Symptoms of anxiety and depression increased in adults living in trigger states that immediately banned abortions after the US Supreme Court Dobbs decision overturned Roe v. Wade, which revoked a woman’s constitutional right to an abortion, new research shows. This could be due to a variety of factors, investigators led by Benjamin Thornburg, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, noted. These include fear about the imminent risk of being denied an abortion, uncertainty around future limitations on abortion and other related rights such as contraception, worry over the ability to receive lifesaving medical care during pregnancy, and a general sense of violation and powerlessness related to loss of the right to reproductive autonomy. The study was published online on January 23, 2024, in JAMA. Mental Health Harm In June 2022, the US Supreme Court overturned Roe vs Wade, removing federal protections for abortion rights. Thirteen states had "trigger laws" that immediately banned or severely restricted abortion — raising concerns this could negatively affect mental health. The researchers used data from the Household Pulse Survey to estimate changes in anxiety and depression symptoms after vs before the Dobbs decision in nearly 160,000 adults living in 13 states with trigger laws compared with roughly 559,000 adults living in 37 states without trigger laws. The mean age of respondents was 48 years, and 51% were women. Anxiety and depression symptoms were measured via the Patient Health Questionnaire-4 (PHQ-4). In trigger states, the mean PHQ-4 score at baseline (before Dobbs) was 3.51 (out of 12) and increased to 3.81 after the Dobbs decision. In nontrigger states, the mean PHQ-4 score at baseline was 3.31 and increased to 3.49 after Dobbs. Living in a trigger state was associated with a small but statistically significant worsening (0.11-point; P < .001) in anxiety/depression symptoms following the Dobbs decision vs living in a nontrigger state, the investigators report. Women aged 18-45 years faced greater worsening of anxiety and depression symptoms following Dobbs in trigger vs nontrigger states, whereas men of a similar age experienced minimal or negligible changes. Implications for Care In an accompanying editorial, Julie Steinberg, PhD, with University of Maryland in College Park, notes the study results provide "emerging evidence that at an individual level taking away reproductive autonomy (by not having legal access to an abortion) may increase symptoms of anxiety and depression in all people and particularly females of reproductive age." These results add to findings from two other studies that examined abortion restrictions and mental health outcomes. Both found that limiting access to abortion was associated with more mental health symptoms among females of reproductive age than among others," Steinberg pointed out. "Together these findings highlight the need for clinicians who practice in states where abortion is banned to be aware that female patients of reproductive age may be experiencing significantly more distress than before the Dobbs decision," Steinberg added. The study received no specific funding. The authors had no relevant conflicts of interest. Steinberg reported serving as a paid expert scientist on abortion and mental health in seven cases challenging abortion policies. Note: This article originally appeared on Medscape

NIH researchers found widespread differences in the brains of children with anxiety disorders that improved after treatment. Researchers at the National Institutes of Health have found overactivation in many brain regions, including the frontal and parietal lobes and the amygdala, in unmedicated children with anxiety disorders. They also showed that treatment with cognitive behavioral therapy (CBT) led to improvements in clinical symptoms and brain functioning. The findings illuminate the brain mechanisms underlying the acute effects of CBT to treat one of the most common mental disorders. The study, published in the American Journal of Psychiatry, was led by researchers at NIH’s National Institute of Mental Health (NIMH). “We know that CBT is effective. These findings help us understand how CBT works, a critical first step in improving clinical outcomes,” said senior author Melissa Brotman, Ph.D., Chief of the Neuroscience and Novel Therapeutics Unit in the NIMH Intramural Research Program. Sixty-nine unmedicated children diagnosed with an anxiety disorder underwent 12 weeks of CBT following an established protocol. CBT, which involves changing dysfunctional thoughts and behaviors through gradual exposure to anxiety-provoking stimuli, is the current gold standard for treating anxiety disorders in children. The researchers used clinician-rated measures to examine the change in children’s anxiety symptoms and clinical functioning from pre- to post-treatment. They also used task-based fMRI to look at whole-brain changes before and after treatment and compare those to brain activity in 62 similarly aged children without anxiety. Children with anxiety showed greater activity in many brain regions, including cortical areas in the frontal and parietal lobes, which are important for cognitive and regulatory functions, such as attention and emotion regulation. The researchers also observed elevated activity in deeper limbic areas like the amygdala, which are essential for generating strong emotions, such as anxiety and fear. Following three months of CBT treatment, children with anxiety showed a clinically significant decrease in anxiety symptoms and improved functioning. Increased activation seen before treatment in many frontal and parietal brain regions also improved after CBT, declining to levels equal to or lower than those of non-anxious children. According to the researchers, the reduced activation in these brain areas may reflect more efficient engagement of cognitive control networks following CBT. However, eight brain regions, including the right amygdala, continued to show higher activity in anxious compared to non-anxious children after