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Wasting Away

An eating disorder is characterized by extreme reduction or increase in food intake, or Feelings of extreme distress or concern about body weight or shape. A person with an eating disorder may start out by eating smaller or larger amounts of food than normal but at some point takes it to an extreme. The two main types of eating disorders are anorexia nervosa and bulimia nervosa.

In her book, “Wasted: A Memoir of Anorexia and Bulimia,” Marya Hornbacher, describes how her eating disorder started with bulimia.

“It was that simple: One minute I was your average nine-year-old, shorts and a T-shirt and long brown braids, sitting in the yellow kitchen, watching the Brady Brunch reruns, munching on a bag of Fritos, scratching the dog with my foot. The next minute I was walking, in a surreal haze I would later compare to the hum induced by speed, out of the kitchen, down the stairs, into the bathroom, shutting the door, putting the toilet seat up, pulling my braid back with one hand, sticking my two fingers down my throat, and throwing up until I spat blood. Flushing the toilet, washing my hands and face, smoothing my hair, walking back up the stairs of the sunny, empty house, sitting down in front of the television, picking up my bag of Fritos, scratching the dog with my foot.”

Bulimia nervosa is characterized by recurrent and frequent patterns of eating unusually large amounts of food (binge-eating) followed by purging (e.g. vomiting, abuse of laxatives or diuretics), fasting and/or excessive exercise. People with bulimia believe that the act of purging compensates for the binge eating. Unlike those with anorexia, those with bulimia are often within the normal weight range for their age. However, they are still preoccupied by the desire to lose weight, are unhappy with their body shape and size and have an intense fear of gaining weight. Bulimic behavior is done secretly because it is usually accompanied by feelings of shame or disgust. In most cases, the binging and purging cycle is repeated several times a week. Bulimia is often comorbid with psychological disorders such as depression or anxiety and accompanied by physical health complications.

Marya Hornbacher also described how she became anorexic.

“Anorexia started slowly. It took time to work myself into the frenzy that the disease demands. There were an incredible number of painfully thin girls at Interlochen, dancers mostly. The obsession with weight seemed nearly universal. Whispers and longing stairs followed the ones who were visibly anorexic. We sat at our cafeteria tables, passionately discussed the calories of lettuce, celery, a dinner roll, rice. We moved between two worlds. When we pushed back our chairs and scattered to our departments, we transformed. I would watch girls who’d just been near tears in the door-room mirrors suddenly become rapt with life, fingers flying over a harp, a violin, bodies elastic with motion, voices strolling through Shakespeare’s forest of words.”

Anorexia nervosa is the inability or unwillingness to maintain a normal body weight for a person’s age and height. A clinician will usually diagnose the disorder when a person fails to meet 85% of their normal or expected weight. Some symptoms include distorted body image and extreme fear of gaining weight, obsession with food and weight control, and extremely disturbed eating behavior. Girls and women may experience lack of menstruation. Some methods of weight loss used are excessive diet and exercise, self-induced vomiting and misuse of diuretics, laxatives or enemas. Other signs of anorexia are yellowish skin, and growth of fine hair all over the body. A person with anorexia may also experience mild anemia, muscle weakness and loss, severe constipation, low blood pressure, slow breathing and pulse, a drop in internal body temperature (feeling cold all the time), and feeling lethargic.

How to Get Help

A trained psychologist can be instrumental in treating eating disorders and helping the patient recover. He or she can help identify the issues that need attention and develop a treatment plan, then helps the patient replace destructive thoughts and behaviors with more positive ones. For example, a psychologist might work with the patient to focus on health instead of weight, or ask the patient to keep a food journal to become aware of what situations trigger disordered eating.

However, psychotherapy goes beyond just changing thoughts and behaviors. The psychologist must work with the patient to uncover the psychological issues underlying the eating disorder, which sometimes involves improving personal relationships and going beyond the specific situations that triggered the disorder. Incorporating group therapy, family therapy, or marital therapy can be helpful for allowing family members to understand the disorder and how they can help. Cognitive-behavioral therapy (CBT) is a common method of psychotherapy used to treat eating disorders. CBT therapists believe that the clients change because they learn how to think differently and then act on that learning. Therefore, an important part of the therapy is teaching self-counseling skills.

Treatments do not work instantly and for many patients may need to be long-term. As with any medical or psychological disorder, the sooner treatment is sought, the better. The longer disordered eating continues, the more difficult it is to treat. The prospects for long-term recovery are good for those who seek help from qualified professionals.

Eating Disorders – General Info and Symptoms

A third category is “eating disorders not otherwise specified” (EDNOS) and includes several other less common types, including binge-eating disorder. These are much more common in women and girls than in men, and according to the National Institute of Mental Health, adolescent and young women account for 90% of the cases. Eating disorders most frequently surface during adolescence or young adulthood, though they can develop at other times and in men or boys.

