Thursday, March 30, 2017

Wellness tip: Look out the window.
Stepping outside may not be necessary, or sufficient, to get some wellness benefits of experiencing nature. The beneficial mental effects of the outdoors are not just about fresh air; it is about looking up, looking around, noticing the complex forms of nature.

Various studies, of prison inmates, city dwellers, and college students, all show that VISUAL exposure to the complex forms found in nature, such as clouds, animals, streams, and most powerfully, TREES, is enough to reduce stress, aggression, problems in mental performance, an...d complaints of feeling sick. Just seeing trees through a window or on screen was enough for these benefits!
This doesn't mean you should avoid going outside.  If you take a walk outside or even pass by a window, be sure to LOOK UP at complex natural forms such as trees, clouds or even our imperfect, assymetrical faces; it may just add peace of mind, clarity of thought, and coping ability to your day.

Photo taken by Jim Foley in Holmes County Ohio in March 2017. Taken from the window of my car, so in this moment, I was hopefully getting some wellness benefits without going fully outside. 

Saturday, March 8, 2014

Having all the symptoms, but no "disorder." DSM and overdiagnosis

Statements from friends or clients about whether there is too much diagnosing: 
1. "I question my sexual identity, but it doesn't freak me out or depress me, why tell me I have Gender Identity 'Disorder.'"
2. "I am totally phobic of snakes, but there are no snakes where I live, so I never have any anxiety or freakouts, just let me have my fear." 
3. "I have compulsions and obsessive thoughts just like in OCD, but it doesn't ruin my day, I just ignore it and no one makes a make a big deal of it."
4.  "I have like 10 of those ADHD symptoms, but I run my own business now, get stuff done even if it's 12 projects at a time, I've always done well enough without medications or anything."
5. "Yeah, I get aroused by weird stuff, but I don't act on it, it doesn't hurt anyone, why is it a disorder." 
6. "I have Asperger's Syndrome, I even meet the new criteria for Autism Spectrum Disorder, but I do fine in life, I'm happy, I don't think I should be labeled as having a disorder."
7. "My brain can't do some things but I have a job and friends and I'm happy. Don't say I'm retarded"

In the psychiatric diagnostic manual used for the past two decades, the DSM IV-TR, many of these clients would indeed be correct:  you can have all the symptoms of a disorder, but still not being given the diagnostic label, because the DSM, for all of its reputation for encouraging overdiagnosis, does not allow you to make a diagnosis unless there is significant distress or functional impairment related directly to the symptoms.*  

The new diagnostic manual, the DSM-5 makes this even more clear, by clearing up some issue related to some of the examples above.  
1. Gender Identity issues are not automatically a disorder.  The new term is "Gender Dysphoria," with the idea that only if your Gender Identity issues led to chronic mood problems, as they might if you fully felt trapped in a body with the wrong sexual organs and sexual role and were misunderstood by others and didn't have access to, or comfort with, sexual reassignment surgery.   
2. Paraphilias, unusual arousal patterns such as transvestism arousal, fetishism, are not necessarily a disorder unless you act on your preferences with a nonconsenting partner, or otherwise act in a way that causes distress for yourself or others or interferes with family life or work. Pedophilia has stricter wording** and is the closest to being automatically a desire just for being aroused by children, but again truly becomes a disorder only when there is a risk of acting on it. But otherwise, being aroused by something unusual is no longer automatically a disorder. 
3. The "Mental Retardation" label is no longer in the manual, partly because its implication of merely delayed development is not accurate.  More importantly, Intellectual Disability/Intellectual Development Disorder (to use  DSM-5 terminology) is not defined by IQ, it's defined by the level of impairment in your social, occupational/academic, and other functioning. 

The point of not overdiagnosing a "difference" such as Asperger's/ASD as a "disorder" is not just to avoid stigmatizing people.  The point of the manual is to have a shorthand way of talking about the conditions which need to be treated.  So if there is no need for treatment, support, or intervention, it can still have a name like "Asperger's," but it's not a disorder. 

The DSM-5 has a lot more ways of describing mental health conditions than in the past; depending on whether all of those ways and specifiers count as separate diagnoses, it may have more diagnoses than ever. But in some cases, it's harder to get those labels than in the past, especially if you don't need treatment.  So don't blame the DSM-5 for overdiagnosis, blame the people who aren't reading the criteria.*** 

(Hmm:  Diagnostic labels mean that there is a need for treatment, not just that there is a disability, not just a reason for not functioning well. Sounds like the subject for another post/article.  I've already started it. )

* Examples of advancements in overdiagnosis prevention even before the DSM-5: : 
1) You can indeed have Asperger's Syndrome but do fine in life and be happy and thus you do not qualify for a diagnosis of Asperger's Disorder (for more on this:  
2) Homosexuality was dropped from this manual, in part because: even though being gay or lesbian may lead to distress, the distress is caused by bigotry or loneliness or hiding part of yourself, rather than by the sexual preference itself). 

