurance carrier, TMS may be approved as an alternative.

What can I expect at a TMS treatment?

• Treatment can be done in a doctor’s office, although doctors performing TMS must be certified and have the right equipment.TMS does not require anesthesia and is not invasive. You do not need to have electrodes implanted in your body or any type of incision.
• You will be taken to a treatment setting and sit in a comfortable chair. You can use earplugs during the treatment because the machine does make noise during the procedure. You can listen to your music player with earbuds if you prefer.
• During the procedure, you will also feel a tapping sensation on your forehead. You may also feel your hands or fingers twitch during the testing phase as the doctor determines the right electromagnetic dose for you.
• The procedure lasts about 40 minutes, and the entire appointment may take up to one hour, including preparation time and post-procedure evaluation.
• After treatment, you can return to your normal activities. You do not require a driver to get you to and from your appointment, as is always the case with ECT.

Are there side effects?

The most common side effects are short term and are headache, scalp discomfort where the magnetic coil was placed, tingling, spasms or twitching of facial muscles, and lightheadedness.

Summary

It is not yet known whether TMS can be used to treat depression for the long term or whether periodic “maintenance” treatments may be required. According to research to date, many people see relief quickly–either in terms of lessening of symptoms or even symptoms disappearing completely. However, not enough data is in to determine whether or not this improvement is lifelong. Still, for those who have previously not been able to find any relief of their depression symptoms, TMS offers a promising option to consider.

Helping both children and adults with Attention Deficit Hyperactivity Disorder (ADHD) is a big part of my practice. This condition is very treatable, and in most cases, significant improvement can be made. Here is some basic information to help you understand ADHD and some of the treatments involved.

What is ADHD?

Individuals with this disorder experience chronic problems with combinations of inattention, impulsiveness, and hyperactivity. The American Psychiatric Association’s Diagnostic and Statistical Manual IV (DSM IV) identifies three separate diagnoses: primarily inattentive type, hyperactive/impulsive type, or the combined type (having inattention, hyperactivity and impulsivity). Difficulties with self-regulation and motivation are common. People can experience ADHD as children, teens or adults. ADHD is not uncommon, and is estimated to affect 5 to 8 percent of school-age children, and about 4 percent of adults. In 60 percent of childhood cases, symptoms persist into adulthood.

What are the symptoms of ADHD?

People with ADHD usually display both symptoms of inattentiveness, and hyperactivity, but some may exhibit greater signs of one than the other. To be diagnosed with ADHD, a person must show symptoms in two different life settings, such as at school and at home, or at home and at work. The inattentiveness or hyperactivity must cause significant problems in functioning at school, work or home, or in social settings. Symptoms are expected to be present by age 7.

Though people may be unaware of symptoms before age 7 (a more common problem when evaluating adults), it is important to emphasize that we do not expect symptoms to appear suddenly in the adult years. A sudden emergence of ADHD-like symptoms in a teenager or adult should initially be assessed by the primary care doctor to rule out the possibility of a major medical cause.

As mentioned above, there are three major categories of ADHD; inattentive type, hyperactive/impulsive type, and “combined type.” The DSM IV lists 9 separate, common symptoms to look for in the inattentive and hyperactive/impulsive subtypes.

Doctors usually look for at least six different symptoms that have persisted for six months or more, and cannot be accounted for by any other mental or physical disorder before making a diagnosis of ADHD.

