Lexapro is a SSRI approved by the FDA for the treatment of generalized anxiety disorder in pediatric patients aged 7 years and older. The Food and Drug Administration (FDA) has approved Lexapro (escitalopram) for the treatment of generalized anxiety disorder (GAD) in pediatric patients 7 years of age and older. Previously, the treatment had only been approved for adult patients. Lexapro is a selective serotonin reuptake inhibitor (SSRI). The expanded pediatric approval was based on data from an 8-week, flexible-dose study (ClinicalTrials.gov Identifier: NCT03924323) that compared escitalopram (10 mg and 20 mg daily) to placebo in outpatients 7 to 17 years of age who met DSM-V criteria for GAD. The primary endpoint of the trial was the change in Pediatric Anxiety Rating Scale (PARS) severity score from baseline to week 8. The PARS is a clinician-rated instrument for assessing the severity of anxiety symptoms; PARS severity scores for GAD range from 0 (none) to 25 (extreme severity), with a score of 15 indicating moderate illness severity. Findings showed a statistically significant treatment difference with escitalopram compared with placebo on the PARS severity score for GAD (least squares mean difference, -1.42 [95% CI, -2.69, -0.15]). As for safety, the overall profile of adverse reactions in pediatric patients with GAD was similar to that seen in adult studies. The prescribing information for Lexapro contains a Boxed Warning regarding an increased risk for suicidal thoughts and behaviors in pediatric and young adult patients taking antidepressants. Patients should be monitored closely for clinical worsening and the emergence of suicidal thoughts and behaviors. The treatment is not approved for patients younger than 7 years old.

Those with 4 or more ACEs by the fall of 2020 had 2.71-fold increased likelihood of reporting a new ACE in spring of 2021. HealthDay News — Adverse childhood experience (ACE) exposure was common before and during the pandemic, and new ACEs were more likely among those who had multiple ACEs before or early in the pandemic, according to a study published online May 9 in Pediatrics. Marci Hertz, from the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues recruited adolescents aged 13 to 18 years (727 in the fall of 2020 [wave 1] and 569 in the spring of 2021 [wave 2]) who responded to questions about household challenges, violence or neglect, and community ACE exposure. There were 506 respondents to both survey waves. The researchers found that 27.2, 50.9, and 34.9 percent experienced violence or abuse, a household challenge, and a community ACE, respectively, by wave 1. By wave 2, 17.6, 6.1, and 2.7 percent experienced one, two, and four or more new ACEs, respectively. The likelihood of reporting a new ACE at wave 2 was increased 2.71-fold for those with four or more ACEs by wave 1 versus those with none. “This study’s findings highlight the occurrence of new ACEs among vulnerable adolescents who had multiple ACEs before or early in the pandemic,” the authors write. “The burden of ACEs and their associated impacts on health necessitates the implementation and scale-up of prevention and intervention strategies across school, home, and community settings to mitigate negative health and academic impacts and promote resilience.” Full Article

Resolving excess weight by adulthood may mitigate mental health risks in adolescents. Increasing weight or persistent overweight status from childhood to adulthood is associated with a higher risk for depression, according to the results published by Obesity Reviews. Researchers conducted a systematic review of the MEDLINE, PsychINFO, Embase, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases for studies with a longitudinal design that assessed weight change from childhood to adulthood that were associated with depression and anxiety. A total of 17 studies were included in the final review. A meta-analysis could not be performed due to a high level of heterogeneity observed across all the studies. The Newcastle-Ottawa scale was used to assess and rate the quality of included studies. The researchers found that 11 studies were determined to be of moderate quality, and the remaining 6 were considered high quality. Of the 17 studies, 11 defined weight change between 2 points in time, and the remaining articles defined weight change based on 3 or more documented weights. Weight status was measured using body mass index (BMI) or BMI z-scores in 14 studies. The remaining articles used retrospective measures to define weight status. Depression outcomes were evaluated in 13 studies, and only one evaluated anxiety as the sole outcome. The remaining 5 studies evaluated a composite risk of anxiety and depression. "[P]ersistent and/or increasing adiposity from childhood to adulthood is associated with an increased risk of depression in adulthood, particularly in women." Depression outcomes were measured as depressive symptoms in 4 studies. Among of the 2 studies that observed BMI change as a continuous variable, one study reported a significant association with depressive symptoms (P <.01). Of the 2 studies that utilized BMI categories to measure weight change, 1 found that there was no association of overweight status changes and depressive symptoms whereas the other study observed the opposite outcome; participants obesity was associated with more severe depressive symptoms (P <.001).