** In Pedophilic Disorder you can have no distress and no functional impairment and still be diagnosed with that disorder due to the common risk of harm to people too young for their level of consent to be determined.

*** The wording which is left out of many popular psychology summaries of DSM disorders:  A collection of symptoms matching those for a disorder is still not a disorder unless it: "causes significant distress, or impairment, or, [in the case of disorders like pedophila] risk of harm to others."

Sunday, January 5, 2014

Sleep problems: One of many mind-body challenges

If only sleep was always as easy and pleasant as it seems to be for this little charmer.

You or your clients or loved ones may:
1) be kept awake by worries and even headaches and stomach aches worsened by worry.
2) wake up in the middle of the night feeling scared, agitated, sweating and afraid
3) take hours to fall asleep and then take hours to become alert in the morning
4) sleep fitfully, up and down throughout the night as if never really falling into a deep sleep.

Although true biologically based sleep disorders are rare, sleep problems are common. Sleep is an arena where our bodies and minds interact; the new psychiatric diagnostic manual recognizes that it's hard to separate cause from effect when sleep, mood, thoughts, the body, and behavior are all not working smoothly.
You have probably heard that  reduced and disrupted sleep can lead to problems in the mind and body; research tells us that sleep loss can lead to problems in thinking/learning/concentration, physical illness, emotions, weight gain, premature aging, inflammation, and more.
the 25 gifs that perfectly describe going to new york university

This list of problems doesn't mean that forcing sleep through medication is the one correct pathway to get the whole sleep/mind/body system working smoothly again.  In fact, I've had clients become "immune" to all sleep inducing medications because there is an underlying problem leading to sleep avoidance.  These problems have included fear of nightmares, or simply not wanting to snore and disrupt a partner's sleep.

Dealing with sleep issues is also not a simple matter of just "dealing with what's on your mind."  People have genuine biologically-involved sleep problems such as narcolepsy, delayed or advanced sleep phases,, sleepwalking, and sleep terrors (not the same as nightmares, in fact they take place in deep sleep, not in REM sleep).  I say "biologically involved" because a problem that began as a lifestyle or anxiety issue can become a biological issue and vice versa.  Depression itself is a mix of emotional, cognitive, and whole-body effects including too much or too little or unrestful sleep. I've learned as a therapist to be flexible in realizing that sometimes the body (medications) are the first point of intervention, sometimes the mind or behavior should change first to bring the body back into balance.
Most often, in the case of sleep, depression, anxiety, anger, thought disorder, or attention and learning problems, getting on the road to health means making coordinated changes in body, thoughts, relationships, and lifestyle.
The new diagnostic manual of mental disorders makes special mention of how sleep issues are not just rooted in mind or brain or body alone; I am glad when medical and mental health professionals recognize this about many mind-body problems and work together with clients/patients on figuring out what's going on and making life better.

Sunday, December 1, 2013

Autism Spectrum Disorder websites fully updated for 2014

I am presenting two full-day workshops this week on Autism Spectrum Disorders.  As part of my prep, I updated my list of websites with information helpful to people on the spectrum and those who care about them or are seeking more information.  I recommend each of these.
Every site below is one I have visited in November 2013, so they should be up to date, so I can guarantee no dead links if you're seeing this post in 2013, and if you comment below on any broken links or new sites for me to recommend, I'll keep it updated.  These are in the order I came across them this month, not any order of priority.
This and other information on ASDs will be at my new blog,  --trainings, conferences, resources for professionals, also lists of professionals with expertise  --parent resources, material on lifestyle issues such as safety and hygiene, focused on younger and more severe cases but material on Asperger’s too.  --descriptions, forums, although site is currently being rebuilt, only basic articles available. --Northern Ohio-based organization for families of people on the spectrum; offers social activities, empowerment network for parents, teen and adult services, and an annual conference in Cleveland in mid-June (I have not attended).  -- News from a foundation supporting research on autism causes and treatment.  Alternative to Autism Speaks. -- supports autism research with the hope of curing autism.   Not as sympathetic to the idea of autism as an alternative mind structure that can be part of a happy life.  Sympathetic to parents, in fact sees autism as a terrible tragedy affecting parents.  But it’s evolving, adding information for helping adults with autism. --Autism Spectrum quarterly, a “Magajournal” of personal stories, promotional pieces for treatment programs, and digested research information.  --News, especially science and policies  --general information and questions Widely trusted source, WebMD, assembling research information on autism, brain, and body. --Sponsored by the Autism Society of North Carolina, but has resources for everyone, is up to date, easy to use, with many topical categories, listing new items and sale items.  Much easier to use for searching than Amazon, which includes tons of self-published e-books as 80% of search results. --blog related to ASDs, lots of common sense advice to parents and teachers and clinicians. 
National Institutes of Health, under their National Institute of Neurological Disorders and Stroke:
Recommended at the above website:
Autism Network International (ANI)
Autism National Committee (AUTCOM)
Autism Research Institute (ARI)
Autism Science Foundation
Autism Society of America 
    --links and to local resources, serves   clients, family members, professionals, advocates
Association for Science in Autism Treatment
--online practice in reading emotions by just looking at the eyes. Interactive Autism Network
   --  Opportunities to participate in research, link to researchers
   -- participate in an online community of families of people with autism  --by Lee Wilkinson, clinician and author of a lot of articles which aid in the undestanding and treatment of ASD