treatment. This persistent pattern of enhanced activation suggests some brain regions, particularly limbic areas that modulate responses to anxiety-provoking stimuli, may be less responsive to the acute effects of CBT. Changing activity in these regions may require a longer duration of CBT, additional forms of treatment, or directly targeting subcortical brain areas. “Understanding the brain circuitry underpinning feelings of severe anxiety and determining which circuits normalize and which do not as anxiety symptoms improve with CBT is critical for advancing treatment and making it more effective for all children,” said first author Simone Haller, Ph.D., Director of Research and Analytics in the NIMH Neuroscience and Novel Therapeutics Unit. In this study, all children with anxiety received CBT. For comparison purposes, the researchers also measured brain activity in a separate sample of 87 youth who were at high risk for anxiety based on their infant temperament (for example, showing a high sensitivity to new situations). Because these children were not diagnosed with an anxiety disorder, they had not received CBT treatment. Their brain scans were taken at 10 and 13 years. In adolescents at temperamental risk for anxiety, higher brain activity was related to increased anxiety symptoms over time and matched the brain activity seen in children diagnosed with an anxiety disorder before treatment. This provides preliminary evidence that the brain changes in children with anxiety were driven by CBT and that they may offer a reliable neural marker of anxiety treatment. Anxiety disorders are common in children and can cause them significant distress in social and academic situations. They are also chronic, with a strong link into adulthood when they become harder to treat. Despite the effectiveness of CBT, many children continue to show anxiety symptoms after treatment. Enhancing the therapy to treat anxiety more effectively during childhood can have short- and long-term benefits and prevent more serious problems later in life. This study provides evidence—in a large group of unmedicated youth with anxiety disorders—of altered brain circuitry underlying treatment effects of CBT. The findings could, in time, be used to enhance treatment outcomes by targeting brain circuits linked to clinical improvement. This is particularly important for the subset of children who did not significantly improve after short-term CBT. “The next step for this research is to understand which children are most likely to respond. Are there factors we can assess before treatment begins to make the most informed decisions about who should get which treatment and when? Answering these questions would further translate our research findings into clinical practice,” said Brotman. This article originally appeared on www.nimh.nih.gov

Sleep regularity may be a risk factor for dementia among older individuals. Inconsistent sleep patterns and sleep irregularity may be a risk factor for incident dementia among older individuals, according to study findings published in Neurology. Researchers conducted a study in participants sourced from the UK Biobank, and reported on the link between sleep regularity and risk for incident dementia. The participants were recruited between 2006 and 2010. The Sleep Regularity Index (SRI) was determined by averaging the likelihood of being in the same asleep/wake state at 2 time points which took place 24 hours apart, observed throughout a 7-day accelerometry period. The final analysis comprised a total of 88,094 participants (average age, 65; 56% women) with a median follow-up period of 7.2 years. During this time, there were 480 cases of incident dementia. This group of participants demonstrated a median SRI of 60. Available evidence suggested a non-linear relationship between SRI and the risk for dementia, displaying hazard ratios with a U-shaped pattern. Dementia rates reached their highest point at lower SRI levels, decreased to a minimum around the median (SRI = 60), and then slightly increased with higher SRI levels. When compared to the median SRI of 60, participants with an SRI at the 5th percentile (SRI = 41) had hazard ratios (HRs) of 1.53 (95% CI, 1.24–1.89). Conversely, for individuals with an SRI at the 95th percentile (SRI = 71), the HR was 1.16 (95% CI, 0.89–1.50). The association between SRI and dementia remained consistent throughout the follow-up period. In a subgroup analysis consisting of 15,263 individuals who underwent brain magnetic resonance imaging (MRI), the researchers observed an inverted U-shaped association between SRI and volumes of gray matter (P =.038) and the hippocampus (P =.035). Volumes continued to increase until the SRI reached the median, after which they started to decrease. The researchers also saw a similar association with reduced gray matter volume and hippocampal volume in individuals at the extremes of SRI. They believe that “both extremes if the SRI are linked to adverse brain health outcomes.” The conclusions drawn from this study may have limitations due to the association between SRI and dementia, potential influence from unmeasured confounding factors, and the possibility of reverse causation. “Future studies are required because, even in individuals with normal sleep durations, improvement of sleep timing schedules may represent a potential target for the primary prevention of dementia,” the researchers concluded. This article originally appeared on Neurology Advisor