Nearly 1 million children are victims of physical abuse every year and every day, 4 to 7 children die from their injuries. These statistics are particularly grim because children who die from maltreatment often have had a healthcare encounter prior to their death. “We all know what physical abuse is, but it’s so much bigger than a lot of us recognize,” said Sheri Carson, DNP, APRN, CPN, CPNP-PC, assistant clinical professor at the University of Arizona. “I want to stress that child maltreatment involves a lot of different things and abuse has a lot of different components to it.” With every child and family encounter, Dr Carson urged practitioners to screen the child for physical abuse, during a presentation at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida. Early Detection Is Often Missed The early detection of child physical abuse is estimated to be around only 10%, and overall, 1.3% to 15% of emergency department visits for a childhood injury are caused by physical abuse, Dr Carson said. If abuse is not detected at the initial health care visit, the recurrence rate is 35% to 50% and the risk for death is 10% to 30%. In 2021, 1820 children died from maltreatment, or 2.46 children per 100,000, according to a report from the Child Welfare League of America. "We must report any suspicion of abuse or neglect. We do not need proof to report, only reasonable belief or suspicion." Nurse practitioners (NPs) and other pediatric providers are often the first medical contact during a health care encounter, and sometimes the only medical contact, placing pediatric NPs in the ideal position to not only start, but also advance, the screening process for child physical abuse, Dr Carson said.

Only 26.2% of children with parent-reported ADHD had ever received outpatient mental health care. HealthDay News — Most children with parent-reported attention-deficit/hyperactivity disorder (ADHD) are not receiving medications and have never received outpatient mental health care, according to a study published online April 28 in JAMA Network Open. Mark Olfson, M.D., M.P.H., from Columbia University and the New York State Psychiatric Institute in New York City, and colleagues describe current ADHD medication use and lifetime outpatient mental health care in a sample of children with ADHD. Data were included from the first wave of the Adolescent Brain and Cognitive Development Study (11,723 participants); 1,206 participants had parent-reported ADHD (aged 9 to 10 years). Of the 1,206 children with ADHD, 12.9 percent were currently receiving ADHD medications. The researchers found that receipt of ADHD medications was increased for boys versus girls (15.7 versus 7.0 percent), Whites versus Blacks (14.8 versus 9.4 percent), children of parents without a high school education versus those with a bachelor’s degree or higher (32.2 versus 11.5 percent), and children with the combined versus the inattentive subtype of ADHD (17.0 versus 9.5 percent). Outpatient mental health care had ever been received by about 26.2 percent of children with parent-reported ADHD. The proportion of children receiving outpatient mental health care was higher for those whose parents had a high school education or some college versus a bachelor’s degree or higher (36.2 and 31.0 percent, respectively, versus 21.3 percent), children with family incomes <$25,000 or $25,000 to $49,999 versus ≥$75,000 (36.5 and 27.7 percent, respectively, versus 20.1 percent), and for children with the combined versus the predominantly inattentive or hyperactive-impulsive subtype of ADHD (33.6 versus 20.0 percent, respectively, and 22.4 percent). “These patterns suggest that attitudinal rather than socioeconomic factors often impede the flow of children with ADHD into treatment,” the authors write. Full Article

Researchers found that overall fracture incidence rate was 334 per 10,000 patient-years (PY) in the ADHD group vs 284 per 10,000 PY in the control group. HealthDay News — Children with attention-deficit/hyperactivity disorder (ADHD) have higher risk of fractures than matched children without ADHD, according to a study published April 1 in the European Journal of Pediatrics. Tomer Ziv‑Baran, Ph.D., from Tel Aviv University in Israel, and colleagues evaluated risk of fractures among children with ADHD. Analysis included 31,330 children diagnosed with ADHD and 62,660 children matched by age, sex, population sector, and socioeconomic status. The researchers found that overall fracture incidence rate was 334 per 10,000 patient-years (PY) in the ADHD group versus 284 per 10,000 PY in the control group. Overall, the fracture incidence rates were higher for boys (388 and 327 per 10,000 PY, respectively). Among girls, rates were lower in both groups versus boys, but higher in the ADHD group versus controls (246 versus 203 per 10,000 PY). Among the children with ADHD, increased fracture risk was seen for boys and girls (hazard ratios, 1.18 and 1.22 for boys and girls, respectively). Risk for two or three fractures was higher for children with ADHD versus controls (hazard ratios, 1.32 and 1.35, respectively). However, for children with ADHD, pharmacological treatment was associated with lower fracture risk (hazard ratio, 0.90) when adjusting for sex, resident socioeconomic status, and population sector. “Recognition of the risk of fractures in this population is important to improve prevention,” the authors write. Full Article