Here are some common ADHD symptoms as defined by DSM IV Criteria for ADHD (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, DC, American Psychiatric Association, 2000)

Inattentiveness

Six or more of the following symptoms of inattention have been present for six months, and to a point that is disruptive and inappropriate for the developmental level:

• Often does not give close attention to details or makes careless mistakes in schoolwork or other activities
• Often has trouble keeping attention on tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Often has trouble organizing activities
• Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time, such as schoolwork or homework
• Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books or tools)
• Is often easily distracted
• Is often forgetful in daily activities

Hyperactivity

• Often fidgets with hands or squirms in seat
• Often gets up from seat when remaining in the seat is expected
• Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless)
• Often has trouble playing or enjoying leisure activities quietly
  Is often “on the go” or often acts as if “driven by a motor”
• Often talks excessively

Impulsivity

• Often blurts out answers before questions have been finished.
• Often has trouble waiting one’s turn.
• Often interrupts or intrudes on others (e.g. butts into conversations or games).
• Some symptoms that cause impairments were present before age 7 years
• Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home)

There must be clear evidence of significant impairment in social, school, or work functioning. The symptoms also do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder. They are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Adult Symptoms

Symptoms in adults may be different than those in children. Here are some common signs of ADHD in adults:

• Puts things off to the last minute
• Fails to follow through on commitments
• Difficulty with prioritization. This can lead to missed deadlines, forgotten appointments or social engagements, etc.
• Has difficulty sustaining attention or reading paperwork
• Feels restless and impatient. This can include impatience waiting in lines or driving in traffic.
• Always “on the go”
• Always needs to be busy at work or on vacation
• Interrupts others at work or in class
• Has difficulty waiting their turn
• Finishes others sentences during conversation
• There is often a history of problems in work, school, or relationships

What causes ADHD?

ADHD is a psychiatric behavioral disorder. The brain uses different chemicals to help send messages across the nervous system. An imbalance in these chemicals, or understimulation of the frontal lobe, may cause the symptoms associated with ADHD, but a definitive answer is not yet in place. Other causes and risk factors, including genetics, may play a role. Some of the other possible causes include brain injury, environmental exposure (such as to lead), alcohol and tobacco use during pregnancy, premature delivery, and low birth weight.

Why is treatment important?

People with untreated ADHD can suffer social and academic failure, failure in the workplace, and chronic difficulties in maintaining relationships. For some, it can contribute to low self esteem, substance abuse, and even a possible risk of antisocial or criminal behavior.

How can ADHD be treated?

Treating ADHD in children usually involves medical, educational, behavioral and psychological interventions. This comprehensive approach is called “multimodal” and involves educating the parent, child, teachers and others involved in the child’s welfare. I always make sure that any course of treatment is tailored to the unique needs of the patient and their family.

Behavior strategies are a major part of treatment for children with ADHD.

These include

• Create a routine for every day–same time getting up, doing homework, having playtime, going to bed.
• Get organized so that items your child needs are always in the same place where he can find them.
• Avoid distractions. Turn off the computer, TV, music etc. if your child is trying to do homework.
• Limit choices so your child doesn’t become overwhelmed or distracted.
• Communicate better by using clear, brief directions that are more easily understood.
• Use positive reinforcement to track positive behaviors and then reward your child’s efforts. Remember to set realistic goals–this kind of progress is often measured in very small steps.
• Help your child discover something they are good at so they feel good about themselves. This builds confidence and self esteem.
• Adults with ADHD can also benefit from creating a routine, minimizing distractions, limiting choices, and organizing key materials. A spouse, family member or friend can help them create a system and a plan that works for them.

For most patients with ADHD, medication is a key part of treatment. It is not used to control behavior, but rather to help with the symptoms of ADHD so the person can function more effectively. Among the most common medications used are psychostimulants, which have a long history of proven success. Contrary to their name, these medications do not increase stimulation within the individual, but rather help important networks of nerve cells within the brain communicate more effectively with each other. Between 70 to 80 percent of children with ADHD respond positively to this type of medication. Common drugs in this class are Ritalin, Concerta, Metadate, Focalin, Dexedrine, Adderall, and Vyanse. A non-stimulant treatment that is highly effective in treating ADHD, particularly when associated with aggression and impulsivity, is guanfacine. In twice per day formulation it is called Tenex. In once per day controlled release formulation it is called Intuniv. Another non-stimulant to consider is Strattera.
Medication does not cure ADHD; it alleviates symptoms during the time it is active. Use of medication should be monitored on an ongoing basis, and the dosage may initially need to be adjusted to find the most effective amount and time of day for administration. With children, medication may also need to be adjusted as they grow.