SPECIAL REPORT: TREATMENT-RESISTANT DEPRESSION DIAGNOSIS The goal of this Special Report is to help you manage treatment-resistant depression (TRD) as best as possible while minimizing harm. This requires first recognizing the kind of depression with which your patient presents to ensure the treatment strategy is the most appropriate. As none of the historical terms (eg, neurotic, psychotic, melancholic) or DSM terms (eg, dysthymia, major depression, mixed features) are distinct biological entities, let us turn to etiology for a better understanding and a refined diagnosis. In my experience, there are 5 kinds of common clinical depression, worth differentiating in that they call for varying treatments (Table). This list is not exhaustive, but the 5 types probably account for most of the depressions seen in clinical practice. Importantly, each type responds best with different approaches. Psychosocial Stressors Halting or decreasing stress is obviously the most direct treatment, but often that is not feasible. Psychosocial stressors can be directly addressed with several forms of psychotherapy. For millennia, the principles of cognitive behavior therapy (CBT) have helped individuals manage situations they cannot change. Aaron T. Beck, MD, a founder of CBT, quoted the Roman emperor Marcus Aurelius: “If thou are pained by any external thing, it is not the thing that disturbs thee, but thine own judgment about it. And it is in thy power to wipe out this judgment now.” Likewise, interpersonal therapy (IPT) could also directly address the source of the problem. But IPT is much less widely available than CBT, especially because a basic version of CBT can be procured via apps that have shown to be nearly as effective as individual CBT from a live therapist, and equally effective if provided with some telephone and text support. Do antidepressants help in chronic psychosocial stress? For many individuals, the answer is yes. However, concern has been raised that the main benefit of antidepressants in this context is an emotional blunting.This sounds like the effects of CBT, but CBT does not blunt other emotional responses, as has been described for antidepressants in 20% to 94% of patients,5 and in asymptomatic volunteers. Childhood Trauma Teicher et al7 noted that childhood trauma is associated with “a cascade of molecular and neurobiological transformations that distinguish patients with maltreatment histories from their nonmaltreated counterparts.” They cited results from the international Study to Predict Optimized Treatment for Depression (NCT00693849), which found that antidepressants led to remission in 84% of patients with no abuse history versus only 16% of those with such a history. Childhood trauma is also associated with a worse outcome in psychotherapy trials.9 However, a recent trial compared cognitive processing therapy (CPT) with a posttraumatic stress disorder (PTSD)-focused variation of dialectical behavior therapy (DBT-PTSD).10 Symptomatic remission, including depression symptoms, was achieved in 58% of the DBT-PTSD participants and 41% of the CPT participants. At minimum, these data suggest that psychotherapy is an important treatment modality to consider for patients with a history of childhood trauma. Medical Conditions and Treatments Depression secondary to a medical condition or treatment may be addressed by resolving the medical issue or switching the medical treatment. However, that too may not be easy or completely feasible. There are some new developments in this area. The advent of neuroactive steroids for postpartum depression is an exciting advance; and yet, as always, any new treatment carries unknown risks that only reveal themselves with years of use. In addition to (or instead of) antidepressants, a modality like behavioral activation therapy (BAT) might be worth considering. For example, the Medical University of South Carolina Hollings Cancer Center is studying an app-based version of BAT11 that has shown evidence of efficacy in depression. Bipolar Depression Patients with TRD have high rates of bipolarity. In one specialty clinic, for instance, 80% of patients referred with TRD had enough bipolarity to warrant switching to a mood stabilizer–based regimen. Failure to recognize subtle bipolarity can lead to multiple trials of antidepressants. For example, in one psychiatric consultation program where undetected bipolarity was common, patients received an average of 2.7 antidepressants before referral. Antidepressants can induce manic episodes and mixed states, although this is relatively uncommon. Thus, antidepressant monotherapy is not recommended in mixed states.17-19 Mood stabilizers are the principal option. When patients are taking a mood stabilizer as well as an antidepressant and are still having mixed state symptoms, clinicians can consider tapering the antidepressant. In one case series, this was associated with a reduction in suicidality as well as anxiety. Although awaiting replication, a study (NCT02519543) from Calkin et al (recipient of the 2023 Best Paper award from the American Society of Clinical Psychopharmacology) suggested that metformin may have an antidepressant effect in select patients with treatment- resistant bipolar depression. Among participants whose insulin resistance reverted to normal on metformin, 80% met response criteria on the Montgomery-Asberg Depression Rating Scale versus 40% of those who did not convert. Other Presentations of MDD The usual list of antidepressant alternatives may be considered (eg, a different psychotherapy; lithium or thyroid augmentation; and light therapy, even in nonseasonal depression), along with some exciting new options. New treatments also have potential applicability in the other kinds of depression. For example, the putative mechanism of psilocybin in depression—Default Mode Network modulation—makes it worth considering for patients with trauma histories as well as major depression. Concluding Thoughts The adage, “When your treatment is not working, question your diagnosis” is still an important one when faced with potential TRD. Are there some treatments that might better target the depression? In reframing the type of depression, we can also reframe what constitutes an “antidepressant,” and choose the safest, most effective treatment for each patient. Although they can be tremendously helpful—indeed, lifesaving—antidepressants carry substantial risks, sometimes with only moderate potential for benefit relative to placebo. With all of this in mind, TRD remains a challenge. The authors contributing to this Special Report will share their perspectives and strategies to further support you and your patients.

