Aug 13

Paul Fleiss, MD, September 8, 1933 – July 19, 2014

By Dr. Micaela Wexler
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In 1997, I was the young mother of two daughters, an infant and a toddler. I was an unemployed playwright, with no marketable skills. I was married to a working actor who struggled to support our family so that I could be home with our daughters instead of working menial jobs. Central in this decision was our fervent wish that I breast feed our daughters “on demand.”

We had a pediatrician at the time who had not been supportive of me breast feeding my first daughter while pregnant with my second daughter. I had attempted to educate this pediatrician with research articles showing there was no harm in breast feeding while pregnant, but this had led to an acrimonious debate in her office during which she warned me my daughter could be removed from my home if I did not stop “harming her.”
I was aware that as a dark skinned minority woman without a college degree, I could not afford to fight with a pediatrician, that this could very well lead to my losing custody of my daughter. In my hormonal state, I began to have nightmares that I was sent to prison and my daughter soon forgot who I was.

I didn’t stop breast feeding. My husband and I simply lied to our pediatrician. We also lied to our obstetrician. I continued to breast feed throughout my pregnancy and then, when my second daughter was born, I started to “tandem feed,” all the time concealing my breast feeding practice from the person, who after my husband and me, was most responsible for my daughters’ health.

I shared all of this one day with my writing group. During the lively discussion that ensued, I was told about a pediatrician who was a champion of breast feeding, including tandem feeding. He was active in La Leche League, and did not turn anyone away, regardless of their ability to pay. His name was Dr. Paul Fleiss.
At that point in my life, I was still shy and timid. One of the women present surmised that I didn’t have the courage to call him, so she went to the phone and called him herself. It was late evening, but Dr. Fleiss answered his phone and listened as she told him my entire story. She got off the phone and told me I had an appointment the next day. When she gave me directions, I realized I had been walking by the cozy craftsman house he used for his practice the entire time I had been a mom.

During my initial appointment, Dr. Fleiss asked me questions in his soft voice, and as I gave my history of my daughters, he praised me, telling me what a great mother I was. He gently examined both my daughters, letting my toddler play with his stethoscope and place her finger on the end of the ophthalmoscope.
He was impressed I had found research articles about breast feeding while pregnant. He invited me to the La Leche League meeting held every other week in his office. He also invited me to join him and other people from the neighborhood in a morning hike in Griffith Park they took every morning at dawn. “Bring the babies,” he said. “They’ll love it. We’ll help you with them.”

Thus began a friendship that lasted until Paul died July 19, which happens to be my birthday. Paul became a friend, mentor and father figure to me.
I began hiking with the group, and developed several close friendships with other hikers. During one of our hikes, Paul shared that he did volunteer work in the Latino community, and could always use a fluent Spanish speaker. I accompanied him on one of these excursions, and my professional life began to take form.

For reasons that are no longer important I was not raised with the stability nor was I taught the skills one needs to pursue a career of any magnitude. During our many hikes I shared with Paul the story of my childhood and he took it upon himself to fill the paternal void in my life. He gave me advice as we climbed the hill in Griffith Park. He supported me in all my endeavors with the same enthusiasm he had for breastfeeding and pediatrics. Paul brought a group of friends to see each of the productions of my three plays.

One day I shared with him my desire to become a doctor, and my fears that I was too old. Whereas many well meaning friends advised me to consider nursing or physician assistant school, Paul never once said a discouraging or negative word about my desire to become a doctor. He gave me nothing but support in every way possible. He assured me that I was not too old, and then he said, “It’s better to be a good doctor for five years than a bad doctor for 20.” He gave me advice on where to take my pre-med classes, and how to make my resume more competitive. He allowed me to shadow him for countless hours in his office. He regaled me with stories about women who had become physicians after having children.

