Jan 15

Want to lose weight? SLEEP!

BabySleepBy Dr. Micaela Wexler

Are you overweight? Are you getting enough sleep?

As I was getting ready to plan my New Year weight loss strategy, I was thrilled when I entered the words sleep and obesity in Google and found countless articles showing that lack of sleep, as in less than seven hours a night, leads to increase in weight. Sleep has been shown to affect the level of the hunger inducing hormone leptin secretion in children, and there is no reason to believe the same doesn’t happen to adults; sleep deprivation causes the decision making center of our brain to become less active, and leads to junk food cravings; sleep deprivation leads to decreased energy and motivation, which results in decreased exercising; sleep loss has a negative impact on metabolism, increasing the risk of obesity and diabetes.
So, if people want to lose weight, instead of starving themselves or hitting the gym, why don’t they just SLEEP more?

As a psychiatrist who listens to people complain of insomnia all day long, I can tell you it isn’t that easy. Many of my patients with sleep problems are also overweight.

Sometimes the reasons people aren’t sleeping are obvious: They have a small baby, they are depressed or anxious, they work nights, they are worried about debt or losing their jobs, they don’t have a job, they have a job but work too many hours (that would be me).

Other times, the reasons are obvious to me and not to them: they have relationship conflicts, they are fighting with or attracted to someone at work, they are watching TV right at bedtime, they are sleeping with smart phones next to their heads and texting and posting all through the night. Some people just have bad sleep hygiene (again, that would be me).
Then there are the people with chronic insomnia who have medical issues preventing sleep, such as chronic pain, restless leg syndrome, obstructive sleep apnea, post traumatic stress disorder, severe mental illness, to name just a few.

So, if you aren’t getting enough sleep, you first need to rule out any medical issues. A medical sleep evaluation includes a physical exam, a medical history, a sleep history and a screening for depression or anxiety.

There are some things you can do in addition to your medical evaluation. Determine what your sleep hygiene is. Sleep hygiene consists of the activities you engage in during the two hours prior to bed time. Do you “work ’til you drop (like I do)? That will keep you up at night. You need to spend those two hours before bed time slowing things down. Don’t expect to fall asleep until at least two hours after you have stopped working. Find relaxing activities to do during that time, such as some stretching exercises followed by a bath. Get your clothes ready for tomorrow, regardless of whether or not you are planning on leaving the house. Plan what your day will be.
Get yourself moving during the day. You can start with just 10 minutes of walking during lunch. You can also do a simple stretch or yoga routine before bed. Increasing your activity during the day will always lead to better sleep at night.

Anything you didn’t get done today, just put on the list for tomorrow. My feeling is this: if I didn’t get all my tasks done, it’s because I didn’t plan my day properly. Better luck tomorrow. I happen to work as a psychiatrist in a critically under served area, so I’m always going to have too much on my plate. That makes it easy for me to let myself off the hook, which I realize is not true for everyone.

Let’s say you’ve dutifully done your sleep hygiene and you STILL can’t sleep. Something that helps me is to keep a small notebook by my bed and write down the thoughts which are racing through my head. If I forget to put the notebook and pen under the pillow, then my toddler tears my thoughts to shreds the next morning, but, nothing is perfect. That usually means that since I didn’t see her sneak up and get it, then I did get to sleep.

I strongly recommend you use paper and pen rather than your smartphone. You will still be able to read it, even if you write in the dark. (Try it right now: close your eyes and write something with a pen.) And, your mind will be focused only on what you are writing, which is not possible with a smartphone.

Writing these thoughts down will help you determine why you are not sleeping. You will be able to figure out if you have insomnia because you’re worried about work, or because you are depressed. If you find that you are writing thoughts that reflect hopelessness and doom, or that you are ruminating over the same things over and over again, or you have so many thoughts you can’t get them all written down, then you may need to see a psychiatrist or therapist. Or, both.

If I go too many nights in a row without writing in the dark at night, then I will do get insomnia again. Something that commonly happens to me when I write my thoughts down in the dark is that I dream solutions to my problems. Sometimes I dream that I forgot to put my notebook under my pillow again.
The bottom line is that we have an important weight losing tool at our disposal: sleep. Maybe I’m just lazy by nature, but the way I look at it, before I start starving myself or start killing myself in the gym to lose weight, I think I’m going to start with something a little bit easier: sleep.

Dr. Micaela Wexler also blogs on child psychiatry topics at kidpsychdoc.com.

Jan 10

Borderline Personality Disorder: what is it?

WexlerPsychiatryWinterBy Dr. Micaela Wexler

The following three fictionalized cases are examples of women with Borderline Personality Disorder.