Scientific America's article outlines the risks and benefits of cannabis usage for those with Bipolar conditions Many people with bipolar disorder have a strong attraction to marijuana. A 2019 review of 53 studies found that almost a quarter of a combined sample of 51,756 individuals with the condition used cannabis or had a problematic pattern of consumption (cannabis use disorder), compared with 2 to 7 percent in the general population—and an earlier study placed usage estimates still higher. Cannabis and bipolar disorder do not go particularly well together. Consumption may increase manic and psychotic symptoms, and there may be a greater risk of suicide. But can the allure of cannabis be explained as a mere form of substance misuse? Why are people with bipolar disorder so attracted to marijuana? Could they be getting any possible benefit from it? Alannah Miranda of the University of California, San Diego, is a postdoctoral scholar working with U.C.S.D. psychiatry professors William Perry and Arpi Minassian to explore these questions. Miranda presented her and her colleagues’ unpublished work at this year’s giant Society for Neuroscience conference, which attracted more than 24,000 people earlier this month. She talked to Scientific American about what she discovered in this continuing study, which has been funded by the National Institute on Drug Abuse. Tell me about what you’re studying. I’m researching the effects of cannabis on cognition in people with bipolar disorder. People with bipolar disorder report that it’s helping alleviate some of their symptoms in terms of issues related to memory, attention, focus and anxiety. What did the preliminary study that you’re presenting at this conference show? Our study had four different comparison groups: healthy participants who do not use cannabis, healthy participants that do use cannabis, people with bipolar disorder that do not use cannabis and people with bipolar disorder that do use cannabis. We tested them on a number of their goal-directed behaviors, including risky decision-making and what we call effortful motivation, meaning their willingness to continue to engage in a task despite the fact that the potential for reward continues to decrease over time. And what we found was that people with bipolar who use cannabis actually made fewer risky decisions and had a decreased tendency to pursue trivial tasks for an excessive amount of time. Those studied without bipolar disorder who ingested marijuana had higher risk-taking and effortful motivation levels. How many people were in the study? There have been about 60 total participants so far. The study is continuing, and we’re aiming for about 100 in total. And we’ll finish it in less than a year. There have been previous studies on the effects of cannabis on people with bipolar disorder. How does your study differ? A lot of the focus in cannabis use for bipolar disorder has classically been on whether the drug affects mood symptoms of the disorder, perhaps making mania and psychosis worse. But impaired cognition such as decision-making is something that tends to be overlooked. So we’re looking at these cognitive functions that are really impacting people’s everyday functioning. Are you also doing animal studies? Yes, I’ve been collaborating with Jared Young at U.C.S.D. on his animal work. So I think what sets our study apart from a lot of previous studies on cannabis and bipolar is that we are looking at this in humans, but we are also looking at this in animals. The paradigm is to test cognitive functions in humans, but we have very similar tasks that we’re using in mice. And we can do some genetic manipulations in mice or administer specific levels of drugs in the animals that we can’t do in humans. We can look at the specific mechanisms of bipolar disorder that we hypothesize exist, such as a dysregulation of the signaling molecule dopamine. It’s much more difficult to look at specific proteins in humans, but we can certainly do that in our animal research. Do you have hypotheses about what might be going on with cannabis and how it’s affecting the brain? Currently, we think that cannabis may be affecting the reward and motivation processing system. Dopamine regulates behavior and functions we use toward achieving certain goals. People with bipolar disorder might have too much of the chemical dopamine activity in their system, and that is what we hypothesize is leading to greater cognitive impairment So we think that cannabis may be reducing the excess dopamine in people with bipolar disorder that’s leading to cognitive impairment. Could you talk about your work’s implications for possible treatments? Clinically, there would be a concern with cannabis about making the mania and psychotic symptoms of bipolar disorder worse. So I wouldn’t go so far as to say people with bipolar disorder should use cannabis. But our research could lead to an understanding of the mechanisms of the effects of cannabis that could possibly lead to drug treatments. What about your work going forward? Right now, with our ongoing study, we’re looking at acute effects of THC (tetrahydrocannabinol) versus CBD (cannabidiol). I think that’s probably one of the more promising directions that we’re taking this research. THC can actually have opposing effects to CBD, and we want to disentangle that. We want to see whether we can maximize any therapeutic benefits of cannabis but minimize any of those harmful effects to produce a lower negative side effect profile. CBD doesn’t have the same kind of psychoactive effects that THC has, generally speaking, so you don’t get a high from it. It’s a possibility that CBD might be a better candidate for a therapy, but there are very little data on it so far. And we’re extending this to other populations as well. That includes HIV patients, who have similar neurocognitive impairments. We are also hoping to study the effects of cannabis on aging populations, who are also at risk for cognitive decline. With the increasing legalization of cannabis, more older people are turning to cannabis as a medical treatment, but we don’t know how cannabis effects the aging brain. I think this is a really important branch off from this current research.