When I received my medical school acceptance letter, Paul was overflowing with pride. He then suggested a way for me to afford medical school: applying for the National Health Service Corp (NHSC) scholarship, a program that pays the entire cost of medical school (tuition plus a monthly stipend) in exchange for four years of service in a primary care specialty in an underserved community. “You’re exactly what they’re looking for,” he said.

During medical school, I did one of my pediatric rotations in his office. He risked our friendship for the greater good of pushing me hard as a medical student. He never passed up an opportunity to share one of his pearls of wisdom. A constant refrain was “always listen to your patient. If you listen long enough and carefully enough, the answer will come to you. The patient will tell you what you need to know.”

My second year of residency took me out of Los Angeles to Kansas City in 2007. The excitement of starting a new life was tempered by leaving Paul. Not only was I leaving an amazing pediatrician for my children, but I was leaving my mentor, father figure and close friend. Paul softened this blow by suggesting that I fly to Los Angeles with my daughters for their annual physicals. “Many people do it,” he said. For the first three years, that’s exactly what I did, and each time we saw him, he treated us as if we had never left.

My NHSC service obligation took me to a small town in Southwest Missouri where I was the only psychiatrist providing outpatient care. I also staffed the inpatient unit. The hours were long, and it was challenging to find coverage so I could take time off. My last trip to Los Angeles to see Paul was in 2011, for a short, impromptu weekend. Despite the short notice, Paul made time to see me. We went on a hike, and I had two of my three meals in town with him. I shared with Paul the challenge I faced in rural Missouri: the patients had come to expect doctors to write them multiple prescriptions for controlled substances. This expectation was especially high when patients saw a psychiatrist. My visit with Paul strengthened my resolve to “listen carefully to the patients,” and not just give out multiple medications.

My job in Southwest Missouri became more demanding as the months passed. The poverty there is brutal; the incidence of substance abuse is staggering. I was physically attacked on several occasions for various reasons: my dark skin, my refusal to dole out narcotics, my reluctance to place patients on disability until all avenues had been exhausted, and on two occasions, when parents became convinced I was the one who had called child protective services.
In the summer of 2012, I called Paul. “I can’t go on,” I told him. “I’m not going to make it through my contract.” We discussed the enormous financial penalties I would face if I didn’t complete the contract: 3 times what it had cost to attend medical school plus 18 percent accrued interest.

“I’m going to have to move to Mexico,” I concluded.

“That’s a wonderful idea!” Paul said. “my son went to school in Mexico. He loved it. You could teach in the medical school.” Always the dreamer, his mind was always brimming with possibilities. His reaction was perfect, it lifted my burden, giving me the freedom to think of other possibilities myself. I began to indulge my desire to treat children with developmental challenges, which became my plan to pursue a child and adolescent fellowship after completing my contract.

That plan fueled me for the rest of my service obligation. In September 2013, I got in touch with Paul to wish him a (late) happy birthday. When I expressed my fears that I would not be accepted into the program, he promised me he would hire me to do child psychiatry in his office. “In my eyes, you’re already a child psychiatrist.”

A month later I was accepted into the fellowship program at KU Medical Center, to start immediately upon completion of my NHSC service. I completed my service July 18, at midnight. Paul died the next day. My mentor and friend saw me through to the end.

There have been many moments since Paul died that I have been overcome with grief. It’s hard to believe I will never hike up the hill at Griffith Park with him, that I will never “talk shop” with him about my work with children. It’s difficult to accept that his seemingly endless energy really has stopped. To me, he will always be that thin man hiking next to me, his mind sparkling with ideas, showering me with flakes of hope and possibility. I get through these sad moments by taking comfort in the many gifts he gave me. Each time I think about Paul, I remember to “listen to the patient, and the answer will come to you.”

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Jul 17

My rural medicine adventure

By Dr. Micaela Wexler

Tomorrow my four year adventure in rural medicine will come to an end. It will be bittersweet. I will complete my four year service obligation for the National Health Service Corps (NHSC). The NHSC is a federal program that provides scholarships and loans to physicians and nurse practitioners willing to provide primary medical care to under served communities. I was in their most competitive program, the Scholar Program for Physicians: the NHSC paid for me to attend medical school in exchange for providing psychiatric care to a community on a “critical need” list.