ADHD can be managed, and with the correct treatment, those with the disorder can live happy productive lives.

Treating autism in adults or children usually requires a multi-disciplinary approach, but I can offer some insights into the condition itself, and the role a psychiatrist can provide in helping with this disorder.

What Is Autism?

Autism spectrum disorder (ASD) refers to a range of complex neurodevelopmental disorders. A person with autism typically has difficulty with social skills and communicating, and often exhibits restricted and repetitive patterns of behavior. The most severe form of autistic disorder is frequently called autism or classical ASD, while the milder form is known as Asperger’s Disorder. In between these two polar points are other variations of the disorder that vary widely from individual to individual. When a person fits the criteria of neither diagnosis, but is substantially affected by some of the symptoms, he or she may be appropriately diagnosed with pervasive development disorder not otherwise specified (PDD NOS).

Experts believe that some form of autism afflicts six children out of every 1,000. It is seen in every ethnic and socioeconomic group, and affects males four times more often than females.

What Are Common Signs of Autism?

A key autism indicator is impaired social interaction. A baby with ASD may be unresponsive to people or become fascinated with one item for long periods to the exclusion of all others. Children with the disorder may also appear to develop normally at first, then suddenly withdraw and avoid contact or interaction. They may fail to respond to their names and refuse to make eye contact. Social clues that are obvious to most people may make no sense to them and they do not respond to changes in tone of voice or facial expressions. They have difficulty understanding what others are thinking or feeling because they do not watch or interpret other people’s faces for clues about what is the correct intention or behavior.

Many children with ASD exhibit repetitive behaviors such as rocking, twirling, or even harmful behaviors such as biting and head-banging. They usually do not speak until later than usual, and when they do, may use a sing-song voice. They often do not know how to play or talk with other children and instead focus both their activities and speech on a narrow range of favorite topics.

Do Symptoms Change Over Time?

For many children, with proper treatment, symptoms can improve with age. However, there are other signs that should be watched for. Children whose language skills disappear early–such as before the age of 3–seem to have a higher risk of developing epilepsy or seizure-like brain activity, which may need to be controlled with medication. Some children with ASD may become depressed or exhibit behavioral issues when they reach adolescence. They may need treatment modification or medication at this time to help them as they transition to adulthood.

How Is Autism Treated?

There is no cure for ASDS. The therapies and behavioral interventions currently used are designed to remedy specific symptoms and can bring about significant improvement.

Most healthcare professionals agree that intervening at the earliest age possible can help achieve the greatest results when it comes to ASD. Typically, autism treatment involves educational/behavioral interventions, and often medication.

With educational/behavioral interventions, therapists use very structured and intensive training sessions to help children develop social and language skills.

A psychiatrist such as myself may also be called in to prescribe medications for treatment of specific autism-related symptoms such as anxiety, depression, or obsessive-compulsive disorder. Some antipsychotic medications are FDA approved to treat severe behavioral problems. Seizures can be treated with anticonvulsant drugs prescribed by a neurologist. The same medications used for treating people with attention deficit disorder can be used to help decrease impulsivity and hyperactivity.
With proper treatment, people with ASD can lead productive lives. They may continue to need services and a support network, but many are able to work and live independently.

Many of us have experienced times when our emotions seemed to be on a roller coaster, whether due to stress, fatigue, or hormonal issues. Usually, within a day or two, things settle down and our emotions are back on a more even keel. But for some people, the roller coaster never stops. Bipolar disorder, formerly called manic depression, creates extreme mood swings that range from the highest highs (mania or hypomania) to intense anger and irritability, to the deepest lows (depression). During the “high” times, those with bipolar disorder feel euphoric and full of energy, but then their mood shifts and they are plunged into depression. Now, they feel sad or hopeless, and often lose interest or pleasure in activities they normally enjoy.