One professional psychiatrist shares his account of living with bipolar affective disorder. Being on the other side of the table, is a phrase often used for situations reversed. In clinical practice today, we hear the experiences of the individuals with bipolar affective disorder (BPAD) in lay terms. At the same time, BPAD is an entity that has been explained in research by professionals across the globe. But what if the healer becomes the wounded? Here we present to you a brief communication with a professional who has been on both sides of the table, thus sharing his distinctive and remarkable experience. He is a senior consultant psychiatrist and has been in successful practice for more than 5 years now. Bipolar disorder (BPAD) is a serious mental disorder characterized by episodes of depression, hypomania/mania and mixed episodes, with interepisodic recovery. However, many patients with BPAD continue to exhibit residual symptoms in the interepisodic period. In your professional and personal experience what is the most common reaction to being diagnosed with BPAD? In my opinion, the most conventional reaction is not fear, apprehension, or worry, it is the confusion. In a country like India, due to limited resources, health care access, and time constraints, many professionals are often unable to properly explain the nature, course, and prognosis of the illness. While psychoeducation is an important part of the management, due to unfavourable psychiatrist patient ratio and time constraints, this aspect is often omitted. Many patients are then left with nothing but unreliable information either portrayed by media or the internet, which leads them to think that BPAD is like having multiple personalities, an illness causing complete dysfunction, something that is uncontrollable—or worse—incurable. In my view, once the illness is explained with adequate psychoeducation about the treatment, advantages, and disadvantages of taking medication, many patients tend to settle down and that confusion is converted into rapport with the psychiatrist. What was your initial reaction to being diagnosed? Have you ever been misdiagnosed? Personally, when I recall, in my final year of medical training, I had no experience with psychiatry or mental health issues. Getting diagnosed with BPAD was more of a relief in my perspective to finally know about my condition and understand what was happening. Unfortunately, like many patients, I was misdiagnosed in the initial stages of my illness with schizophrenia. I went into denial and did not research anything about my symptoms or my illness. I went on with my life. But I know now that, long term, that ignorance would have been harmful. What are initial reactions of caregivers at the time of diagnosis? What are the common pitfalls at the time of BPAD diagnosis? For patients and caregivers, being diagnosed with BPAD may result in initial confusion. A major pitfall during diagnosis of BPAD is that, as clinicians we are so rigidly trained and attuned to tick boxes and criteria that we often forget that our brains do not follow a textbook. Mania can be misdiagnosed as hypomania, borderline personality disorder can be confused with mania, and so on. We should aim for an open-minded approach and rather than focussing on labelling. Similarly, in the western world, guideline fulfilment is rigid and insurance becomes a trouble when it comes to mental illness. Surely, we all know the elaborate discussion of the pitfalls is beyond the scope of this narrative. Please share your experience of first episode mania. Were there any differences between first and subsequent episodes of mania? Mania was not a scary experience for me. I remember parts of it very fondly. Recalling my first episode, I remember I had zero insight, and was ignorant about it. I felt like I had multiple superpowers all at once. It was an escalation of the basic joys of life. I felt a high, but I am glad that I did not carry on in ignorance and got professional help. My 2nd episode of mania was after a 7-year gap. Meanwhile, I was much more aware about the warning signs of an active episode. I have some recollection of the first episode of mania, but I do remember my subsequent second episode clearly. I was working in a peripheral service centre when I started having trouble sleeping for a few days. I recall being invited as an expert witness in a session court. So, there I was, presenting a case and had a “nice” conversation with the judge. The judge however, later mentioned that I did not need to return as an expert witness. Strutting out of the court, I called my father and told him how happy the judge was after talking to me. He must have sensed something odd, because as soon as I came back to my house, my parents said something is wrong and advised me to take a low dose antipsychotic, which I refused. Later that day, sitting in my room, I reflected on my behavior and finally decided to take the pill. Due to the awareness and support of my family, I curtailed this episode while it was in hypomania. But even after taking the medicine, the prime cause of distress was not the symptoms but my obsessive thoughts. I would have racing thoughts and would be too self-conscious. As medication took time to act, I would exhibit repetitive questioning and checking from my family members if I was behaving “normally.” Its distressing for your loved ones to see you like this and I did appreciate later what they went through. I think that is why ignorance