The nationwide shortage of stimulant medications approved for the treatment of attention-deficit/hyperactivity disorder (ADHD) remains unresolved nearly 1 year after the US Food and Drug Administration (FDA) first announced a shortage of the short-acting stimulant Adderall (amphetamine mixed salts).1 More recently, supply chain issues have expanded to include other central nervous system (CNS) stimulants used in ADHD treatment, including methylphenidate and lisdexamfetamine. At the time of this reporting, both immediate-release and extended-release formulations of these medications are affected by the shortage, and extended-release oral suspension amphetamine is the only ADHD stimulant drug that is not currently in shortage, according to the US Food and Drug Administration’s (FDA’s) Drug Shortages database. The limited availability of these medications has been linked to various factors, including manufacturing delays and below-quota production of amphetamine products that has resulted in a shortage of at least 1 billion doses. In addition, there has been an unprecedented increase in the number of Adderall prescriptions that reportedly exceeds the number of individuals with a formal ADHD diagnosis. The surge in prescription rates for Adderall and its generic has been partly attributed to unlawful telehealth-based prescriptions from direct-to-consumer companies that increased substantially during the early part of the COVID-19 pandemic. This occurred after the US Drug Enforcement Administration (DEA) suspended the requirement for an in-person evaluation before controlled substances could be prescribed. Michael Bloch, MD, MS, associate professor and director and co-founder of the Pediatric Depression Clinic in the Child Study Center at Yale School of Medicine in New Haven, Connecticut, and Ty Schepis, PhD, professor of psychology at Texas State University in San Marcos spoke with about key considerations regarding appropriate prescribing practices for ADHD medications as well as alternate treatment strategies to be considered as the ADHD drug shortage continues. Dr Bloch recently co-authored a paper describing best practices for the online assessment and treatment of ADHD. Dr Schepis has co-authored studies funded by the FDA and the National Institute on Drug Abuse (NIDA) that investigated the nonmedical use of prescription stimulants and the use of illicit stimulants among adolescents taking prescribed ADHD pharmacotherapy. What is the proper process for prescribing of ADHD stimulant medications? Dr Bloch: The proper process for prescribing ADHD stimulant medications involves first doing a thorough evaluation of the patient which would involve personally examining them to verify the diagnosis and doing rating scales of ADHD symptoms. Generally, an ADHD diagnosis requires verification that the symptoms occur in multiple settings such as school, work, home, and during examination. Dr Schepis: Proper prescribing starts with establishing an ADHD diagnosis and ruling out other potential causes for the person’s symptoms. Sometimes, symptoms of conditions like anxiety disorders overlap with those of ADHD, such as increased distractibility and inattention, so other potential diagnoses need to be ruled out. If someone comes in with a preexisting ADHD diagnosis, a clinician may still want to gather information and make their own formal diagnosis, given the risks associated with prescription stimulant misuse and diversion. Once the diagnosis is made, the process of finding the ideal medication dose through careful titration is the next step. This can be a longer process, depending on the individual’s medication response and their experience of side effects. What are some questionable prescribing practices that may occur with stimulant medications for patients with ADHD, and what are some of the risks that may result from improper prescribing? Dr Bloch: The most questionable prescribing practices that I have heard about are prescribers not personally examining patients or doing a thorough examination. I believe that the time and efficiency pressures of the current practice environment, along with economic incentives in diagnosing and treating patients in less time, has exacerbated the situation. Dr Schepis: With increased use of telehealth during the COVID-19 public health emergency, there are legitimate concerns that people were prescribed stimulant medication without undergoing a careful ADHD diagnosis. Individuals who receive stimulant medication without an ADHD diagnosis often do not benefit in the ways that they anticipate or hope, and their risk for side effects lead to greater potential harms than benefits from the medication. With a thorough diagnosis and good communication with the patient, risks from prescribing should be minimal. What adverse events might occur in patients taking stimulant medications for ADHD, and how should those be addressed in clinical practice? Dr Bloch: The most common adverse events with stimulants are poor appetite and insomnia. These symptoms improve when the stimulant medication is out of the patient’s bloodstream. These side effects are also a common reason that individuals misuse these medications — so they can lose weight and stay up later, often to study. Typically, the best way to manage the side effects is to make the patient aware of