Anorexia is a treatable condition, and some recover completely. However some who have anorexia set well but have relapses, while others have a more chronic form of the illness in
which their health continues to deteriorate for many years. Treatment of anorexia involves three major components: restoring the person to a healthy weight, treating the psychological issues related to the eating disorder, and reducing or eliminating thoughts and behaviors that lead to disordered eating and preventing relapse.

Other symptoms include:

• Chronically inflamed sore throat
• Swollen glands in the neck and below the jaw
• Worn tooth enamel and increasingly sensitive and decaying teeth as a result of
  exposure to stomach acid
• Gastroesophageal reflux disorder
• Intestinal distress and irritation from laxative abuse
• Kidney problems from diuretic abuse
• Severe dehydration from purging of fluids

Binge-eating disorder is characterized by a lack of control of one’s eating, resulting in recurrent episodes of binge-eating. People with the disorder are often overweight or obese and experience guilt and shame or distress over the episodes, which can lead to more binge-eating. Like other eating disorders, binge-eating coexists with other physical and psychological illnesses.

Some people live with eating disorders without family or friends expecting a thing. Withdrawal from social contact, hiding the behavior and denial that there is a problem are often indicators that an eating disorder is present. There are some risk factors that predispose a person to developing eating disorders, including low self-esteem, feelings of helplessness and very negative body image or dissatisfaction with appearance in general. Genetics, gender and ethnicity, and weight and shape can also play a role. It is important to realize that environmental factors like teasing, traumatic or stressful events often trigger the development of an eating disorder.

Eating disorders are some of the most often unreported and untreated mental illnesses because ol the misperception that they will go away on their own. Making an accurate diagnosis and treatment should be left to a licensed psychologist or mental health expert. Because each case is different, there is no generalized treatment plan for eating disorders; treatment plans are often tailored to the patient’s specific needs.

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Wasting Away

An eating disorder is characterized by extreme reduction or increase in food intake, or Feelings of extreme distress or concern about body weight or shape. A person with an eating disorder may start out by eating smaller or larger amounts of food than normal but at some point takes it to an extreme. The two main types of eating disorders are anorexia nervosa and bulimia nervosa.

In her book, “Wasted: A Memoir of Anorexia and Bulimia,” Marya Hornbacher, describes how her eating disorder started with bulimia.

It was that simple: One minute I was your average nine-year-old, shorts and a T-shirt and long brown braids, sitting in the yellow kitchen, watching the Brady Brunch reruns, munching on a bag of Fritos, scratching the dog with my foot. The next minute I was walking, in a surreal haze I would later compare to the hum induced by speed, out of the kitchen, down the stairs, into the bathroom, shutting the door, putting the toilet seat up, pulling my braid back with one hand, sticking my two fingers down my throat, and throwing up until I spat blood. Flushing the toilet, washing my hands and face, smoothing my hair, walking back up the stairs of the sunny, empty house, sitting down in front of the television, picking up my bag of Fritos, scratching the dog with my foot.

Bulimia nervosa is characterized by recurrent and frequent patterns of eating unusually large amounts of food (binge-eating) followed by purging (e.g. vomiting, abuse of laxatives or diuretics), fasting and/or excessive exercise. People with bulimia believe that the act of purging compensates for the binge eating. Unlike those with anorexia, those with bulimia are often within the normal weight range for their age. However, they are still preoccupied by the desire to lose weight, are unhappy with their body shape and size and have an intense fear of gaining weight. Bulimic behavior is done secretly because it is usually accompanied by feelings of shame or disgust. In most cases, the binging and purging cycle is repeated several times a week. Bulimia is often comorbid with psychological disorders such as depression or anxiety and accompanied by physical health complications.

Marya Hornbacher also described how she became anorexic.

Anorexia started slowly. It took time to work myself into the frenzy that the disease demands. There were an incredible number of painfully thin girls at Interlochen, dancers mostly. The obsession with weight seemed nearly universal. Whispers and longing stairs followed the ones who were visibly anorexic. We sat at our cafeteria tables, passionately discussed the calories of lettuce, celery, a dinner roll, rice. We moved between two worlds. When we pushed back our chairs and scattered to our departments, we transformed. I would watch girls who’d just been near tears in the door-room mirrors suddenly become rapt with life, fingers flying over a harp, a violin, bodies elastic with motion, voices strolling through Shakespeare’s forest of words.

Anorexia nervosa is the inability or unwillingness to maintain a normal body weight for a person’s age and height. A clinician will usually diagnose the disorder when a person fails to meet 85% of their normal or expected weight. Some symptoms include distorted body image and extreme fear of gaining weight, obsession with food and weight control, and extremely disturbed eating behavior. Girls and women may experience lack of menstruation. Some methods of weight loss used are excessive diet and exercise, self-induced vomiting and misuse of diuretics, laxatives or enemas. Other signs of anorexia are yellowish skin, and growth of fine hair all over the body. A person with anorexia may also experience mild anemia, muscle weakness and loss, severe constipation, low blood pressure, slow breathing and pulse, a drop in internal body temperature (feeling cold all the time), and feeling lethargic.