Friday, November 15, 2013

The power and magic of engagement

"How can I be happy?"
"I know it's my responsibility to make myself happy, but I can't keep it up."

Clients trying to emerge from depression often seek a path toward happiness.

Sometimes they achieve a feeling of happiness, even euphoria, but it doesn't last.  When depression returns, the client may feel that they failed at the goal of finding happiness.  In my experience with seeing clients emerge from depression into well-being, the real failure might be that they were seeking an unsustainable goal.

After the impulse to flee from depression into buying stuff, love affairs, entertainment, reassurance, deep insights about better ways to think, sometimes clients actually latch onto a new activity or interest that they like pursuing in an of itself, not as a psychotherapeutic intervention.  Or they may drop habits that were part of the depressive lifestyle and adopt new ones, by choice rather than routine.  Or they may take a fresh look at the people and roles that are part of their daily lives, and take initiative in those roles and interactions.

Ironically, these acts of engaging with the world may lead to more lasting contentment than seeking happiness itself.  Waiting to find the happy place can leave you feeling lost and disappointed, and back into depression.

If depression includes an element of learned helplessness, then actively making choices and initiating changes in behavior creates an intuitive experience of learned involvement, purpose, mastery, control.

As I found myself saying to a client this week, in my inspiration for making this post:  Sometimes, for some people, the opposite of suicidal feelings (or apathetic resignation, for a client earlier in the week) might not be happiness, it might be: engagement.

Addendum:  this idea of seeking engagement rather than happiness has worked for an anxious client too: it was a relief for her to drop the agenda of figuring out how to discover some ideal place called happiness, and instead just decide what action she wanted to take next, even if that was to simply drop her simulated happy face, be silent, and rest.  Even rest can be a form of being more actively engaged:  instead of putting on a fake smile to be "strong," lie down and really let your head nestle into that pillow.

Sunday, November 10, 2013

How will clinicians do DSM-5 diagnosis with no Axes?

Okay, these are not the Axes in the DSM, but this is the kind
of Axes we're talking about; various dimensions that can
describe an object, or person.  Axes work best for dimensions
that can be counted, like levels of severity of different
symptoms; doesn't work so well to make a picture based
on diagnostic labels.  Another reason to drop "Axes."
That’s “Ax-eees”, plural of ‘axis,’ not “Ax-iz,” plural of ‘ax.’

Clinicians are faced with using the first major revision to the diagnostic manual in 19 years.  Here’s a behind the scenes look at the changes in how they’ll manage writing down a diagnosis.  Actually choosing which diagnosis is correct will be a matter of mastering the new and changed diagnostic criteria; I’ll be posting about that, category by category.

The most burning question at my last presentation on the DSM 5 was:  How do I “diagnose,” which meant in part, “what do I write on the form now that there won’t be 5 Axes to fill out?” 

Here’s a crosswalk from the old process to the new process: 

Until summer 2014 (or later, depending on when agency paperwork is updated) “Diagnosing” used to mean filling in information in five “Axes” on a form:

Axis I:  Clinical disorders and other conditions (“V” codes) that are a focus of clinical attention
            à  The primary and secondary conditions being treated by the person filling out the form, and other diagnoses also present but not as much the focus of treatment

Axis II:  Presence of personality disorder or cognitive disability/”mental retardation”
à Conditions that might not necessarily be the subject of treatment, but that affect how treatment proceeds.

Axis III:  Medical Conditions
à Especially those which may affect mental health problems and treatment

Axis IV:  Psychosocial Stressors
            à A list of conditions outside the individual which affect mental health problems and treatment

Axis V:  Global Assessment of Functioning (GAF)
            à  a number from 1-100 (0 used only if there is no information) describing the impact of the mental health condition on the person’s ability to successfully manage the tasks of everyday life.   This number was used as a comparison point to show progress in treatment. 


Basic answer:  Just list the diagnosis you’re focusing on, and others that might be important to mention.

When I say “basic” I don’t mean “easy”; you do have to use the revised manual and find out what’s a match for your clients; more guidance on that for a variety of different conditions in upcoming posts. 