them and then discuss how to manage the side effects when they occur — for example, lower the dosage, switch formulations, or take the medication earlier. Immediate-release generic amphetamines have been the most consistently back-ordered ADHD meds. How should clinicians pivot patients who are taking ADHD medications that are currently unavailable? Dr Bloch: I tend to encourage my patients to take longer-acting stimulants regularly, so the shortage has certainly affected my patients less than others. I would encourage prescribers to transition patients who benefit from stimulant medications to transition to longer-acting formulations and take them regularly. Many long-acting forms of amphetamine are available, although many of those have gotten caught up in the shortage as well as prescribers are generally all transitioning to the same alterative medications, and that leads to another shortage. Dr Schepis: Considering a similar amphetamine can be the next step, but transitions from a generic to brand name medication or between different generic amphetamines can lead to restarting the process of titration and dealing with side effects. Switching to a branded amphetamine may not be allowed by insurance or it could be cost-prohibitive, and even then, most generic and branded formulations have subtle differences that can require changes to dosing. What are some alternate treatment options — including nonpharmacologic strategies — that may be used for patients who can’t access prescribed ADHD drugs affected by the ongoing shortage? Dr Bloch: A lack of access to stimulant medications for patients who benefit from them can cause a major worsening of their ADHD symptoms. By far, the most effective intervention is to find a suitable replacement medication. There are nonstimulant medications and nonmedication interventions for ADHD, but generally these interventions take several weeks or months to reach full efficacy, so they really are not great short-term replacement for stimulants. That being said, over the long run they can decrease the need for and needed dosage of stimulant medication. Dr Schepis: There are options that include pharmacologic agents like atomoxetine, clonidine, and guanfacine, but the consensus is that these nonstimulant medications are not as effective as stimulant medications for ADHD. There is a new nonstimulant, viloxazine, but there is not the level of data on it that exists for older nonstimulants. For nonpharmacologic treatments, cognitive-behavioral therapy (CBT) is the best behavioral treatment for ADHD, but the consensus is that it needs to be part of a multi-modal treatment regimen that includes medication — ideally, stimulant medication. While I would strongly recommend CBT be part of treatment, it takes weeks to be effective as the patient builds skills and improves coping techniques — that kind of learning and behavior change takes time. If a stimulant medication is not available or not an option, CBT and a nonstimulant medication is probably the best option, with the strongest evidence for atomoxetine as a nonstimulant pharmacotherapy. This article originally appeared on Neurology Advisor

SPECIAL REPORT: CLINICAL COMPLICATIONS OF COMORBIDITIES FAQ How can hospital staff provide the most effective care to patients with comorbid medical illness and serious mental illness? Following is a discussion about these comorbidities, the 7 personality types, and best practices for hospital staff to follow in treating patients with each personality type. What Makes Comorbidities Important? Psychiatrists see many patients who have comorbid psychiatric disorders such as a substance use disorder and a mood disorder, or epilepsy and psychogenic nonepileptic seizures. The most common comorbidities are medical disorders and personality traits and/or disorders. Psychiatrists in every setting encounter these individuals; however, the comorbidity is most common in the consultation-liaison experience. Here personality traits or disorders can create problems in the treatment of patients with complex medical illness. Why Does This Happen? Serious medical illness is a regressive experience. The individual who is hospitalized with a serious medical illness is placed in a position of depending on others, akin to the experience of being a child. Regression can be seen as using coping skills from an earlier stage in life or using less mature defenses. The regression can be quite adaptive (eg, allowing other individuals to take care of them without feeling that they have lost control). Patients are typically dressed in hospital gowns; they may have to relinquish control of toileting or feeding. Patients may have to relinquish the accoutrements of business life such as cell phones and computers, and in some cases, they must allow a machine to breathe for them. The individual may accommodate in an adaptive or a maladaptive way, influenced by their personality style. For critically ill patients, the severity of the illness can be maximally disruptive to their typical coping mechanisms. What Are the 7 Personality Types and How Do They Differ in the Ability to Cope With Serious Medical Illness? Kahana and Bibring outlined 7 personality types in 1964.1 Geringer and Stern2 modernized these descriptions in a later paper. The 7 types are dependent, obsessional, histrionic, masochistic, paranoid, narcissistic, and