Carol (not her real name) is 29 years old. She was brought to the emergency room by police after they were called by her girlfriend when Carol threatened to kill herself with a butter knife. This is Carol’s fourth time in the emergency room in the past year for suicidal behavior. Carol and her girlfriend had been fighting over “nothing” and when her girlfriend tried to leave the apartment, Carol became frightened, and at that moment she really did want to “just die.” This is not the first time Carol has done this to this girlfriend. Carol tells me she does things to push her girlfriend away, and then when her girlfriend responds, Carol becomes frightened, because she is afraid of being alone. Carol’s girlfriend tells me that when they are not fighting, they get along extremely well. Carol is fun, witty, spontaneous, and is very bright, which makes this behavior very puzzling to her girlfriend. Both Carol and her girlfriend tell me that Carol’s emotions “change at the drop of a hat.” On the day she was seen in the emergency room, Carol had been very happy, and suddenly flew into a rage when her girlfriend questioned some charges on the credit card Carol had borrowed to get gas. Carol had stopped to buy her girlfriend a “present,” a new pair of boots she felt her girlfriend needed for the snow and would not take the time to buy for herself. At the time she bought the boots, a month ago, her girlfriend had expressed gratitude, and, in fact, she was wearing those same boots in the emergency room. Carol had meant to tell her eventually that the boots had been charged on her girlfriend’s credit card, but had put it off, not wanting to ruin the moment. “I was afraid she would get angry at me for that and just dump me, and here she is, about to do exactly what I was afraid of.”

Cheryl (also not her real name) is 28 years old. She has three children under the age of five from three different relationships, and they were all taken into state custody after Cheryl had a string of admissions to the inpatient psychiatry unit for suicidal behavior and self-injurious behavior. These admissions all occurred following Cheryl’s break-ups with different men. She has a history of putting men she meets on a pedestal, and then breaking up with them when she either perceives a flaw, or discovers a genuine problem, such as a drug history or criminal history. In the past four months, Cheryl has had three break-ups, and the last one was violent because the man didn’t want to break up (and find another place to live), and led to Cheryl losing custody of her children. Cheryl’s pattern is the following: she meets a man, and idealizes him. She tells me, “this is the one,” and I hear her fantasizing about the wonderful life she and her children are now going to have because she finally met a really nice guy who “treats me like a queen.” Whenever I ask Cheryl to describe what she means when she says she is treated like a queen, she describes what to me sound like mundane actions: he bought her dinner once; he didn’t leave while she was still asleep, he filled her car up with gas when they used it to go out, he was nice to the kids, he didn’t complain when her babysitter cancelled at the last minute. Usually, Cheryl idealizes these men so quickly she doesn’t take time to get to know them very well. This puts her and her children in jeopardy. When she discovers they are spending the night because they are hiding from their meth dealer, or from the police, she feels genuinely betrayed. When she is forced to break up with them, Cheryl is left with feelings of emptiness alternating with feelings of despair. To cope with her feelings she cuts herself or bangs her head into the wall until she passes out.

Cindy (definitely not her real name) is 33 years old. She has been married for 8 years, and she and her husband have three children. She is employed full time, and is active in her church. When I first met her in clinic, she was wanting to be evaluated for Adult ADHD. She had just gone back to school part time, with plans to become a surgical nurse, and possibly “going all the way to becoming a nurse practitioner.” She was almost euphoric with excitement about her new plan. She presented to her next visit a month later in tears over her news that she had discovered her husband was being unfaithful and they would probably divorce. I advised her to get into therapy, and refilled her medications. At the next visit two months later, not a word was mentioned about either the divorce or school, something I didn’t notice until after she had left, because she had presented in a rage as she described an altercation she had at work with a fellow employee. She reported, “it might have gotten physical, I don’t know because I blacked out. They were going to try to send me to the unit, but [the other employee] is my brother-in-law’s cousin, and so we settled our fight before they could do that.” Cindy confessed to me that every few months, she will have a “huge drag out fight” with someone at work because “I don’t know how to say no, and then they just walk all over me and I snap.”

Each of these patients was evaluated further over the months, and they each met criteria for Borderline Personality Disorder. The disorder occurs by early adulthood. There is a pervasive pattern of unstable interpersonal relationships. They also have marked impulsivity, seen in different settings. They complain of emotions that are out of control with rapid mood swings and are sometimes mistakenly diagnosed with Bipolar Mood Disorder.

To meet criteria, the person has to have five or more of the following:

• Frantic efforts to avoid real or imagined abandonment expressed by becoming emotionally unstable when they PERCIEVE someone might be breaking up
• A pattern of unstable and intense interpersonal relationships
• Identity disturbance expressed by very low self-esteem
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• Emotional instability due to significant reactivity of mood (e.g., intense sudden episodic depression, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• Transient, stress-related paranoid thoughts or severe dissociative symptoms

How is Borderline Personality Disorder Diagnosed?