is a bliss, because awareness of symptoms made me differentiate between usual and unusual and it was quite distressing. Here, it is important to understand that an individual going into mania is not necessarily devoid of insight into their illness or psychopathology. Timely medication and sensitive dealing prior to the episode will ease the fright of patient and motivate them to participate in treatment. Please share more about your first depressive episode experience. My first depressive episode occurred in mid to late 2006. It was a difficult time as I stopped socializing with others. My friends would check up on me and I would actively opt out of going to social events. Throughout 2007, I did not have any episodes. The most severe depressive episode happened in 2008. That depressive episode was without any stressor and the guilt was overwhelming. I would have self-deprecating thoughts and would endlessly self-compare with others. No matter how many medications I took, I would sleep all the time and there were a lot of crying spells. I spent the better part of approximately 4 years in that state, lasting until 2012. The peak of my depression was in 2009 when I stopped eating, as every action including eating seemed futile. I was filled with complete nihilism and emptiness. That was the most crippling phase of my life I would say. It was around that time I was offered electroconvulsive therapy, but like many caregivers, my parents refused out of apprehension. The actual game changer was cessation of valproate and initiation of lithium in 2012. Since starting on lithium, I have had no active episodes. I did have a reactive episode of depression in 2019, which was precipitated by the ending of a significant relationship, but otherwise medication has helped me a lot. How can you differentiate between normal ups and downs and an active episode? I have an anankastic personality, so it is a bit of problem but I keep an eye on minute details. Therefore, when I am happy, there is this nagging feeling I might end up in mania. But with time, you get to know your relapse signature. In my total 17 years of illness, I have had 1 full blown manic episode and 1 hypomanic episode. The major differentiating feature is sleep disturbance, both in depressive episodes and mania. I have dealt with depression way more than mania. So, I know my relapse signature: it usually starts with irritability, which my family members will notice too. However, being a professional, I manage my own medication and it has been a positive experience so far. What do you think is most important for a good prognosis? I would mention here that there are 2 vital reasons for my excellent prognosis: (1) my interpersonal and social support system and (2) my rigorous medication compliance. Just like any caregiver, my family does have certain issues with stigma related to the illness and others getting to know about my diagnosis, but they have always supported me in every possible way. My close friends are supportive, and they would often seek professional and personal advice from me. Additionally, regular compliance to treatment is very important. What are certain pitfalls while treating the BPAD? I think there are several pitfalls, but most important is poor redressal of the confusion. We focus too much on mania and do not explain depression to the patient or family members. After an active episode of mania, depression can often be mistaken for normalcy in the initial part and pure laziness after. Thus, in my professional opinion, ignorance and confusion are the major problem. It is important to educate the patient and family members, and even more important to emphasise the need for medication. We need to be timely and avoid the nihilism that might build inside a patient, who hopes to reduce and stop the medication altogether. The other mistake often made is not assessing the choice of mood stabilizer correctly. In my case, I was kept on valproate for a long time despite having adverse effects and no contraindications for lithium. Along with the provision of psychoeducation about the illness and need for treatment, it is important that we teach patients about the relapse signature as well. They should know the warning signs of both manic and depressive episodes and how to maintain mood charting. Deviation from the usual pattern of sleep for 2 to 3 nights is a clear-cut indication of the impending episode. While prescribing, it is beneficial to inform the patient about the nature of treatment and any possible adverse effects of the medication. If the patients and caregivers are not educated about the medication as its adverse effect profile, they are going to get frightened and stop the medication. What is the biggest “don’t” for a caregiver managing an individual with BPAD? One should never blame the patient for the episodes or the actions in the active episodic state. It is gut wrenching to know some caregivers do that. Once the patient is recovering from mania, one should not blame or make them recall all the things they did. Never criticise the patient in the depressive phase. Bipolar depression is one of the most crippling things one can experience, it is difficult to treat and is often long standing. Patients with BPAD are often high achievers, and it is cruel to shower them with criticism about not being able to do something in life. What take home messages do you have for clinicians and patients? To all the professionals, I would like to add that BPAD, just like