schizoid (Figure1,2). These do not match exactly to the DSM-5-TR personality disorders, but they are useful concepts to understand how different types of individuals cope with illness. For each type there are differences in the meaning of being ill, how the individual interacts with medical staff (transferences), and how staff respond to the individual (countertransference). Managing countertransference and providing care unique to each type of individual can reduce the stress on patient and hospital staff. Can You Review Each of These Personality Types? The dependent personality type tends to be needy, demanding, and clingy. They may be unable to reassure themselves and thus repeatedly seek reassurance from the medical staff. Illness is experienced as a threat of abandonment. Initially, hospital staff may feel important and needed, but the constant need for reassurance leads to staff feeling annoyed or overwhelmed. This may result in them avoiding the patient, which increases the individual’s fear of abandonment. Scheduling time-limited visits, providing realistic reassurance, and employing other resources for supporting the patient help mitigate the negative feelings and create a successful hospital stay. The obsessional personality type likes to feel in control and may be meticulous about details. They may focus on what is “right” or “wrong” in the care they receive. The illness stimulates fears of losing control over their body, emotions, or impulses. Initially we may admire their attention to detail, but repeated questioning, especially when the questions have been thoroughly answered, can feel draining for the staff. The patient may research the illness and therapies, resulting in the physician feeling that the patient does not trust them. Respecting the patient’s need for detail, giving them “homework” between visits, and creating a collaboration with the patient will work against a battle of wills between the patient and the staff. Histrionic patients may initially be entertaining, although they can be melodramatic. They can be enticing and seductive in their interactions with staff. Illness stimulates their fears of not being loved or loss of attractiveness. Initially the patient may seem attractive, but when the patient is seductive, that generates discomfort in the staff who may then confront the patient. Seduction may come in the form of gifts or offering tickets to special events. Maintaining clear boundaries of what is and what is not permissible, providing warmth within a framework of formality, and encouraging the patient to discuss their fears creates an environment in which patient and staff all feel safe. The masochistic patient seems to be a long-suffering, perpetual victim. They may experience illness as a punishment, although this is often not conscious. Such patients may anger staff who think the individual “wants to be ill” or does not want to recover. Staff may feel helpless in their experience of the patient’s apparent need to suffer. Avoid being too positive, which may increase the individual’s unconscious need to suffer. The acceptance of the individual’s experience of suffering, while encouraging them to recover as a “responsibility” to family and friends, can guide the patient through the hospital stay. Paranoid personality types view the world with suspicion. They fear they will be taken advantage of by hospital staff. Illness can be experienced as the world is against them. Medical procedures may be viewed as an exploitation. When kept waiting for a procedure longer than expected, the patient may then refuse the procedure, not accepting that the delay was not targeted at them. Not surprisingly, staff may feel they are being attacked, feel defensive, and experience anger toward the patient. Acknowledging how the patient feels, while presenting the reality of what happens in hospitals, avoids unproductive confrontation. Narcissistic personality types can seem arrogant, self-important, and devaluing of staff. They may question why a student or resident is involved in their care, as they expect the head of the department to be their physician. Illness threatens their fears of being vulnerable and unimportant. They may not have lofty positions in everyday life, but they portray themselves as VIPs with expectations of special treatment. Patients can delay examinations or procedures, claiming they must attend to more important business such as talking on their cellphone. Staff may be treated as though they are inferior to the person, or as being privileged to take care of such an important individual. When devalued by the patient, staff may wish to counterattack with “Who do you think you are?” types of comments. However, these comments only escalate the situation. Encouraging the patient to be collaborative by reframing their entitlement as someone who can understand that not everyone is as perfect as are they helps them to be magnanimous and accepting. Schizoid personalities may appear aloof, remote, or odd. Illness is experienced as a potential and frightening intrusion. Staff may find it difficult to engage with the individual and thus avoid interactions. Maintaining an active involvement, while respecting the individual’s need for privacy, aids in the patient’s treatment; however, not allowing the patient to completely withdraw also is important to a successful hospitalization. These patients benefit from knowing the routine of procedures, meals, and medication administration. Thinking through how each personality type copes with the stress of a serious medical illness prepares us to be the most understanding of their experience. Patients with personality disorders are particularly vulnerable when medically hospitalized. Nevertheless, every patient deserves the best care, which we can help our colleagues provide as part of the consultation-liaison psychiatry interaction both with patients directly and with hospital staff. Post written by Psychiatric Times