Some may experience these mood shifts several times a week, while for others they may only occur every few months. In either case, bipolar disorder can be disruptive to having a normal life. Without treatment, it can cause problems at work, school and with relationships.

Are there different types of bipolar disorder?

Yes, there are actually several types, as well as related disorders. For each type, the symptoms can vary from person to person. In general, the changes in mood are usually severe enough to cause noticeable difficulty in dealing with daily life, and are not caused by alcohol, drug use or a medical condition. There may also be signs of unusual talkativeness or activity in a manic episode, or excessive sleeping or inability to function in a depressed episode. When depressed, patients may also demonstrate suicidal tendencies.

Doctors look to see if a manic episode has occurred and is followed by a depressed episode. Frequency, duration, and other factors then determine exactly which type of bipolar disorder (or related) a person has.

Is bipolar disorder ongoing?

Bipolar disorder is an illness that requires long-term treatment. Some people go for long periods without episodes, others “cycle” frequently through symptoms, while still others are influenced by the seasons. Whatever the circumstances, treatment is required and must be maintained to avoid relapses.

What causes bipolar disorder?

The exact causes are unknown, but several factors seem to be involved. People with bipolar disorder have physical changes in their brains. Scientists are still researching what these changes mean. There is also an imbalance in naturally-occurring brain chemicals called neurotransmitters; neurotransmitters play a significant role in bipolar and other mood disorders.

There may be a gene that causes bipolar disorder and researchers are pursuing this possibility. Bipolar disorder is more common in people who have a sibling or parent with the condition and may be inherited.

How is bipolar disorder treated?

Specific treatment varies according to the individual and the exact type of the disorder they are diagnosed with. Those with a bipolar disorder may also be prone to post-traumatic stress disorder, anxiety disorders, ADHD, substance abuse, and physical issues. It is important that these associated conditions also be treated.

In all cases, treatment is best undertaken by a professional with experience and expertise in this area. Typically, the first step after a full diagnosis is to prescribe medications to balance the mood swings. Once these are under control, additional medications may be prescribed to help with other symptoms, if present–anti-psychotics, antidepressants, and anti-anxiety medications may all be used if needed. Your physician will usually only add one drug at a time in order to evaluate which medication works best on which symptoms, and to try to find those drugs that cause the fewest side effects. Finding the right combination of prescriptions that work best can take some time as certain medications can take weeks to months to fully take effect.

Other treatments for bipolar disorders include psychotherapy. This may be done in a private setting or a group setting. A number of different therapy options may be suggested, including cognitive behavioral therapy, which identifies unhealthy and negative thoughts and behaviors and replaces them with positive ones, and interpersonal therapy, psychodynamic or social rhythm therapy, which helps patients stabilize daily rhythms such as sleeping, waking and meal times. Sticking to a consistent schedule can help individuals better manage their moods.

What about Transcranial Magnetic Stimulation (TMS)?

TMS may be recommended for those who have not responded to antidepressants. During TMS, the patient sits in a reclining chair with an electronic coil placed against their scalp. The coil sends magnetic impulses to the brain, targeting those areas that are involved n controlling mood and depression. The treatment is not painful and has proven very successful in many cases. Five to six weekly treatments are usually required in order to see results.

Changing Your Lifestyle Can Help

If you suffer from bipolar disorder, it is important to make healthy lifestyle changes. Do not drink and do not take illegal drugs. Get involved in positive activities that you enjoy. Keep busy and surround yourself with positive people. Get regular physical exercise. A good workout releases positive endorphins that make you feel better; it reduces stress, and will help you sleep. Getting plenty of good sleep is also key. If you are sleep deprived, you are more likely to be depressed or irritable. If sleeping well is an issue, talk with your doctor. Finding ways to reduce stress is also helpful, whether that means joining a support group, or taking up a proven relaxation activity such as yoga, tai chi or meditation.

Why is continuing treatment important?

People who discontinue treatment are at risk for having a relapse of symptoms. Such a relapse may not be minor, it could trigger an all-out manic or depressed episode. This could put them at risk for hospitalization or suicide.