Borderline personality disorder is typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians, internists, some counselors and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. People outside of the health professions are not at all qualified to make this diagnoses. A person must be over the age of 18 to be diagnosed.

Most people with Borderline Personality Disorder suffer for years without a diagnoses or treatment, and it usually takes a crisis, such as those listed in the examples above, for the person with Borderline Personality Disorder to get identified.

Causes of Borderline Personality Disorder

At this time, the exact cause is not known. However, the theories which have the most support are those that subscribe to a biopsychosocial model of causation — that is, the causes of are likely due biological and genetic factors, social factors, and psychological factors. In other words, the nervous system a person was born with can put them at risk. People with BPD have bound found to have larger amygdalas than those without BPD. How a person was treated by their family in their early years seems to have a great influence. For example, people who were sexually abused as young children have a significantly higher rate of Borderline Personality Disorder than other people. Also, a person’s temperament, which is also influenced by the manner in which they were treated as children, can also put them at risk. Children whose feelings are invalidated, ie, a child cries and is told, “stop crying,” or “you’re okay, you’re not sad,” are at higher risk of developing Borderline Personality Disorder. Also, children who are emotionally abused or neglected have a higher rate of Borderline Personality Disorder as adults.

Treatment of Borderline Personality Disorder

Long term psychotherapy in the outpatient setting is the treatment of choice for Borderline Personality Disorder. There is a type of psychotherapy developed SPECIFICALLY for Borderline Personality Disorder by Dr. Marsha Linehan called Dialectal behavior therapy (DBT). This is the most widely used successful treatment for Borderline Personality Disorder. Dr. Linehan is a well known and respected psychologist on the faculty at the University of Washington, and she recently began to speak publicly about her own struggles during her early adulthood with Borderline Personality Disorder. By her own reports, she was a “cutter,” cutting herself excessively until she was finally treated.

Dialectical Behavior Therapy is a long term, intense therapy program, with both individual therapy and group therapy components. Clients (they are not referred to as patients) are given homework, and are taught skills to identify their emotions and to cope with their interpersonal relationships. Remaining in the outpatient setting, ie, not going to the hospital, is an important goal of treatment, and meeting this goal improves the prognosis for people with Borderline Personality Disorder.

Dr. Linehan has developed a web site, behavioraltech.org, outlining the rigorous qualifications therapists need to fulfill in order to be qualified to provide Dialectical Behavior Therapy.

Although Dialectical Behavior Therapy is the most widely used successful therapy, there is another therapy that has provided some results, and is often available in places that do not provide DBT. It is called General Psychiatric Management for Borderline Personality Disorder. As found in the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder, it is described in the following way: “this coherent, high-standard outpatient treatment consists of case management, dynamically informed psychotherapy, and symptom-targeted medication management. Pharmacotherapy was based on the symptom-targeted approach but prioritized treatment of mood lability, impulsivity, and aggressiveness, as presented in the APA guideline.” This type of therapy requires a psychiatrist (a medical doctor). Although it is not as successful as DBT, it has been shown through research to offer some relief, and result in decreasing suicidal behavior.

For more information about Borderline Personality Disorder, click here.

kidpsychdoc.com – Child and Adolescent Psychiatry blog

Jan 09

Spirituality is good for the brain!

by Dr. Micaela Wexler

Turns out that religion and spirituality are good for the brain! A strong connection to spirituality actually makes the brain tissue itself stronger.

For years, psychiatrists have known that religion and spirituality protect against depression. Studies have shown up to a 90% decreased risk of depression in people who had a strong religious or spiritual connection.

A study published in the American Journal of Psychiatry in 2011 showed that having strong religious or spiritual beliefs prevented a recurrence of depression. In this study, led by Lisa Miller, Ph.D., an associate professor of psychology and education at Columbia University Teachers College, assessed the influence that a strong connection to religion or spirituality had on the mental health of 114 adult children of both depressed parents and non-depressed parents. The study found that those who reported a high personal attachment to religion or spirituality had only a one fourth risk of experiencing depression as those who did not.

WexlerSpritualBrainReligion and spirituality also protected those with a family history of depression. For people whose parents had depression, a strong attachment to religion or spirituality reduced their risk of experiencing depression to just one tenth.

It turns out that a connection to religion or spirituality actually affects brain tissue.

In a new study, published in JAMA Psychiatry, a strong attachment with religion or spirituality was associated with thicker cortices in multiple brain regions. Thicker brain cortices are associated with decreased risk of developing depression. Depression has been found to cause the brain cortices to thin. The theory is that if they are thicker to begin with, they are less likely to thin to a level that causes depression.