This is my prior painting with aspects or elements of St. Louis. Thus, far I have really enjoyed living in St. Louis, based the environment, the culture, the people, the rich history, and amazing architecture. Its been an incredible experience learning how to paint as an adult, as art was a big part of my childhood. I use to love creating art as a child, particularly drawing cars, maybe it has been a long standing obsession =) However, as I got older a majority of my time was dedicated towards academic pursuits that I kind left that enjoyment behind. But, I have learned a lot about life through painting. Painting has taught me that its important to recognize that something that you view as a "mistake" could be easily be corrected and its important not to dwell on such "imperfections". Also doing something consistently will help you become better at a skill or trait, before you leap to negative conclusions about your ability. I think its has taught me to be more creative and free-spirited, as there is no right or wrong way of expressing yourself. Its pretty cool to try new things and challenge yourself to become better at a craft, while enjoying the process and growth. I guess there will never be a destination for me when it comes to art, but rather a journey. Here is another painting I made for my Child Psychiatry program Washington University at St. Louis. If you like my paintings and want to see all of my art collection. You can look at my public social media pages. Follow my Art Page, if interested Source: Vilash Reddy, MD

Gaslighting is a type of manipulation that causes a person to doubt their own beliefs, sanity, or memory. Gaslighters undermine the trust a person has in their reality. They create a world in which the victim’s point of view is untrustworthy, dysfunctional, or wrong. Rather than a single event, gaslighting tends to occur over weeks or years. The gaslighter steadily chips away at the victim’s self-confidence and well-being. Over time, the victim’s self-doubt can lead them to feel confused, scared, and unhappy. Gaslighting can occur in romantic relationships, friendships, families, and in the workplace. Why Do People Gaslight? Gaslighting is often used as a method of control over another person. When someone begins to doubt their own memory or sanity, they may come to depend on the gaslighter to make sense of things. In this way, the gaslighter is elevated to a position of power or authority. Additionally, gaslighting invalidates the victim’s point of view. The victim is made out to be wrong or not to be trusted, so that the gaslighter always has the upper hand in the relationship. The gaslighter becomes the only one in the relationship who can be trusted. How Does Gaslighting Work? The gaslighter convinces the victim they are wrong, misremembering, or are mentally unwell. They might say things such as “that never happened” or “you’re crazy.” Initially, the victim may not be convinced. However, the gaslighter is persistent, and over time the victim comes to believe the gaslighter’s point of view. Gaslighters often enlist others—friends, children, or other family members—to bolster support for their tactics. For example, they may tell others that the victim is “crazy” and is not to be trusted. The Experience of a Gaslighting Victim A victim of gaslighting is likely to feel deep self-doubt. Additionally, they may feel confused, hurt, and sad. How to Defend Against Gaslighting

Imposter Syndrome: Why You May Feel Like a Fraud Imposter syndrome is that uncomfortable feeling you experience when you think you're unqualified and incompetent. You might look around and assume everyone knows what they're doing except you. And if you achieve something good, you'll chalk your accomplishments up to “good luck.” It’s normal to feel out of place or doubt yourself occasionally. But if you have these feelings most of the time, you may be experiencing imposter syndrome. Imposter syndrome refers to long-lasting feelings of unworthiness that don’t match up with the facts or others’ perceptions. The key feature of imposter syndrome is a persistent fear of being exposed as a fraud.

Riding the Craving Wave Urge Surfing is a technique for managing your unwanted behaviors. Rather than giving in to an urge, you will ride it out, like a surfer riding a wave. After a short time, the urge will pass on its own. This technique can be used to stop or reduce drug and alcohol use, emotional reactions such as “blowing up” when angry, gambling, and other unwanted behaviors.

Coming out is a process of acknowledging your sexual orientation or gender identity and choosing to share this with others. This process is unique to each person.