I decided to pursue medicine after my two oldest daughters were born, and without the NHSC, I would not have been financially able to attend medical school. I was thrilled to discover that my area of interest, psychiatry, was on the list of required specialties. The financial support from the NHSC felt like a luxury: they paid my medical school tuition and fees up front along with a monthly stipend. This made medical school extremely enjoyable for me. I didn’t have the shadow of mounting student loans looming over me, which made me almost giddy as I immersed myself in anatomy, pathophysiology and clinical rotations. It wasn’t until I was in residency, exposed to critically underserved populations that I began to consider the rigorous job options that awaited me.

At the beginning of my last year of residency, I learned that psychiatrists in my cycle of service would be required to serve in remote rural communities. This had a profound impact on my family. There were absolutely no rural communities which had a Jewish community. My best option was to be placed in a community one and a half hours from a Jewish community. I chose Southwest Missouri, 85 miles away from where my children would be living. This meant I would be living alone as I completed my service obligation.
This turned out to much more difficult than I ever imagined. When I arrived, I was convinced the commute would be easy, that this would be no different than when I did my rotations during medical school in Los Angeles and regularly did 3 hour round trip commutes due to traffic. Well, it’s a completely different story when you’re the only provider and 20 to 30 people need your care on a given day. You can forget about making that commute. And, when you do make that commute, be prepared for something worse than traffic: no other cars at all. No one to help you if you hit a deer or get a flat tire, or, worse, you fall asleep and fly off the road. All of those things happened to me at least once.

When I arrived in my community, I assumed I would pursue multiple hobbies with all my “spare time.” I had hopes of making a quilt, joining the gardening club, riding with the local cycling group. Well, again, that huge patient load made all of that impossible. I never even had time to go inside the quilting store, something that still makes me sad. I rode my bicycle alone in the pre-dawn hours.

I spent many days when the only people I had conversations with were my patients and the nursing staff. I ate most of my meals alone, while I completed charts. I engaged in stress eating, which caused me to gain weight.
While I did manage to visit my children at least twice a week for the entire four years, I did miss quite a few parent teacher conferences, school performances, and even a couple of birthdays.

So, why am I not absolutely ecstatic that my service is over? The patients. I was able to start an outpatient psychiatry clinic from scratch, and provided face to face care to people of all ages. I provided inpatient care to patients from all over the state who typically arrived in a state of crisis. I never had even one hour when I felt I was useless or superfluous. I learned about the brutality of rural poverty and the devastating effect it has on children and adolescents. This knowledge focused my efforts in a profoundly meaningful manner.

My work in the clinic afforded me the opportunity to treat entire families: children, parents, grandparents, and in a couple of cases, great grandparents. I acquired deep knowledge of their hopes and struggles, of the fierce family loyalty which survived substance abuse, incarceration, chronic unemployment and severe mental illness. I witnessed the miracle of children growing and thriving despite their many obstacles.

I fell in love with my patients. I will never stop being inspired by their admirable struggles to overcome the challenges of mental illness. Their hope and optimism in the face of considerable adversity will inform my practice of medicine from this time forward.

May 29

96 Hour Involuntary Holds Save Lives

By Dr. Micaela Wexler

In the aftermath the murderous rampage at UC Santa Barbara May 2014, I found myself feeling profoundly grateful to be practicing psychiatry in Missouri, a state that allows law enforcement officers to issue a warrant on people suspected of having a mental health crisis so they can be taken to an emergency room to be evaluated by a mental health provider for an involuntary hold for 96 hours. The public has been eager to blame this rampage on an easily identifiable cause. It has been blamed on misogyny, easy access to guns, video games. Our collective ignorance of mental health issues allows us to blame these factors, while allowing mental illness to claim more lives. At the same time, we ignore, or take for granted factors which allow the mental health system to work.