WexlerPrayDepressionAwayYou don’t need organized religion. The same studies showed no correlation between frequency of attendance and protection against depression. Nor did they find any particular denomination offered increased protection. In other words, it was the connection to spirituality or religion that offered protection rather than level of participation in an organized religion. What this means for you is that to protect yourself against depression, you just have to find your own spiritual path. So pray your depression away in whatever manner suits you. Your brain will thank you.

Jan 05

When you lose a parent to suicide

PeaceWinter2By Dr. Micaela Wexler
The loss of a parent is devastating for any adult. As a psychiatrist, it is one of the most painful transitions I encounter. Your status in the world is dramatically changed. Immediately upon the death of your parent, you are plunged into a sea of nostalgia, and it is easy to feel unmoored. You are no longer being tugged by the larger vessel that guided you your entire life. Now YOU are that vessel that will have to take the lead. It is a transition that we all anticipate but for which we can never truly be prepared.

When the death is due to suicide, it is not a transition; it is a calamity. While an accidental death brings shock and denial, death from suicide generates horror, anger, guilt, confusion and shame. Add to this the fact that there is still a great deal of stigma about suicide, which can become a significant obstacle to getting help. This is most likely why people who have lost a parent to suicide are at increased risk for committing suicide themselves: the feelings are overwhelming and it is difficult to know where to turn.

It is natural to turn to family members for help. They are the ones who knew your parent best, they have been part of your entire life, and there is no need to overcome the stigma of suicide with them. However, they are not the best choice in the immediate aftermath for the simple reason too have suffered a tragedy and are devastated, and therefore unable to offer much support.
This is a time when psychiatric or mental health care is absolutely essential.

Psychiatrists and other mental health professionals are well aware of the magnitude of this event, and will treat it with the urgency it requires. Besides needing someone with whom to talk, chances are that the suicide has caused enough of a physiological shock that you also need at least a short course of pharmacological assistance until you start your recovery. A psychiatrist or therapist can assist you in this manner safely. (A therapist will refer you to a physician if you need medication.)

It’s difficult to think while in such a state of shock, so I have provided the following advice and information.

First, call your primary care physician and ask for a referral.

If that doesn’t work, call your local emergency room. They will give you the number to local resources.

If you feel utterly incapable of doing either of the two previous items, then you need emergency care. Call 911.

If you have a family member who has become non-functional due to a family member’s suicide, do not put yourself in the position of being their main support. This is risky for both of you, especially if you were also affected by the suicide.

Helping someone else before you have coped with your own feelings is simply a bad idea. You are very likely to bury your own feelings while giving someone inadequate care.

If you and your loved one were both hit by a car while crossing the street, no one would expect you to become the primary care provider. With a family suicide, you are even more incapacitated than you would be if you were hit by a car.

So, in the aftermath of a family suicide, get a psychiatrist or therapist to help you and your family.

For more information, please visit my post on losing a loved one to suicide.

Jan 01

More suicides during the holidays?

PeaceWinter2By Dr. Micaela Wexler

Holidays are associated with a higher suicide rate. Is this true? It turns out that this is largely a myth. As a psychiatrist, I can tell you that suicides are actually pretty low in December, compared to other months. Spring and fall are the seasons which have larger numbers of suicides.

The reason for this myth is most likely due to greater impact on families and friends when a suicide occurs during a holiday season. If a family member commits suicide on Christmas Day, for example, that holiday is forever marked for the family.

Despite this myth it is important to remember that people DO commit suicide during the holidays, and people with addiction disorders are at increased risk. Suicide is just as fatal, no matter when it happens.

Preventing suicide is a good New Year’s Resolution.

Start by learning the warning signs for suicide. An easy mnemonic has been developed by the American Association of Suicidology: IS PATH WARM (Ideation, Substance Abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood Swings). Students should know where to turn for immediate help if they suspect a fellow student is suicidal.

If you are wishing you were dead yourself, you must get help immediately. Call 911 if you don’t know what to do. Or, call one of the following numbers:

If you just need someone to talk to, you should also call those numbers. They can point you to resources in your area.

Websites where you can go for help:

www.suicidology.org – American Association of Suicidology – has a section for survivors

allianceofhope.org - provides an online support group. They have different forums for the different types of survivors, ie parents, children, co-workers.

www.suicide.org – a list of resources for those at risk as well as resources for those who have lost a loved one to suicide.

www.suicide.com – created by a suicide attempt survivor to help people who are suicidal

attemptsurvivors.com – a good blog to help understand the WHY behind suicide, blog posts written by people who have survived a suicide attempt

No Time To Say Good-bye, surviving the suicide of a loved one, by Carla Fine – carlafine.com – the best book on this subject which I have read

And, a reminder: if you need IMMEDIATE help, call 911.