How to Get Help

A trained psychologist can be instrumental in treating eating disorders and helping the patient recover. He or she can help identify the issues that need attention and develop a treatment plan, then helps the patient replace destructive thoughts and behaviors with more positive ones. For example, a psychologist might work with the patient to focus on health instead of weight, or ask the patient to keep a food journal to become aware of what situations trigger disordered eating.

However, psychotherapy goes beyond just changing thoughts and behaviors. The psychologist must work with the patient to uncover the psychological issues underlying the eating disorder, which sometimes involves improving personal relationships and going beyond the specific situations that triggered the disorder. Incorporating group therapy, family therapy, or marital therapy can be helpful for allowing family members to understand the disorder and how they can help. Cognitive-behavioral therapy (CBT) is a common method of psychotherapy used to treat eating disorders. CBT therapists believe that the clients change because they learn how to think differently and then act on that learning. Therefore, an important part of the therapy is teaching self-counseling skills.

Treatments do not work instantly and for many patients may need to be long-term. As with any medical or psychological disorder, the sooner treatment is sought, the better. The longer disordered eating continues, the more difficult it is to treat. The prospects for long-term recovery are good for those who seek help from qualified professionals.

Eating Disorders – General Info and Symptoms

A third category is “eating disorders not otherwise specified” (EDNOS) and includes several other less common types, including binge-eating disorder. These are much more common in women and girls than in men, and according to the National Institute of Mental Health, adolescent and young women account for 90% of the cases. Eating disorders most frequently surface during adolescence or young adulthood, though they can develop at other times and in men or boys.

Anorexia is a treatable condition, and some recover completely. However some who have anorexia set well but have relapses, while others have a more chronic form of the illness in
which their health continues to deteriorate for many years. Treatment of anorexia involves three major components: restoring the person to a healthy weight, treating the psychological issues related to the eating disorder, and reducing or eliminating thoughts and behaviors that lead to disordered eating and preventing relapse.

Other symptoms include:

• Chronically inflamed sore throat
• Swollen glands in the neck and below the jaw
• Worn tooth enamel and increasingly sensitive and decaying teeth as a result of
  exposure to stomach acid
• Gastroesophageal reflux disorder
• Intestinal distress and irritation from laxative abuse
• Kidney problems from diuretic abuse
• Severe dehydration from purging of fluids

Binge-eating disorder is characterized by a lack of control of one’s eating, resulting in recurrent episodes of binge-eating. People with the disorder are often overweight or obese and experience guilt and shame or distress over the episodes, which can lead to more binge-eating. Like other eating disorders, binge-eating coexists with other physical and psychological illnesses.

Some people live with eating disorders without family or friends expecting a thing. Withdrawal from social contact, hiding the behavior and denial that there is a problem are often indicators that an eating disorder is present. There are some risk factors that predispose a person to developing eating disorders, including low self-esteem, feelings of helplessness and very negative body image or dissatisfaction with appearance in general. Genetics, gender and ethnicity, and weight and shape can also play a role. It is important to realize that environmental factors like teasing, traumatic or stressful events often trigger the development of an eating disorder.

Eating disorders are some of the most often unreported and untreated mental illnesses because ol the misperception that they will go away on their own. Making an accurate diagnosis and treatment should be left to a licensed psychologist or mental health expert. Because each case is different, there is no generalized treatment plan for eating disorders; treatment plans are often tailored to the patient’s specific needs.

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How Does Bipolar Disorder Affect Your Life or the Life of Someone You Love?

Colloquially known as manic-depression, how does bipolar disorder affect your life or the life of someone you love? Learn about how treatment can help.

Jonathan is a 35-year-old attorney who moved from Colorado to North Carolina. He started seeing a psychiatrist to continue his medication treatment with a mood stabilizer. He had been successful in work and relationships since he was diagnosed with bipolar disorder and treated in college. Moving to North Carolina was difficult because he worked all the time and had not made many new friends. About six months after he moved, he noticed a change in his mood. For about a month, he felt increasingly energetic although was not sleeping more than three hours at night. Co-workers noticed he was talking very quickly, and he seemed to have so many thoughts going through his head that he could not get them all out. He started working longer and longer hours, but did not really get anything completed, and jumped from project to project. He also went out to bars after work each night and drank until they closed. What was going on with Jonathan?

Jonathan had a Manic Episode, which includes a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (Jonathan’s mood would be described as elevated). Three or more of the following symptoms generally persist (four if the mood is only irritable) and are present to a significant degree.