In this part of Missouri, guns are ubiquitous. So are video games. It is popular for young men to express misogynistic views. Given what I have seen in the media, we should be having these sorts of events all the time here in Missouri. The fact we are not may be due to the role of the 96 hour involuntary hold. If a family member or therapist suspects a person may be in crisis, law enforcement officers do a “wellness check.” Very often, the person is taken to the nearest emergency room to be evaluated by a mental health professional who can then determine if the person requires an involuntary 96 hour hold.

In looking at the videos and reading the killer’s manifesto, it is clear to me, as a psychiatrist, that it is very possible he was experiencing a bipolar manic episode. In his manifesto, he claims to have been planning his revenge for years. This may be true, or it may be the grandiose expression borne of mania. A person in mania could easily write a document of that length in a short amount of time. If is true that he was planning this rampage for years, then it was, fortunately for us, poorly executed. He stated that he was going to go to a sorority house and kill all the women inside, yet he had no real plan for accomplishing this. He didn’t even know how to get into the sorority house once he arrived. Instead of killing everyone inside, he killed two innocent bystanders who were not even members of that sorority. As the rampage proceeded, it became more disorganized, ending with his suicide.

He uploaded a large number of repetitive videos in a short amount of time, another sign of mania. We have no evidence other than what he states in his videos and manifesto that he was a virgin, that he was suffering for years in a deep rage, nor has anyone come forward with any proof of his hatred that he talks about. We have no way of knowing for sure how long he had truly harbored these thoughts. One of his childhood friends mentioned in the manifesto expressed genuine surprise that the killer had these feelings.

When a person experiences mania or mixed mania, thought processes become derailed. They become irritable and paranoid. Time perception is disturbed. The level of activity is increased, however this activity is not well organized. His manifesto has been quoted widely, with the implication that what he said should be accepted as fact. He says he planned it for years, then it must mean he was planning this for years. However, it is just as likely he was planning it for a much shorter time, and his report of years was the result of the same psychotic thinking that motivated his rampage. He talks about previous attacks on women and couples, and blames a high school crush for his “retribution.” Again, we have no real proof that he really carried out these attacks. Nor is there any proof he really did harbor hatred against his childhood crush for so many years.

I am not his psychiatrist, and I am not claiming that my assessment is accurate. However, if it is true that his rampage was the result of a psychotic break or manic episode, then shame on all of us. These episodes are easily treated in the inpatient units. In the amount of time since the killer first posted his videos on YouTube, in April, here at our lowly rural behavioral health unit (BHU) we have successfully treated over a dozen young men experiencing either a manic or psychotic episode. Many of these young men were brought in by law enforcement officers. Every one of us should be grateful to these officers for doing their job to keep us all safe.
Click on this link for a great reference guide if a family is looking at the process of involuntary procedures in Missouri.

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

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Logo Copyright Debby Bloom

Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Apr 28

Talk to your kids about sex . . . and love

By Dr. Micaela Wexler
This is an important topic parents have a hard time discussing with their children. Too often I find that my adolescent patients have never had an in depth discussion about sexuality with their parents. In the best case scenarios, they have been told about pregnancy and STDs, but usually sex has been presented as a forbidden activity, in an atmosphere of discomfort and embarrassment. There is rarely any discussion about relationships, intimacy, sexual expression, body image, masturbation and acceptable behavior. Parents seem to be oblivious to the fact that according to the Guttmacher Institute, 46% of teenagers age 14-19 report having had sex at least once.

Failing to talk to your teenager about sexuality puts him or her at grave risk for a variety of dangers ranging from the obvious – pregnancy – to others that are less obvious but potentially more life threatening, like depression and relationship abuse. Depression is the greatest risk factor for teenage suicide. Romantic break ups are a common trigger for depression in teenagers. Teenagers most at risk for depression following a relationship break up are those who have limited support and poor coping skills. Parental support is a potent protection against teen dating violence.