multiple other illness, has a polygenic inheritance therefore, patients are prone to metabolic impairments. I developed type 2 diabetes a few years ago. Looking back, I feel that could have been avoided or delayed if I was more active. Therefore, it is beneficial to tell patients in the first consultation with health services to be physically active while maintaining regular compliance. I feel that having personally experienced what many professionals read in textbooks, I can relate with patients and caregivers spontaneously, irrespective of their diagnosis. Therefore, my illness has played a crucial role in my empathy and ethical clinical practice towards individuals with mental illness and made me the contented clinician I am today. Similarly, patients with BPAD should not feel like their illness is a crutch. Yes, compliance to treatment is the ultimate game changer, I believe. Truly speaking, I see my glass way more than half full and that is what I want to convey to all the patients battling this condition. Win that battle. I know you can. Note from the author: "My sincere gratitude to the astounding clinician, who is an inspiration to millions of others out there, for sharing his valuable insights and providing a transparent mélange of personal and professional perspectives towards an important diagnostic entity. We need more of such bold and ethical practitioners like him who share their experiences out loud in a society and world full of stigma. Their story can be life changing for millions of others out there struggling with BPAD." Dr Kaur is a consultant psychiatrist in Punjab, India.

What are Personal Boundaries? Types of Boundaries Physical boundaries refer to personal space and physical touch. Healthy physical boundaries include an awareness of what's appropriate, and what's not, in various settings and types of relationships (hug, shake hands, or kiss?). Physical boundaries may be violated if someone touches you when you don't want them to, or when they invade your personal space (for example, rummaging through your bedroom). Intellectual boundaries refer to thoughts and ideas. Healthy intellectual boundaries include respect for others' ideas, and an awareness of appropriate discussion (should we talk about the weather, or politics?). Intellectual boundaries are violated when someone dismisses or belittles another person's thoughts or ideas. Emotional boundaries refer to a person's feelings. Healthy emotional boundaries include limitations on when to share, and when not to share, personal information. For example, gradually sharing personal information during the development of a relationship, as opposed to revealing everything to everyone. Emotional boundaries are violated when someone criticizes, belittles, or invalidates another person's feelings. Sexual boundaries refer to the emotional, intellectual, and physical aspects of sexuality. Healthy sexual boundaries involve mutual understanding and respect of limitations and desires between sexual partners. Sexual boundaries can be violated with unwanted sexual touch, pressure to engage in sexual acts, leering, or sexual comments. Material boundaries refer to money and possessions. Healthy material boundaries involve setting limits on what you will share, and with whom. For example, it may be appropriate to lend a car to a family member, but probably not to someone you met this morning. Material boundaries are violated when someone steals or damages another person's possessions, or when they pressure them to give or lend them their possessions. Time boundaries refer to how a person uses their time. To have healthy time boundaries, a person must set aside enough time for each facet of their life such as work, relationships, and hobbies.) Time boundaries are violated when another person demands too much of another's time. What are Personal Boundaries? Personal boundaries are the limits and rules we set for ourselves within relationships. A person with healthy boundaries can say "no" to others when they want to, but they are also comfortable opening themselves up to intimacy and close relationships. A person who always keeps others at a distance (whether emotionally, physically, or otherwise) is said to have rigid boundaries. Alternatively, someone who tends to get too involved with others has porous boundaries. Common traits of rigid, porous, and healthy boundaries. Rigid Boundaries / Porous Boundaries / Healthy Boundaries Most people have a mix of different boundary types. For example, someone could have healthy boundaries at work, porous boundaries in romantic relationships, and a mix of all three types with their family. The appropriateness of boundaries depends heavily on setting. What's appropriate to say when you're out with friends might not be appropriate when you're at work. Some cultures have very different expectations when it comes to boundaries. For example, in some cultures it's considered wildly inappropriate to express emotions publicly. In other cultures, emotional expression is encouraged. Source: Therapist Aid (2016)