1. Inflated self-esteem or grandiosity. – This did not appear to happen with Jonathan.
2. Decreased need for sleep. – Jonathan felt rested after only three hours of sleep.
3. More talkative than usual or pressure to keep talking. – This was noted by Jonathan’s co-workers.
4. Flight of ideas or subjective experience that thoughts are racing. – Jonathan felt he had so many thoughts going through his head that he could not get them all out.
5. Distractibility. – This was evident in Jonathan’s inability to finish projects at work.
6. Increase in goal-directed behavior – This was demonstrated by his longer and longer hours spent at work.
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences such as unrestrained shopping sprees, sexual indiscretions, or foolish business investments. – Jonathan drank until the bars closed each night after work.

Bipolar disorder is often comorbid with other disorders such as alcohol or drug abuse or dependence, anxiety disorders, eating disorders, and personality disorders.

So, what can be done to help Jonathan?

Bipolar disorder is the result of genetic and biological vulnerability that leads to mood disorder symptoms and dysregulation. This, combined with life and family stressors, triggers episodes.

The most common forms of treatment are medications such as mood stabilizers (for example, Lithium & Depakote). Sometimes, in an acute manic phase, an antipsychotic (such as Risperdal) is prescribed. After someone has been stabilized for a while, they might be prescribed an antidepressant (such as Prozac). Because people often go through phases when they do not take their medication, (and even when they do, they have ‘breakthrough episodes’ – similar to what happened to Jonathan; breakthrough episodes develop when there is a reoccurrence of symptoms.) It is recommended to people with bipolar disorder that they also attend therapy.

In individual therapy, people learn the importance of medication adherence and stress management. They develop an understanding of their signs of depressive and manic episodes. They realize the importance of self-care such as balanced eating, exercise, regular sleep routines, and relaxation. They develop a plan with family and friends to recognize their symptoms and intervene when necessary. They also learn to challenge their depressive thinking and increase positive experiences to help manage their emotions.

In family and marital therapy, individuals learn how to express emotions, communicate, and recognize when they are experiencing stress and other symptoms. Education about bipolar disorder is often completed with families to help them understand their loved one’s vulnerability to future episodes and the need for medication. Families also need to be taught the difference between symptoms and personality, how to recognize and learn to cope with their own stressors, and the importance of reestablishing relationships after episodes.

What happened to Jonathan?

Jonathan was taken to the emergency room and a call was placed to his psychiatrist. The psychiatrist was able to work with him on an out-patient basis to adjust his medication, although Jonathan did take a week off of work to help reduce his stress level. The psychiatrist also recommended Jonathan see a clinical psychologist trained to do therapy with people with bipolar disorder. Jonathan started to readjust within a week and started to really feel better within about a month. For the past year, he has learned to only work 40-hours a week, get enough sleep, exercise, eat healthfully, take his medication, and spend time getting to know people and relaxing. He has also learned to recognize his symptoms in case he starts to feel depressed or manic.

Bipolar disorder is not unmanageable, but it cannot be treated by self-help alone. If you think you or someone you know suffers from bipolar disorder, now is the time to seek a consultation regarding prevention and treatment.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: APA.

Miklowitz, D. (2001). Bipolar Disorder. In Barlow, D. (Ed.). Clinical handbook of psychological Disorders, 3rd ed. (pp. 523-561). New York: Guilford Press.

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Understanding Autism

Parents are usually the first to notice their child having difficulty and failing to meet developmental milestones. Some things parents might notice are lack of joyful facial expressions by six months, difficulty engaging in give and take interactions by nine months, and delayed language development.

There are three distinctive areas of difficulty which characterize autism. Autistic children have difficulties with social interaction, problems with verbal and nonverbal communication, and repetitive behaviors or narrow, obsessive interests. These behaviors can range in impact from mild to disabling.

The hallmark feature of autism is impaired social interaction. Some children show hints of problems within the first few months of life, while others may not show deficits until they are two years old or later. Some children may develop normally until the age of two, but then they stop making gains in language and social skills or they lose skills that they had already acquired. No two children with autism are alike and presentation may vary significantly.

Autism impacts 1 in 150 people. It occurs in all racial, ethnic, and socioeconomic groups. Autism is four times more likely to occur in boys. Autism impacts one’s overall ability to communicate with and relate to others. Symptoms range from mild to severe. There are five disorders that fall under the Autism Spectrum. These include Asperger Syndrome, Rett Syndrome, Pervasive Developmental Disorder, NOS, and Childhood Disintegrative Disorder.

As children with autism grow up, they may respond differently to their environment. Many adolescents are overwhelmed by the transition between childhood and adulthood. Parents should expect this to be true of adolescents with autism as well. While some behaviors improve during teenage years, some tend to get worse. You may notice an increase in repetitive and aggressive behaviors as the teen has difficulty managing the stress and confusion associated with adolescence. Not to mention the physical and hormonal changes! This is also a time where the teen is at risk for developing anxiety or depression as they become increasingly aware that they are different from their peers.

Treatment: The presentation of autism and other spectrum disorders varies significantly in adults. Some are able to live independently and maintain employment while others have significant difficulty completing daily tasks.

Long before your child finishes school, parents should research available social supports to assist your child with autism in adjusting to the “adult world.”