It is never too early to talk to your child about sex. Ideally, the “sex” talk should begin at birth. Use correct words for genitalia when changing diapers or giving your child a bath. Make positive statements about their body (and yours) throughout their childhood. Early childhood is when boundaries should be taught, that their private parts are their own and no one else should touch them. The same is true about other people’s private parts. Introduce the physiological aspects of sexuality in the elementary school years, with anatomy lessons, including the different processes that occur, such as hormonal and physical changes, pregnancy and orgasms.

I recommend that birth control and STD protection issues be brought up during elementary school years, even if you are a strong believer in abstinence before marriage. Hearing about both birth control and abstinence at the same time does not lead to children engaging in sexual activity earlier. Parents should remember that children hear alternative, even conflicting views about many topics in their lives. Presenting children with choices teaches them decision making skills.

Children are being exposed to sexual topics outside of the home at an earlier age, and they will be safer if they have heard about them from you. In addition, talking about birth control and STDs helps children open up about other sexuality related topics; they are less shy about sharing what they have been exposed to at school and in the media. Don’t be afraid of letting them know the meanings of words they hear, ie blow jobs, fuck, cunt, etc. These are valuable opportunities for parents to express their views on acceptable sexual behavior.

Explore your own thoughts and feelings about sexuality. If you are uncomfortable discussing the topic of sexuality, try to figure out why. Are you unhappy with your own sex life? Are you disappointed with the level of satisfaction you are achieving? Maybe you have a history of domestic abuse or childhood sexual abuse. Were you taught negative views about sexual expression during your own childhood? Or, perhaps you are mourning the loss of a relationship. Getting in touch with your own emotional feelings regarding your sexuality will help you address the emotional impact sexual expression has on your teenager.

Studies show that most parents do not discuss the emotional aspects of sexuality with their teenagers. They do not discuss intimacy, relationship conflicts and violence in relationships. Teenagers are left to navigate the confusing world of dating, relationship building, sexual expression without any skills and with no one to turn to when problems occur. Whether they are engaging in sexual activity or not, teenagers experience very strong emotions when it comes to relationships. Due to their raging hormones, every aspect of the relationship is magnified. This is a dangerous time to withdraw parental support.

Once you have talked to your child about all the concrete aspects of sexuality, you have set the groundwork to talk about the complex emotional issues surrounding sexual expression. It is important to approach the topic in a non- judgmental and non-threatening manner. Open the discussion by asking if their friends are in relationships. Rather than focusing on sex, focus on issues like trust, mutual respect, friendship and honesty. Guide your teenager through a relationship conflict. Be on the lookout for signs of teenage violence. Do not trivialize their feelings. Teach your teenagers that their sexuality is a gift that should be treasured, and that it should never be used to hurt them.

Mar 13

Madison Holleran: we must increase the dialogue about depression

MadisonHolleran
by Dr. Micaela Wexler

On January 17, 2014, Madison Holleran, an accomplished athlete and student at U Penn, jumped to her death. She seemingly had everything going for her. She was popular; she had a family who was close and supportive; she was academically gifted, having earned a 3.5 GPA her first semester at an Ivy League university; and she was a talented athlete, running on the school’s cross country team. An hour before her death, she had been making dinner plans with friends.

“You can’t really understand why a girl who seemingly has everything going for her would want to end it,” her father said.

Her death shocked so many in her college community as well as her home town who reported there had been no clues, no warning signs. People all across the country have been saddened by her death, not only because this is a tragic loss to our society, but because her death strikes fear in so many that this could happen to one of their loved ones.

As a psychiatrist, I treat a large number of people who have been left permanently scarred by the death from suicide of a loved one. Several people have expressed the fear that if suicide could claim the life of someone “who had everything,” what is to keep their loved ones safe?