People with hoarding disorder have persistent difficulty getting rid of or parting with possessions due to a perceived need to save the items. Attempts to part with possessions create considerable distress and lead to decisions to save them. The resulting clutter disrupts the ability to use living spaces (American Psychiatric Association, 2013). Hoarding is not the same as collecting. Collectors typically acquire possessions in an organized, intentional, and targeted fashion. Once acquired, the items are removed from normal usage, but are subject to being organizing, admired, and displayed to others. Acquisition of objects in people who hoard is largely impulsive, with little active planning, and triggered by the sight of an object that could be owned. Objects acquired by people with hoarding lack a consistent theme, whereas those of collectors are narrowly focused on a particular topic. In contrast to the organization and display of possessions seen in collecting, disorganized clutter is a hallmark of hoarding disorder. The overall prevalence of hoarding disorder is approximately 2.6%, with higher rates for people over 60 years old and people with other psychiatric diagnoses, especially anxiety and depression. The prevalence and features of hoarding appear to be similar across countries and cultures. The bulk of evidence suggests that hoarding occurs with equal frequency in men and women. Hoarding behavior begins relatively early in life and increases in severity with each decade. Consequences Hoarding disorder can cause problems in relationships, social and work activities, and other important areas of functioning. Potential consequences of serious hoarding include health and safety concerns, such as fire hazards, tripping hazards, and health code violations. It can also lead to family strain and conflicts, isolation and loneliness, unwillingness to have anyone else enter the home, and an inability to perform daily tasks, such as cooking and bathing in the home. Diagnosing Hoarding Disorder Specific symptoms for a hoarding diagnosis include (American Psychiatric Association, 2013): Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, or the authorities).” The hoarding causes major distress or problems in social, work or other important areas of functions (including maintaining a safe environment for self and others). An assessment for hoarding may include questions such as: Do you have trouble parting with possessions (such as discarding, recycling, selling or giving away)? Because of the clutter or number of possessions, how difficult is it to use the rooms and surfaces in your home? To what extent does your hoarding, saving, acquisition and clutter affect your daily functioning? How much do these symptoms interfere with school, work or your social or family life? How much distress do these symptoms cause you? Mental health professionals may also ask permission to speak with friends and family to help make a diagnosis or use questionnaires (rating scales) to help assess level of functioning. Some individuals with hoarding disorder may recognize and acknowledge that they have a problem with accumulating possessions; others may not see a problem. Excessive acquisition occurs in the vast majority of cases and—although not a core diagnostic feature—should be carefully monitored. In addition to the core features of difficulty discarding and clutter, many people with hoarding disorder also have associated problems such as indecisiveness, perfectionism, procrastination, disorganization and distractibility. These associated features can contribute greatly to their problems with functioning and the overall severity. Animal hoarding may form a special type of hoarding disorder and involves an individual acquiring large numbers (dozens or even hundreds) of animals. The animals may be kept in an inappropriate space, potentially creating unhealthy, unsafe conditions for the animals. People who hoard animals typically show limited insight regarding the problem. Many people with hoarding disorder also experience other mental disorders, including depression, anxiety disorders, attention deficit/hyperactivity disorder or alcohol use disorder. Causes and Risk Factors The cause of hoarding disorder is unknown. Due to its recent classification, the neurobiology of hoarding disorder in humans is a newly burgeoning field; making it somewhat premature to draw firm conclusions. Hoarding is more common among individuals with a family member who also has a problem with hoarding. A stressful life event, such as the death of a loved one, can worsen symptoms of hoarding. Hoarding disorder has a symptom profile, neural correlates, and associated features that differ from OCD and other disorders. A number of information processing deficits have been associated with hoarding; including planning, problem-solving, visuospatial learning and memory, sustained attention, working memory, and organization. Hoarding behaviors appear relatively early in life and then follow a chronic course. Most studies report onset between 15 and 19 years of age. Early recognition, diagnosis, and treatment are crucial to improving outcomes. Treatment Treatment can help people with hoarding disorder to decrease their saving, acquisition, and clutter, and live safer, more enjoyable lives. Randomized controlled trials have established cognitive behavioral therapy (CBT) for hoarding disorder as an effective treatment. During CBT, individuals gradually learn to discard unnecessary items with less distress—diminishing their exaggerated perceived need or desire to save these possessions. They also learn to improve skills such as organization, decision-making, and relaxation. Despite the effectiveness of CBT for hoarding disorder, a substantial number of hoarding disorder cases remain clinically impaired by their hoarding symptoms after treatment. Regarding medication treatment, studies of hoarding disorder psychopharmacology have been small and open-label, which limit the conclusions that can be drawn from this literature. To date, there are no controlled trials to support efficacy. Despite this, there is some evidence of benefit from paroxetine, venlafaxine extended-release, amphetamine salts, methylphenidate, methylphenidate extended-release, and atomoxetine. There are no data on comparative efficacy between these drugs. These drugs should be considered only after better proven treatments—including cognitive behavioral therapy for hoarding disorder—have been attempted. For some people, medications are helpful and may bring improvement in symptoms. If you or someone you know is experiencing symptoms of hoarding disorder, contact your doctor or mental health professional. In some communities, public health agencies can assist in addressing problems of hoarding and getting help for individuals affected. In some instances, it may be necessary for public health or animal welfare agencies to intervene. Hoarding assessment scales: Structured Interview for Hoarding Disorder (Nordsletten, et al., 2013) Clutter Image Rating (Frost et al., 2008) Saving Inventory-revised (Frost et al, 2004) Hoarding Rating Scale-Interview (Tolin et al, 2010) Source: International OCD Foundation