While there is no identifiable fully effective cure for autism, early intervention obtains maximum benefits for your child. Early intervention should focus on improving communication, social, and cognitive skills.

Although there is no single treatment protocol for all children with autism, most individuals respond best to highly structured behavioral programs.

Psychosocial and behavioral interventions are key parts of comprehensive treatment programs. In addition to these interventions, therapies often include occupational therapy, sensory integration therapy, and speech therapy.

If you have concerns about your child’s development, speak to your pediatrician to determine the best course of action and complete screenings with other qualified professionals, such as a psychologist.

Click here to download this article as a PDF

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Understanding Autism

Parents are usually the first to notice their child having difficulty and failing to meet developmental milestones. Some things parents might notice are lack of joyful facial expressions by six months, difficulty engaging in give and take interactions by nine months, and delayed language development.

There are three distinctive areas of difficulty which characterize autism. Autistic children have difficulties with social interaction, problems with verbal and nonverbal communication, and repetitive behaviors or narrow, obsessive interests. These behaviors can range in impact from mild to disabling.

The hallmark feature of autism is impaired social interaction. Some children show hints of problems within the first few months of life, while others may not show deficits until they are two years old or later. Some children may develop normally until the age of two, but then they stop making gains in language and social skills or they lose skills that they had already acquired. No two children with autism are alike and presentation may vary significantly.

Autism impacts 1 in 150 people. It occurs in all racial, ethnic, and socioeconomic groups. Autism is four times more likely to occur in boys. Autism impacts one’s overall ability to communicate with and relate to others. Symptoms range from mild to severe. There are five disorders that fall under the Autism Spectrum. These include Asperger Syndrome, Rett Syndrome, Pervasive Developmental Disorder, NOS, and Childhood Disintegrative Disorder.

As children with autism grow up, they may respond differently to their environment. Many adolescents are overwhelmed by the transition between childhood and adulthood. Parents should expect this to be true of adolescents with autism as well. While some behaviors improve during teenage years, some tend to get worse. You may notice an increase in repetitive and aggressive behaviors as the teen has difficulty managing the stress and confusion associated with adolescence. Not to mention the physical and hormonal changes!  This is also a time where the teen is at risk for developing anxiety or depression as they become increasingly aware that they are different from their peers.

Treatment: The presentation of autism and other spectrum disorders varies significantly in adults. Some are able to live independently and maintain employment while others have significant difficulty completing daily tasks.

Long before your child finishes school, parents should research available social supports to assist your child with autism in adjusting to the “adult world.”

While there is no identifiable fully effective cure for autism, early intervention obtains maximum benefits for your child. Early intervention should focus on improving communication, social, and cognitive skills.

Although there is no single treatment protocol for all children with autism, most individuals respond best to highly structured behavioral programs.

Psychosocial and behavioral interventions are key parts of comprehensive treatment programs. In addition to these interventions, therapies often include occupational therapy, sensory integration therapy, and speech therapy.

If you have concerns about your child’s development, speak to your pediatrician to determine the best course of action and complete screenings with other qualified professionals, such as a psychologist.
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September is National Alcohol
and Drug Addiction Recovery Month

Like all behaviors, drug and alcohol use occurs along a continuum. Some of us drink ‘socially’ or use drugs ‘recreationally.’ Others find themselves using substances in a way which leads to some mild impairment in their lives while others use to an extent that can be devastating or even deadly.

A common misconception is that the user does not wish to quit and is content with their use. Most ‘addicts’ desperately want to end their dependency but have had little success because of the chemical and psychological dependence. They may earnestly try to quit but soon return to their habit when attempting to quit without assistance. Therapists, trained in substance use, can help an individual combat their use, help their family, and make recommendations for when medical intervention is necessary.

Not all substances are illegal drugs. Some common household products can be ingested to achieve a ‘high.’ Some drugs are inhaled, such as powdered cocaine, while others are ‘huffed’ such as gasoline and glue. Common prescription medications can be used such as Valium, Xanax, or Oxycodone. Other drugs that are taken in pill form, which are called ‘uppers’ and ‘downers,’ include amphetamines, sedatives, pain killers, and hallucinogens. Injectable drugs include heroin. Smokeable drugs include crack cocaine, marijuana, and cigarettes. Alcohol is also considered a substance and common household products such as vanilla extract made be ingested as well.

There are two distinct categories of problem substance use, abuse and dependence.

Substance abuse involves the recurrent use of a chemical that leads to distress for the individual or people around them. Difficulties can include: (1) not fulfilling major role obligations at work, home, or school such as repeated absences or neglect of one’s children; (2) placing oneself in physically hazardous situations, such as drinking and driving, or (3) legal problems such as disorderly conduct. Also, despite overwhelming physical and social difficulties, such as arguments with a partner or physical fights, abusers will continue their habit.