One of the reasons Madison Holleran’s death by suicide was so shocking is that relatively few people in her life were familiar with the facts of her depression. Those who were found themselves at a loss as to how to help her, and were not aware of the serious risk depression poses to those it affects. The stigma of mental illness is so great that people who struggle with depression suffer in silence and isolation.

As a society, we do not know how to help people with depression. Many people do not recognize that when a person has become irritable, is feeling unmotivated, has lost interest in things that were once enjoyable, is complaining of having low energy and not being able to sleep, that person is not being lazy or “needy;” that person is most likely depressed. That person is potentially in danger of losing his or her life to suicide.

There is not enough dialogue about depression for most people in the midst of their despair to know that there is treatment available that works, that will make them feel better. This was illustrated a while back by a patient who came to see me for his monthly follow up in the clinic. He was a college professor at that time, in his 50’s. He was (most likely still is) bright, witty, very popular with his students, and a joy to see in clinic. Two years earlier, he had become acutely suicidal, and his wife had the wisdom to bring him to me for an emergency visit. She was able to petition to have him admitted to the inpatient psychiatric unit against his will. Several months later, he again became suicidal, but at that time, he entered the psychiatric unit voluntarily.

One day, as I asked my routine questions about suicidal ideation, he said to me, “That first time, I just didn’t see how it was possible to feel anything but despair. There was just too much going on in my head for me to have anything resembling a rational thought. To me, suicide was rational. Then you put me on the mood stabilizers, threw me into those groups, and by the end of the week, I was feeling better. Suicide became a ridiculous idea. The next time it happened, I knew that I would feel better. I knew that this feeling of despair would go away , that as soon as I changed my medications and got some therapy, it would go away. I just needed to get to that place.”

As a college professor who had himself been suicidal, suicide among college students was something my patient thought about regularly. He mentioned it every month at his regular visits. “There has to be a way to let EVERYONE know that there is stuff that WILL make that desperate feeling go away, that there are medications, and that you can spend a few days going to groups and coloring and talking to people and you’ll feel better!”

For me, as a psychiatrist, the greatest tragedy of Madison Holleran’s death by suicide is that even though she was in an environment with so many resources and knowledge, the information about treatment and its effectiveness remained elusive to her and her family. As so many patients tell me, “that desperate feeling is so painful, you finally just snap and want to make it go away!” They always emphasize to me how important to their lives it is to know how to get treatment.

There is a way to make the pain go away. You don’t have to jump off a building or jump in front of a car. There are therapies and medications that really do work. Suicide is the SECOND leading cause of death among college students. This is a tragedy that should not be happening on college campuses. Information about depression and treatment should be ubiquitous.

All students and professors should know the warning signs for suicide: IS PATH WARM (Ideation, Substance Abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood Swings).

Mental health services need to be made truly accessible. Every student, parent and professor should know the numbers to call if someone they know is depressed. The number 800-273-TALK should be on everyone’s bathroom mirror and refrigerator. Substance abuse on college campuses needs to be addressed. We need to recognize that it is not a benign part of college life, but rather a potential warning sign of depression and a risk factor for suicide.

Need help? In the U.S., call 1-800-273-TALK (8255) for the National Suicide Prevention Lifeline.

Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.

Early diagnosis beneficial in AD
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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Mar 04

SAD? Or just blue?

PeaceWinter2By Dr. Micaela Wexler

Are you feeling the post-holiday let down? After all the parties are over and the guests have left, many people feel anxiety, disappointment and depression. That is normal.

However, if you are feeling depressed, tired, weak, achy or ANGRY, you might be SAD
The “winter blues” might be something more: you might have SAD – Seasonal Affective Disorder. This is a type of depression that occurs every year during the winter months. It’s not just the “winter blues,” which is a feeling of mild disappointment and irritation most people get as they cope with the challenges of winter.