Childhood housing insecurity also associated with higher depression symptom scores in adulthood. HealthDay News — Housing insecurity in childhood is associated with anxiety and depression during childhood and with depression during adulthood, according to a study published online June 20 in JAMA Pediatrics. Ryan Keen, Ph.D., from the Harvard T. H. Chan School of Public Health in Boston, and colleagues examined whether childhood housing insecurity is associated with later anxiety and depression symptoms in a prospective cohort study including individuals aged 9, 11, and 13 years at baseline. From January 1993 to December 2015, participants were assessed up to 11 times. The researchers found that compared with those who never experienced housing insecurity, children who experienced housing insecurity had higher standardized mean baseline anxiety and depression symptom scores (anxiety: 0.49 versus 0.22; depression: 0.20 versus −0.06). Higher anxiety symptom scores and higher depression symptom scores were seen for individuals who experienced childhood housing insecurity (standardized mean difference: 0.21 and 0.25 for fixed and random effects, respectively, for anxiety; 0.18 and 0.26 for fixed and random effects, respectively, for depression). Childhood housing insecurity was also associated with higher depression symptom scores in adulthood (standardized mean difference, 0.11). “Our results underscore the importance of interventions that optimize services and resources to ensure safe and secure housing for all children,” the authors write. Full Article

Getting Out of Abusive Relationship * Are you in any relationship right now in which someone: 1. Offers you substances or uses in your presence after you've asked the person not to? 2. Repeatedly criticizes you, invalidates your feelings, or humiliates you? 3. Manipulates you (e.g., threatens to harm your children)? 4. Is physically hurting you or threatening to? 5. Discourages you from getting help (e.g., medication, therapy, AA)? 6. Lies to you repeatedly? 7. Betrays your trust (e.g., tells your secrets to others)? 8. Makes unreasonable requests (e.g., demands that you pay for everything)? 9. Exploits you (e.g., sells pornographic pictures of you)? No 10. Ignores your physical needs (e.g., refuses safe sex)? No 11. Is controlling and overinvolved(e.g., tells you what to do)? No If you said "Yes" to any of the questions above, read the rest of this handout. You deserve better than destructive people! HOW TO DETACH FROM DAMAGING RELATIONSHIPS If you have difficulty with boundaries, you may not in notice dangerous cues in others. This makes sense if you lived in a past in which a veil of silence was imposed, you were not allowed to express your feelings, or you could not tell others about your trauma. You may need to make special efforts now to notice your reactions to people and to learn when to end relationships that are hurtful. If someone doesn't "get it," give up for now. In early recovery, don't waste your energy on changingother people; just focus on helping yourself. If someone doesn't understand you after you've tried to communicate directly, kindly, and repeatedly, find other people. Even if you cannot leave a damaging relationship, you can still detach from it. If it is someone you must see (such as a family member), protect yourself by not talking to that person about vulnerable topics, such as your trauma or your recovery. If enough reasonable people tell you a relationship is bad, listen to them. You may feel so confused or controlled that you have lost touch with your own needs. Listen to others. * It's better to be alone than in a destructive relationship. It may be that for now, your only safe relationships are with treaters. That's okay. Destructive relationships can be as addictive as drugs. If you cannot stay away from someone you know is bad for you, you may be addicted to that person. Destructive relationships may feel familiar, and you may be drawn to them over and over if your main relationships in life were exploitative. The best strategy is the same as for all addictions: Actively force yourself to stay away, no matter how hard it feels to do so. 1 Remember that you are no longer a child, forced to endure bad relationships. You have choices. 1 Recognize the critical urgency of detaching from bad relationships. They impair your recovery from PTSD and substance abuse. They prevent you from taking care of yourself and others (e.g., children). • Once you make a decision to leave a damaging relationship, the "how" will present itself. If you do not know how to leave, it usually means that you have not yet made the decision to leave. * If you feel guilty, remember that it is your life to live. You can decide how to live it. Expect fallout. When you leave a bad relationship, others may become angry or dangerous. Find ways to protect yourself, including the support of people "on your side,' your treatment team, and shelter if necessary. * You do not have to explain yourself to the other person; you can just leave. Create an image to protect yourself. For example, you are knight in armor and you don't have to let the person in; you are a TV and a you can change the channel. Try Co-Dependents Anonymous. This is a twelve-step group for S people who become dependent on damaging relationships (A 602-277-7991). You should never have to tolerate being physically hurt by anyone. If you are in a situation of domestic violence, this is very serious and requires expert help. You can call: National Domestic Violence Hotline M National Resource Center on Domestic Violence 800-799-7233; 800-537-2238 If someone is physically hurting you, don't buy into "I'll be different next time." If there is a pattern of abuse after you have given someone repeated chances to treat you decently, get out. Listen to the person's actions, not the words. From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press.