Substance dependence or ‘addiction’ also involves the recurrent use of a chemical. Individuals who become dependent on substances develop tolerance and/or withdrawal. Tolerance occurs when an individual needs more of the substance to have the same effect and/or has less of an effect when using the same amount. Withdrawal includes physical symptoms that are specific to the substance and/or taking the substance to avoid the withdrawal. Therefore, when someone attempts to quit using it, they often claim to “not feel quite right” and return to their addiction.

Other symptoms of dependence include: (1) taking the substance in larger amounts or over longer periods than was intended; (2) a persistent desire or unsuccessful effort to cut down on use; (3) spending a great deal of time in activities to obtain the substance; (4) giving up or reduced participation in important social, work, or fun activities; (5) using despite knowing that it is problem. There are psychological symptoms associated with dependency as well. For example, smokers who use a cigarette during a specific time each day may feel the need to smoke during that time. Alcoholics going to a restaurant with friends may have the urge to drink solely because there is alcohol available.

If you or someone you love struggles with substance use or dependence, there are many ways to find help. Our website Resources page lists some free or reduced fee local resources. At Lepage Associates we have psychologists who specialize in working with users, and family and friends affected by use. Our Addictions & Compulsions group, Co-Dependency Support group, DBT group, and Women’s group can also be helpful. Our Substance Abuse Assessment can help you determine what level of treatment is required for a person struggling with this problem. Our staff would be happy to speak with you and provide more information and guidance.

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Suicide Prevention Can Help Save Lives

September also houses National Suicide Prevention Week. The major elements of suicide prevention include awareness, open communication, and knowledge of access to resources.

A suicidal crisis often occurs when someone is experiencing an intense depression. You may notice changes in someone’s behavior such as negative thoughts and actions, harmful acts, and deteriorative functioning. Despite the intensity of suicidal thoughts, they are usually associated with problems that can be treated. Individuals experiencing a suicidal crisis are usually overwhelmed and are unable to think of alternative solutions in their current state of mind. Therefore, people need help from their loved ones to encourage them to get help. Suicidal crises are almost always temporary and the most important aspect is getting through the crisis without self harm.

Awareness

Risk factors for suicide include psychiatric disorders, genetic predisposition, history of attempted suicide, and impulsivity. Other warning signs are: (1) looking for ways to die (internet searches, acquiring a gun or pills, etc), (2) preoccupation with death, (3) becoming suddenly happier and calmer, (4) loss of interest in things the individual used to care about, (5) visiting or calling people one cares about (good-bye calls), (6) making arrangements to settle affairs, and (7) giving things away (such as prized possessions).

You can use this common acronym when assessing risk factors:

I – Ideation (thinking, talking, or wishing about suicide)
S – Substance use or abuse (increased use or change in substances)

P – Purposelessness (no sense of purpose or belonging)
A – Anxiety (restlessness, irritability, agitation)
T – Trapped (feeling like there is no way out)
H – Hopelessness (there is nothing to live for, no hope or optimism)

W – Withdrawal (from family, friends, work, school, activities, hobbies)
A – Anger
R – Recklessness (high risk-taking behavior)
M – Mood changes (dramatic changes in mood)

Open Communication

It is a common misconception that talking about suicide can give someone the idea of suicide. If you are recognizing the warning signs of suicide, do not be afraid to ask about it. Initiating this conversation can give the individual the opening to discuss their thoughts and feelings.  If you fear that someone may take their life, be willing to listen and take them seriously. If you are feeling suicidal…Do not keep these thoughts to yourself!  There are people willing to listen and offer a helping hand.  

Resources

There is no shame in seeking professional help. If there is a risk of suicide do not leave the person alone until help is available, and remove any sources that can aid in a suicide attempt. Do not hesitate to call 911 or take the person to the nearest emergency room. It is important to encourage the individual to follow up with treatment once the suicidal crisis passes. There are many protective factors that an individual can use including the assistance of professionals. Other resources include family and community support, skill building, and religion/spirituality. Helping the individual identify reasons for living can help sustain a person in pain.

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Post Traumatic Stress Disorder (PTSD)

What is PTSD and what does it have to do with my case?

Traumatic events can include, but are not limited to, military combat, violent personal assault (rape, domestic violence), being kidnapped, being taken hostage, terrorist attack, torture, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.  It can result in substance use, depression, and anxiety.

Trauma can complicate any legal case. Your client may have difficulty participating in the legal process and require therapy. The event precipitating legal action may be the cause of the trauma and need to be considered in a settlement case. PTSD can also be malingered. If you are able to recognize the symptoms of PTSD, you can obtain an expert to help argue a stronger case for your client.

A person should be evaluated for PTSD if they witnessed, experienced, or were confronted with an event that involved actual or possible death, grave injury, or threat to physical integrity. However, having the experience does not in itself lead to a diagnosis of PTSD. The person’s response must have included severe helplessness, fear, or horror. In children, this may be expressed instead by disorganized or agitated behavior. Further, in order to receive a diagnosis of PTSD, the following symptoms must occur for at least one month and interfere with one’s work, family, and/or social life. Several symptoms must occur in a number a categories, it’s actually quite a high bar to be diagnosed with PTSD.