How do you know if you’re SAD and not just blue?
WexlerPsychiatryDepressedGirl
People with SAD feel the following:
- worthless, guilty, tense
- fatigue
- down and depressed
- arms and legs feel heavy, achy
- increased headaches
- irritable
- worried, increased checking behavior
- indecisive
- increased urination, heart palpitations, stomach aches
- difficulty focusing
- suspicious, paranoid, think co-workers don’t like them
- increased difficulty starting the day
- increased insomnia

These symptoms go on for at least two weeks at a time and can recur. They start in late fall and fade away in early spring.

It isn’t in your head. Well, actually, it is: it is caused by your hypothalamus, a part of your brain, secreting more melatonin when your eyes are exposed to less sunshine. So, if you’re having insomnia, don’t take melatonin. When light hits are eyes, melatonin starts to go down.

There is also a decrease in serotonin caused by a decrease in physical activity. An additional contributing factor is the disruption of your circadian rhythms by the change in weather, shorter days and change in routine. Many people first notice these symptoms following the time change.

SadWomanWexlerPsychiatryWomen are at higher risk, as are people with a family history of depression. Living far from the equator doesn’t help.

There are some dangerous symptoms you should not ignore:
- feeling suicidal, or feeling that life just doesn’t matter – get help right away
- irritability leading to behavior that is out of character: yelling at co-workers, engaging in physical fights or road rage
- social isolation that is out of character – missing the company holiday party even though you are known as a social person, for example

Why you shouldn’t ignore it:

- Decreased focus can lead to problems with work, increased debt, child neglect
- SAD can become major depression
- suspicious thoughts can cause irreparable harm: premature termination of a job or relationship. Many people file for divorce during these months.
- your immune system can become depressed

Treatment is easy and effective
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- Increase physical activity – increases serotonin levels
- Watch your diet: beware of giving in to carb craving; eat more nuts and fruits – maybe this is why fruitcake is a traditional fruit at this time of year
- Eat more walnuts – have been shown to help make you less SAD
- Make home brighter
- Bundle up and step outside – nothing makes your home feel warmer than stepping in from the cold
- Light box therapy
LightphoriaWexlerPsychiatry
Does light therapy work?

Yes. it is supported by at least two meta-analyses. It also works for non-seasonal depression. Most companies will your refund money in 30 days if symptoms don’t decrease.

What type of light works?

Bright sunshine in the morning works best – not available in the winter time
10,000 lux for 30 minutes
5,000 lux for 60 minutes

Light boxes – what to look for:

- beware of blue light – not proven to be effective, may cause macular degeneration
- light must shine in your face
- 10,000 lux – 30 minutes
- research shows the bigger the better, less lux requires longer exposure

Look at lux distance
- 22 inches: normal distance from computer when working
- 28 inches: distance from computer when you lean back in the chair

Dawn stimulators:
- require longer exposure
- effective – eyes more sensitive in the morning
- help reset sleep-wake cycle
- convenient – can use in bedroom

And, I can’t stress this enough, if you feel suicidal, please call 911 or go to the emergency room.

Early diagnosis beneficial in AD
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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Feb 09

Smartphones and your love life

SmartphonesLoveLifeWexlerby Dr. Micaela Wexler

Do smartphones hurt relationships?
It turns out that smartphones and electronic gadgets can hurt our interpersonal interactions. What is worse, a recent study shows that intimate interactions are affected more than casual interactions.

A study published in the Journal of Social and Personal Relationships July 19, 2012 shows that the mere presence of a smart phone can interfere with conversations between two people.

Two experiments were done to measure quality of relationship and feelings of empathy. In the first experiment strangers were put in pairs, and sat in a room that contained only a table two chairs and a book on the table and another object. For half the pairs, the other object was a smartphone and for the other half, the object was a pocket notebook the same size as the smartphone.

In this experiment, the pairs of strangers were asked to discuss an interesting event that occurred in the past month. Following the 10 minute discussion, the participants filled out questionnaires that measure relationship quality over time. This questionnaire included questions such as, “It is likely that my partner and I could become friends over time.”