How do I know if someone is bipolar?

If you or someone you love have symptoms of mania or depression, see your doctor or mental health provider right away. A mental health provider can diagnose the situation fairly quickly and start providing the help needed. Bipolar disorders do not get better on their own and can lead to even more serious issues, including risky behavior, drug use, alcohol abuse, and suicide. Bipolar disorder can occur in children and teens, although it is more difficult to diagnose in those age groups due to normal mood swings that typically occur. Still, if you have concerns, consult a mental health professional.

The good news is that bipolar disorder is very treatable and people with the condition can lead productive, fulfilling lives once treated. The sooner the illness is diagnosed and treated, the sooner quality of life can be restored.

We all have periods when we feel blue or “down in the dumps,” but when dark, sad moods become the norm, for us, or for a loved one, then depression may be the cause.

What is depression? It is a debilitating illness that can significantly compromise a person’s ability to enjoy their life and the companionship of others. It can reduce their capacity to be productive at school or at work. It can happen to anyone—young or old, male or female, and from any walk of life. While it is sometimes triggered by a significant event or a biological cause, it can also occur for no obvious reason, and in rare cases, be caused by medication.

Know the Signs

How do you know if you or a loved one is being affected by depression?
The classic symptoms include a persistently sad mood, irritability, an inability to enjoy activities that are usually a source of pleasure, fatigue, lack of energy, poor sleep (or increased sleep), guilt, excessive worrying, and a decline in what doctors call cognitive functioning– meaning memory, concentration, decision-making, and thinking clearly. A decline in sex drive, appetite, and interest in social interaction can also occur. Sometimes thoughts of suicide are also present, and this is obviously of significant concern.

If you, or a loved one, have a combination of these symptoms, a psychiatric evaluation is recommended.

What Happens During a Psychiatric Evaluation?

A psychiatric evaluation consists of a thorough review of a person’s history. The psychiatrist will ask about the current episode of depression and when those feelings began, as well as explore possible past episodes. Further areas of exploration include past psychiatric history, family psychiatric history, substance abuse history, trauma history, medical history, social history, and educational history (particularly important with children and adolescents). Stress factors that may be contributing to the depression are reviewed. Symptoms need to be clearly defined so they can be targeted and treated. We make sure to clearly identify the target areas so we can measure improvement.

Types of Treatment

Treatment for depression can take several forms. A number of types of psychotherapy can be used. Psychotherapy is a way of healing a mental disorder by psychological rather then medical means. I will provide referrals for psychotherapy if it is indicated and the patient does not presently have a therapist. As a psychiatrist (who is a medical doctor and can prescribe medications), I feel it is extremely important for anyone suffering from depression to become aware of the medication options that may be useful for treatment. I discuss these options thoroughly with my patients, including their pros and cons, along with the option for psychotherapy. This way, patients, or their family members, can make informed decisions as to what course of treatment may work best. Sometimes the choice is medication, sometimes therapy, and sometimes a combination is used.

The birth of a child is a wonderful event, and triggers many emotions. Most women experience some anxiety about caring for an infant and the responsibility a baby brings. But for some women, giving birth sends their emotions into a darker place, causing depression.

Postpartum depression is more than just the “baby blues”–those mood swings and crying spells caused by hormonal changes. Those quickly fade but postpartum depression lingers, and usually requires professional help to be resolved. Here are some common ways to tell the difference between postpartum depression and baby blues:

Symptoms

Baby Blues

The baby blues usually last only a few days or weeks; symptoms include:

• Mood swings
• Anxiety
• Sadness
• Irritability
• Crying
• Decreased concentration
• Trouble sleeping

  Postpartum Depression  

The symptoms for postpartum depression can be similar to the baby blues, but usually are more intense and last longer. They can also interfere with the mother’s ability to care for her baby or cope with daily life. Symptoms include:

• Loss of appetite
• Insom nia
• Overwhelming fatigue
• Loss of interest in sex
• Taking no pleasure in life
• Feelings of shame, guilt or inadequacy
• Severe mood swings
• Difficulty bonding with the baby
• Withdrawal from friends, family and social contact
• Untreated, postpartum depression can last a year or more.
  Signs of postpartum depression usually develop within four weeks of giving birth.