1. Reexperiencing symptoms– at least one must be present:

1. 1. 1. Memories of the trauma which intrude into consciousness repetitively, without warning, without triggers, or reminders to elicit them. In children, repetitive play may occur in which themes or aspects of the trauma are expressed.
      2. Vivid reenactments or flashbacks of the event. In children, trauma-specific reenactment may occur.
      3. Nightmares about the event. In children, there may be frightening dreams without recognizable content.
      4. When faced with actual or symbolic cues related to the event, the person has intense psychological reactions such as terror or physiological responses such as increased heart rate.
      5. The symptoms are viewed as intrusive and distressing because the person has no control over when or how they occur.

2. Avoidance and numbing symptoms– at least three must be present:

1. 1. Avoidance of thoughts and feelings about the trauma.
   2. Avoidance of situations and events that remind the person of the trauma.
   3. The person actually forgets specific aspects of the trauma.
   4. One is cut off from both positive and negative emotions.
   5. These symptoms make it hard to relate to others, enjoy life, remain productive, and plan for the future.

3. Physiological hyperarousal – at least two must be present:

1. 1. A state of fight or flight exists similar to the response during the traumatic event.
   2. One is primed for danger in most situations even when it’s safe.
   3. Difficulties with sleep, concentration, and/or irritability are present.
   4. People can have very strong startle reactions as well.

Can you have trauma and not have PTSD?

Most people exposed to trauma do not develop PTSD. In fact, a major study that surveyed almost 6,000 people found most had experienced at least one major traumatic event. It has been theorized that people who experience trauma who do not develop PTSD have protective factors such as a high level of education and considerable social and emotional support.

What causes PTSD?

Research indicates that about 20% of women and 8% of men who experience traumatic events are likely to develop PTSD. The types of trauma that are more likely to lead to the development of PTSD include rape, combat, childhood neglect, childhood physical abuse, threat with a weapon, sexual molestation, and a physical attack.

There is some research that suggests certain individuals are predisposed to develop PTSD when exposed to trauma. Some people are more prone to perceive a situation as dangerous and to be more physiologically reactive. For example, subjects with PTSD exhibit higher resting heart rates than those without PTSD. There are several risk factors for developing PTSD which include: female sex; neuroticism; lower social support; lower IQ; preexisting psychiatric illness, especially mood and anxiety disorders; childhood physical or sexual abuse; childhood separation from parents; a family history of mood, anxiety, or substance abuse disorders; and family instability. If someone dissociates (mentally disconnects) at the time of the event they are also more likely to develop PTSD.

There are multiple theories for the development of PTSD. An individual with PTSD has learned to associate events related to the trauma with fear, and avoidance with escape. Therefore, when someone encounters a fearful situation they experience the avoidance and numbing symptoms described above. Intrusive reexperiencing symptoms appear related to mental fear structures that form a network in the memory. This fear network is activated by reminders of the trauma and, again, avoidance behaviors are employed. This activation also interferes with daily life because it impacts a person’s belief system and her or his expectations of the world are shattered. These include beliefs about safety, trust, control/power, self-esteem, and intimacy. Therefore the person often blames them self for the event and feels shame or embarrassment.

Does it interfere with someone’s ability to work?

PTSD does not resolve quickly. If symptoms are not resolved within about three months then they tend to persist over time and worsen without appropriate intervention. PTSD can co-occur with a number of problems such as pain, depression, anxiety, substance abuse, and personality disorders. Not only does PTSD affect a person’s emotional and interpersonal functioning but it also affects the body in several different ways. For example, people with PTSD exhibit higher heart rate, blood pressure, and skin conductance (sweaty palms). People with PTSD are more prone to startle in reaction to loud noises as evidenced by larger eye blink and brain wave responses. Exposure to inescapable stress releases chemicals in the brain that blunt sensitivity to pain which may underlie numbing. Acute stress triggers the release of excessive stress hormones which suppresses the immune and metabolic systems thus making someone more prone to illnesses. In other words, if PTSD goes untreated it can interfere with someone’s ability to work. However, with appropriate treatment, most people with PTSD can return to a normal level of functioning, including work.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: APA.
McNally, R. (1999). Posttraumatic Stress Disorder. In T. Millon, P. Blaney, and R. Davis
(Eds.), Oxford textbook of psychopathology (pp.144-165). New York: Oxford University Press.

Resick, P., and Calhoun, K. (2001). Posttraumatic Stress Disorder. In D. Barlow (Ed.),
Clinical handbook of psychological disorders, third edition (pp. 60-113). New
York: The Guildford Press, NY.

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Psychological Forensic Evaluations

What is the difference between a clinical psychological evaluation and a forensic evaluation?

How do you pick the right expert for your evaluation?