First, we have some Axes to mourn.  
Where will we put that important information that was in the Axes?

Axis I:  mental health diagnosis will still be there.  There will be some more writing here than in the  past:  The codes will not be enough to clarify all the “specifiers” that must be written our verbally, such as the course, severity, and associated features that can go along with a condition.  More about specifiers soon.

Axis II:  Personality Disorders and Intellectual Disabilities (moving on from the old term “mental retardation”) are just listed like any other diagnosis, though it’s still likely in many settings that there is some other condition that is the primary focus of treatment.

Axis III:  Medical conditions are sometimes the direct cause of the mental health symptoms and should be listed separately as a medical diagnosis, and then listed as part of the diagnosis, as the example on p. 181 of the DSM-5:  244.9 hypothyroidism; 293.83 Depressive Disorder due to hypothyroidism.

Axis IV: Psychosocial stressors are included in the expanded list of V codes, “Other Conditions that may be a Focus of Clinical Attention.”

Axis V:  GAF rating scores for the client as a whole are gone, but we are increasingly rating severity as part of the diagnostic process.  For many diagnoses there are guidelines for rating severity of symptoms and/or severity of the impact on functioning. 

What has changed most in the process of writing down a diagnosis:  The loss of the Axes.  Separating this kind of information into five Axes has been… given the Ax. 

Coming up:  how to search for the right diagnosis,
How to correctly diagnose using the criteria for the brand new diagnoses found in the DSM-5
Important changes to the criteria for existing diagnoses,
Preventing overdiagnosis and misdiagnosis,
Changes in thinking about some diagnoses reflected in the new categories and chapters.   For example, OCD and PTSD are moved out of the category of Anxiety Disorders, but Selective Mutism is moved IN to the category of Anxiety Disorders,

And more, including responses to questions about the DSM or some of the other realms of Mental Health Knowledge. 

Saturday, November 9, 2013

That controversial diagnostic manual DSM-5

It has been popular in the blogosphere to critique the criteria for diagnosing mental health disorders.  Some writers criticize the whole diagnostic establishment of the American Psychiatric Association, claiming that this is an effort to push drugs and stigmatize people.  Other critics* are focused on the newest version of the APA's diagnostic manual, the DSM-5.
    I'd like to take a different approach to talking about the new diagnostic manual.  It's here.  It's what we will be using.  Let's talk about how to prevent stigma rather than saying that the manual has the power to create it.  Let's talk about how to prevent overdiagnosis and thus overmedicating rather than saying it will automatically happen. And when we get into specific controversies, let's look at the facts and details rather than just echo slogans from yet another blogger who hasn't read it.   I will address some of the main controversies head on (as I did in a post already, exerpted from material on several DSM controversies that I've written for an upcoming edition of a textbook on mental health disorders).
    I welcome comments on my take on these controversies, but we all would benefit more if you comment with a DSM-5 open in front of you rather than echoing what you've heard about what's inside its 900+ pages.  Over the summer and early fall of 2013, after teaching a college course about mental health diagnosis,  I've paged through the entire manual side by side with the previous edition of the manual, in preparation for training people about mental health diagnosis in general and for specific diagnoses.  So, we can disagree in our predictions about the impact of the new criteria, but I will make sure we base our discussion on some agreement about what the manual actually says.  I'm stunned that after 11 solid months of researching the DSM, it is very hard to find comments on the internet based on actual information rather than speculation and echoes.  So I'm putting this together myself.  I want to simply lay out the facts and get mental health clinicians back to work helping clients rather than alarming them, and getting clients and patients back work trusting clinicians (psychiatrists, clinical social workers, and other psychotherapeutic professionals) rather than fearing them and the scary blue books.

*I find it interesting that the two main critics of the new version, Allen Frances and Robert Spitzer, were the coordinators of the publication of the previous versions of the manual and began their criticisms, years before the manual were produced, based on the new DSM task force being too secretive, even though subsequent criticism of the criteria, starting years before the manual was published, were based on proposed versions made available for public comment.  Is this a case sour grapes that they weren't in charge any more? That's speculation on my part, and they know the internal politics of the process much, much better than I do. But some of the alarming pronouncements by Frances and others about the Bereavement Exclusion and DMDD and other diagnostic topics are just simply wrong, or at least disconnected with the facts except the distorted, selected, neglectful version of the facts that fit a preconceived notion.
      Controversy generates viewership.  I wouldn't mind readership (though I have no books to sell nor any other benefit I can think of), but I'd rather generate knowledge and agreement than alarm and controversy.  If you're interested in the same, keep visiting; I'll be hitting the major controversies and then going diagnosis by diagnosis to talk about what's new in the first change in diagnostic criteria since 1994, affecting nearly every diagnosis you'll encounter.  I hope this will be helpful.