Impacts to Mother and Family

Sometimes postpartum depression can lead to a chronic depressive disorder. Even with treatment, postpartum depression can increase a woman’s risk for depression in the future. However, your doctor can help you identify possible triggers and signs to watch for so that such occurrences can possibly be avoided, minimized or treated as soon as possible if they do occur.

Postpartum depression affects the entire family. Left untreated, it can interfere with long-term mother-child bonding and cause future family problems. Children of depressed mothers are more likely to have behavioral problems such as difficulty sleeping and eating, frequent tantrums, and hyperactivity. Delays in language development are also common.

Postpartum depression can erode the bond between couples and dissolve relationships.

Common Causes

Postpartum depression can be caused by a number of physical, emotional and lifestyle issues. Here are some examples:

Physical: After childbirth, your body experiences a dramatic drop in hormones, particularly estrogen and progesterone. This drop can contribute to postpartum depression. Your thyroid hormones can also dip significantly, leaving you tired and depressed. Changes in your immune system, metabolism, blood volume and blood pressure can also contribute to fatigue and mood swings.

Emotional: If you are tired, it is easy to feel overwhelmed. Even minor problems can seem too much to cope with. As a new mother, you may be worried about caring for a new baby. You may not feel ready to be a mother or you may be concerned about your appearance. Some women feel that they no longer have control over their own lives–they feel like everything now and for years to come revolves around the child. These kinds of feelings can lead to postpartum depression.

Lifestyle: A new baby changes everyone’s schedule. These changes can be exhausting initially –even more so, if there are also other children in the family who also need attention. Some women have difficulty breast-feeding–which creates stress. Others may feel that their partners are not providing enough help with care of the baby, household, or other children. And some families are burdened with financial worries. All of these items can trigger postpartum depression.

Are You at Risk?

Postpartum depression can develop after the birth of any child, not just the first one. You may be at risk if you have these factors:

• You have a history of depression, either during pregnancy or at other times
• You had postpartum depression after a previous pregnancy
• You have experienced stressful events during the past year–such as illness, loss of job, or pregnancy complications
• You are having problems in your relationship with your spouse or significant other
• You don’t have a strong support system to help you
• You have financial problems
• The pregnancy was unwanted or unplanned

The risk of postpartum depression is also higher for women with bipolar disorder.

Treatments

If you have symptoms of postpartum depression, call your doctor–do not let shame or anxiety stop you. Postpartum depression is common–it is NOT your fault. But do get treatment as soon as possible.

Your doctor may suggest a referral to a psychiatrist and/or therapist to help you find better ways to cope with your feelings, solve problems and set realistic goals. Sometimes, having your spouse or family members attend such sessions with you can be helpful, too.

Medication may also be prescribed. Antidepressants are a proven treatment for postpartum depression, although if you are breast feeding you need to be aware that any medication you take will enter your breast milk. However, some antidepressants can be used during breast feeding with little risk of side effects for your baby. Your doctor can advise you.

Often, a combination of counseling, medication and lifestyle changes is recommended. With appropriate treatment, postpartum depression can wane within a few months. However, it is important to continue treatment even after you feel better. Stopping treatment too early can lead to a relapse.

What You Can Do

Postpartum depression does require professional treatment, but there are some things you can do that can help enhance the healing process.