Knowing when and how to obtain a forensic evaluation – which typically goes beyond the scope of a basic clinical interview – could make or break your case.

Following are several things you should look for in a forensic evaluation:

• In all evaluations, psychologists complete a clinical interview with the client. Some psychologists stop here, and while a clinical interview is certainly better than no evaluation, it is not the most thorough method of assessment as it is purely self-report.
• It is more helpful to use psychological testing so that the bulk of information is not based on the client’s self-report. Many psychologists administer psychological instruments such as the Minnesota Multiphasic Personality Inventory (MMPI-2), which is an objective measure of personality and major categories of psychopathology. The MMPI-2 is widely used because it is well known to be a reliable, valid test. It also has a Lie Scale to help determine if someone is trying to form a favorable impression or mislead the examiner regarding severity of illness. However, though better than an interview only, this test is, again, based on the client’s self-report.
• It is therefore recommended that multiple tests be completed. A full battery should look at the client’s cognitive, emotional, and personality functioning. A battery gives added weight to your argument that the client was fully evaluated. (Tests that are specific to the situation are described below.) This may be where some psychologists end their evaluation.
• However, a full battery could still be a clinical evaluation and not a forensic evaluation. According to the American Academy of Forensic Psychology, a full forensic evaluation includes actively seeking information from more than one source that would differentially test plausible rival hypotheses. This means psychologists need to actively seek prior records. They also need to talk to people who know the client, to assess both pre- and post-functioning. These collateral contacts are not only family members with a vested interest in the client, but also professionals or disinterested parties who will provide impartial accounts of the client.

Competency to Stand Trial

• Psychologists can help determine if your client has an adequate understanding of the legal proceeding and ability to work with you. The focus of the evaluation is on current functioning and mental status. Psychologists can administer psychological instruments such as the MacArthur Competence Assessment Tool-Criminal Adjudication. This instrument helps the psychologist determine if the client understands the charges and trial process as well as her appreciation of relevance of information for her defense. This instrument also helps uncover the client’s ability to reason during decision making tasks and her logical problem-solving abilities.
• A subset of this type of evaluation is competency to plead guilty. The psychologist helps determine if the client understands the criminal process, is able to work with the attorney, why she wants to plead guilty, and her understanding of the implication of relinquishing certain rights.

Competency of Juveniles

• The community often disagrees on the topic of whether juveniles should be tried as adults. Psychological research suggests one’s cognitive abilities are still developing in most “normal” children prior to age 14, that is, a child without mental disorders or cognitive disabilities. Therefore a child’s ability to understand information that is provided to defendants regarding the trial process, and to reason with the information that they acquire or bring to the situation, is not fully developed. It is suggested that most children under 12 be evaluated. As should children with a history of mental illness or mental retardation, borderline intellectual functioning, and learning disabilities. If you observe that your young client has deficits in memory, attention, or interpretation of reality you may consider an evaluation as well.
• A psychologist should look at psychosocial factors such as self-control, self-concept, relationships with adults in authority, and the child’s capacity for perspective taking in decision making.

The Insanity Defense

• Psychologists can help determine your client’s mental condition at the time of the offense and if they should be held responsible for the crime committed. North Carolina insanity laws are based on the McNaughton standard, which asks if the client is suffering from a mental disease (mental illness) or defect (mental retardation). If so, did it impact their ability to know and understand the nature and quality of their act? Was the client able to understand and appreciate what they were doing was wrong? This standard emphasizes the quality of one’s thought process and their perception of reality. The burden of proof is on the prosecution.
• Some psychologists use the Rogers Criminal Responsibility Assessment Scale which looks at brain disorders, mental disorders, behavioral control, the ability to control one’s thoughts, and reliability of the person’s report.

Malingering

• Psychological instruments can be administered such as the MMPI-2; however, as stated earlier, it is a self-report measure. More sophisticated measures of malingering are instruments such as the Structured Interview of Reports Symptoms (SIRS). The SIRS assesses a variety of areas such as defensiveness, uncommon symptoms, changes in behavior during the assessment, and common symptoms. One can determine if someone is trying to fake memory problems by using an instrument such as the Test of Memory Malingering.

Death Penalty Cases

• North Carolina has instituted laws against executing individuals with mental retardation. There is also a push to create legislature regarding execution of individuals with severe and persistent mental illness. Therefore, a psychologist may help determine if a client is competent to be executed. An assessment of mental retardation would include cognitive testing such as the Wechsler Adult Intelligence Scale (WAIS-R) and might include neuropsychological testing regarding brain injury. In these cases, there needs to be evidence that mental retardation was present prior to age 18 so record review and speaking with collateral contacts is vitally important.

References:

American Academy of Forensic Psychology website listed below:
https://www.ap-ls.org/links/currentforensicguidelines.pdf

Wrightsman, L. & Fulero, S. (2005). Forensic Psychology, Second Edition. Thomson Wadsworth.

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