It is so vital to have good, healthy boundaries with friends, family, and loved ones as they can strongly impact your mental health and well being. Here are various topics that address the different types of boundaries and how to deal with difficulty strongly with each one. Healthy Boundaries Healthy boundaries are: Flexible. You are able to be both close and distant, adapting to the situation. You are able to let go of relationships that are destructive. You are able to connect with relationships that are nurturing. Safe. You are able to protect yourself against exploitation by others. You are able to read cues that someone is abusive or selfish. Connected. You are able to engage in balanced relationships with others and maintain them over time. As conflicts arise, you are able to work them out. Both PTSD and substance abuse can result in unhealthy boundaries. In PTSD, your boundaries (your body and your emotions) were violated by trauma. It may be difficult for you now to keep good boundaries in relationships. In substance abuse, you have lost boundaries with substances (you use too much, and may act in ways you normally would not, such as getting high and saying things you don't mean). Learning to establish healthy boundaries is an essential part of recovery from both disorders. Boundaries are a problem when they are too close or too distant. Boundaries can be too close (letting people in too much; enmeshed). Here are very important questions to ask yourself. * Do you? Have difficulty saying "no" in relationships? Give too much? Get involved too quickly? Trust too easily? Intrude on others (e.g., violate other people's boundaries)? 0 Stay in relationships too long? Boundaries can be too distant (not letting people in enough; detached). * Do you? Have difficulty saying "yes" in relationships? Isolate? Distrust too easily? Feel lonely? Stay in relationships too briefly? Note that many people have difficulties in both areas. Boundary problems are a misdirected attempt a to be loved. By "giving all" to people, you are trying to win them over; instead, you teach them to exploit you. By isolating from others, you may be trying to protect yourself, but then don't obtain the support you need. Healthy boundaries can keep you safe. Learning to say "no" can ... keep you from getting AIDS (saying "no" to unsafe sex); keep you from using substances (saying "no" to substances); prevent exploitation (saying "no" to unfair demands); protect you from abusive relationships and domestic violence. Learning to say "yes" can ... allow you to rely on others; let yourself be known to others; help you feel supported; get you through tough times. Setting Boundaries in Relationships Setting good boundaries prevents extremes in relationships. By setting boundaries, you can avoid painful extremes: too close versus too distant, giving too much versus too little, idealizing versus devaluing others. Neither extreme is healthy; balance is crucial. It is important to set boundaries with yourself as well as with others. You may have difficulty saying "no" to yourself. For example, you promise yourself you won't smoke pot, but then you do. You may overindulge in food, sex, or other addictions. You may say you won't go back to an abusive partner, but then you do. You may have difficulty saying "yes" to yourself. For example, you may deprive yourself too much by not eating enough, working too hard, not taking time for yourself, or not allowing yourself pleasure. People with difficulty setting boundaries may violate other people's boundaries as well. This may appear as setting up "tests" for other people, intruding into other people's business, trying to control others, or being verbally or physically abusive. If you physically hurt yourself or others, you need immediate help with boundaries. Hurting yourself or others is an extreme form of boundary violation. It means that you act out your emotional pain through physical abuse. Source: From Seeking Safety by Lisa M. Najavits (2002). Copyright by The Guilford Press.