• Make physical activity part of your daily routine–a walk, going to the gym–anything that gets you moving.
• Eat healthy foods and avoid alcohol.
• Lower your expectations–don’t expect to run the perfect household at this time. Don’t put pressure on yourself to accomplish an unrealistic list of tasks. Do what you can and don’t worry about the rest.
• Don’t be afraid to ask for help–with errands, childcare, getting meals–whatever needs doing.
• Make time for yourself. Take a break to do something you enjoy; be sure to keep connected socially. Make time for your partner.
• Avoid being alone too much. Talk with your family and friends about how you are feeling and encourage visits. Also make sure you get dressed and go out. Talk with other mothers about their experiences. Your doctor may be able to recommend support groups for postpartum mothers or new mothers.

With proper treatment, you, too can be enjoying this special time in your life as you welcome your new baby.

We hear a lot about post-traumatic stress disorder (PTSD) in terms of veterans who are afflicted. However, anyone who has suffered a horrifying event may experience PTSD. It is especially common among those who have served in combat, but it can also develop in people who have experienced rape, childhood neglect and physical abuse, sexual abuse, or being physically attacked or threatened. Cases have also been reported with people who have been through car accidents, plane crashes or natural disasters such as fires and hurricanes. Essentially, any terrifying experience can trigger PTSD.

What is PTSD?

Most people who go through a traumatic event have difficulty copying for awhile. They may experience nightmares, anxiety, or spells of uncontrollable crying, but usually, with time, rest and support from loved ones, they get better. However, in some cases, the symptoms of trauma get worse. In addition to nightmares, the victims experience flashbacks, severe anxiety, and cannot stop thinking about the event. In the worst cases, those traumatized are no longer able to function normally and have difficulty holding a job, maintaining relationships, and just getting through the day.

What are the symptoms?

PTSD symptoms are usually grouped into three types: intrusive memories, avoidance and numbing, and increased anxiety or emotional arousal (hyperarousal). Those suffering from intrusive memories may relive the event for minutes or days at a time, and also have disturbing dreams. Those who have become emotionally numb avoid talking about what happened to them; they no longer enjoy activities that once gave them pleasure; they feel hopeless about the future, and have trouble with concentration and memory lapses. Relationships are difficult to maintain. The third group, those with hyperarousal and anxiety, easily become irritable or angered, and often indulge in self-destructive behavior, such as drinking or drugs. They have trouble sleeping and are easily startled or frightened. They may see or hear things that are not there. This group also often feels overwhelming guilt or shame about the event–either about being victimized or surviving.

When do symptoms appear?

PTSD symptoms usually appear within three months of a traumatic event, but sometimes, they can take years to manifest themselves. PTSD symptoms can also come and go. If life is on an even keel, symptoms may retreat, but if things become stressful, they may reappear. Another traumatic event, like loss of a loved one, can also act as a trigger. Sometimes, seemingly harmless incidents can act as triggers, such as a car backfiring or fireworks causing combat vets to flashback.

When should you get help?

If symptoms of sadness, fear, lack of sleep, lack of concentration or mood swings continue for more than a month after experiencing a traumatic event, these could be signs of PTSD, and seeing a mental health provider is recommended. The earlier you start treatment for

PTSD, the better your chances of preventing symptoms from becoming worse, and starting your recovery.

PTSD can place you at risk for developing other mental health issues, such as depression, drug or alcohol abuse, and eating disorders. PTSD can also make you more prone to suicidal thoughts.

If you feel like you want to harm yourself or others at any point since the event, then you should seek emergency medical help immediately.

How is PTSD treated?

PTSD is usually treated with a combination of medication and psychotherapy. Medications can help alleviate symptoms of PTSD while therapy can teach patients skills for coping with what they experienced. Among the medications used are antipsychotics which can help relieve anxiety, difficulty sleeping and mood swings.

Antidepressants can help ease depression and anxiety, and also help you sleep better and improve concentration. Zoloft and Paxil are two that are frequently prescribed. Anti-anxiety medications may also be used to reduce feelings of anxiety and stress.

Patients suffering from repeated nightmares may also be prescribed Prazosin which can help suppress bad dreams.
Whatever medication, or combination of medications are used, patients frequently see improvement in mood and other symptoms within a few weeks.

In addition to traditional cognitive therapy, where you talk about what happened, PTSD patients today may also be helped by Exposure Therapy, which helps them safely face the very thing that traumatized them. Sometimes virtual reality programs are used to help them safely relive the experience and put the trauma to rest. This therapy has proven very effective with veterans of the Iraq War and the War in Afghanistan.

Other helpful tips:

You can also help control PTSD by taking care of yourself. Get enough rest,eat well, exercise, and avoid caffeine and nicotine which can make you feel more anxious. Do not turn to drinking and drugs for escape–they will not help you heal. Take up a hobby or sport so you have an outlet. Be sure to stay connected to family and friends and avoid becoming isolated. Even if you do not talk to them about the trauma, knowing that you have people around you who care is important. Finally, find a support group–people who have been through what you have been through can be lifelines when it comes to recovery. Your mental health care provider can help you find the right group.

The bottom line is, if you or a loved one, is suffering from PTSD, get help. What you experienced cannot be undone, but with treatment, you can overcome the suffering and reclaim your life.

Occasionally, doctors will have a patient who requires the use of multiple medications in order to best manage their care. I have had patients such as this, and the situation is not unusual. We call this practice “polypharmacy.” Let me explain how it works and why it can be necessary.

What is polypharmacy?

Polypharmacy is the term used to describe the prescription of a number of psychotropic medications simultaneously. (A psychotrophic drug is a psychiatric medication that alters chemical levels in the brain, thus affecting mood and behavior.) Polypharmacy generally involves a mixture of medications from different categories. When practiced correctly, it involves a step-by-step, logical approach towards treating targeted symptoms. With today’s newer and safer medications, it is becoming more common for psychiatrists to use a polypharmacy approach when a patient may see significant benefits from such treatment.

How does it work?

Polypharmacy generally involves the use of medications that have different neurotransmitter profiles. The goal is to cover one neurotransmitter system, allow time to assess the effectiveness of the treatment for that symptom, then once that is stable, add another medication which works on a different neurotransmitter. Although a person may end up taking multiple medications, each one has a unique effect, has limited overlap with the other, and has limited drug interactions.

Why is polypharmacy affective?

At times, an added medication may be used to increase the effect of a medication that is already being prescribed. For example, the traditional approach for treating a client with major depression would be to prescribe an antidepressant. Usually, this would be an antidepressant with a potent serotonergic effect (an SSRI). (A serotonergic effect is one that boosts feelings of well-being and aids in re-establishing normal sleep/awake patterns.) If this doesn’t work, the psychiatrist may change antidepressants, or he may add an antidepressant that increases dopamine and norepinephrine activity. (Increasing dopamine can improve mood as well as foster increased brain function and alertness.) In this case, two antidepressants are used simultaneously, but each works in a very different way.

Sometimes, an antidepressant alone is not enough; in those cases, the doctor may add on medications from other families of medicines. If anxiety is another predominant symptom, then Klonopin or Ativan may be added, or a medication that enhances the effect of the SSRI.

If the patient complains of intolerable mood swings, then a mood stabilizing medication may be added. If a patient has psychotic symptoms, or requires a stronger medication for mood stabilization or relaxation, then an antipsychotic medication could be added. Today, most doctors prefer using antipsychotic medications from the “atypical” class. While these are more expensive, they have superior safety profiles to older “typical” antipsychotic medications, with far fewer side effects.

Therefore, patients with difficult-to-treat psychiatric illnesses may be on a number of medications simultaneously. Each medication will represent a different class and will involve a different mechanism in terms of how it is used by the body. The more common polypharmacy regimens may involve one antidepressant, one mood stabilizer, one antipsychotic, and one anxiolytic.

In summary:

Polypharmacy must reflect a well-thought-out strategy by the physician. This strategy needs to address target symptoms, how each drug will work, the patient’s metabolism and ability to handle the medications, the potential for drug interactions, and possible side effects. When all are taken into account, and a carefully balanced plan is put into place, there can be significant benefit to the patient.