The group with the smartphone present reported lower relationship quality and less closeness. Few of them believed they could ever become friends with their partner, for example. The results showed a lower level of connection between the partners when a smartphone was present.

The second experiment measured the effect of smartphone presence on intimate conversations and casual conversations. The set up was the same, but the pairs of strangers were given different tasks. One half of those pairs in each group were given the task of discussing their feelings about plastic trees for 10 minutes. The other half in each group were given the task of discussing the most meaningful event that had occurred in the past year.

The results of this experiment spell trouble for couples.

Partner empathy and partner trust were the items most adversely affected by the presence of a smartphone. The groups discussing the plastic tree showed a small difference from each other; however the groups discussing a meaningful events showed a dramatic difference.

The smartphone groups scored lower on the question “I felt I could really trust my partner,” and “I felt my partner could understand my feelings.” That is not good for intimate, romantic relationships.

So, why is this? How can the mere presence of a smartphone lead to such dramatic differences?

First, anything that provides a source of instant gratification will stimulate the reward centers of our brains. Studies show that just thinking about a morning cup of coffee causes endorphins to rise.
ChildPsychiatrySnow9

When alcoholics just look at a drink or drive by a liquor store, the reward center in the brain fires up. It isn’t much of a stretch to realize a smartphone could have the same effect.

Smart phones are full of apps that provide instant gratification. Think of all the games you play you just can’t put down. That type of brain stimulation is addictive. We are all naturally driven to engage in those types of activities; we enjoy the endorphin rush these thrills give us. We can reliably feel good after playing one of these games, so we begin to depend on them.

When facing a stressful event, we crave that endorphin rush even more. For example, we crave our morning cup of coffee more on work days than weekends. So it is very likely that the mere presence of a smartphone is causing the reward center to fire away.

Except for that beginning stage, when everything is new and exciting, relationships do not provide a reliable endorphin rush. People with their complexities and needs are not very predictable: sometimes they thrill, sometimes they don’t. Our partner does not just offer fun and games. More often than not partners approach each other with topics that are stressful: bills, children, work conflicts, emotional needs and jealousies. Our brains respond to this, the parts of our brains dealing with danger are activated in the mere presence of anything that has been a source of stress. If there is a smartphone nearby, our partners lose out, because the reward center will always win.

So, what do we do? Smartphones are an ever present part of our lives.

I will confess, I am one of those people addicted to my smartphone. It is a significant part of my work as a rural psychiatrist. I get calls and text messages from all over the hospital and clinic all day long as well as several nights a week. Given the stressful nature of my job, I also began to rely on the endorphin rush provided by my games.

Dr. Wexler Smartphones

I have started to experiment with designated “no smartphone zones.” As a family psychiatrist, I advice families to keep gadgets away from the dinner table. For people who depend on their phone for work, as I do, I suggest the smartphone be placed away from the table. I have started forwarding my calls to a landline during dinner time with my partner or family. When a landline is not available, I have a special ring tone for the hospital. All other sounds are ignored. I will be the first to admit that implementing this plan is not easy.

For couples, I recommend no cell phones in the bedroom. I know how difficult this is to follow because I have yet to do it myself. But, given the results of these studies, I am sure I will reap the benefits when I finally banish the smartphone from the bedroom.

Another strategy that has worked for me came about by accident. I have an older version of the iPhone and I inadvertently updated the operating software. All my games stopped working! I was able to easily update my medical apps, but I couldn’t find newer FREE versions of my favorite games. Rather than buying new games, instead I went into my kindle and found free games through Amazon Prime. Now, whenever I need that endorphin rush I grab the kindle. Over time, my smartphone has become less associated with fun, so I’m probably not getting that endorphin rush. So, that might be a solution for you: take the games out of the smartphone and use a different device.

Smartphones can be used to enhance our relationships!

There are several apps specifically designed for couples.

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Couple is a free app available for both iPhone and android. It is similar to the Facebook app, except you each have just one friend. You can poke each other, share pictures, videos, texts and voice clips. It even has a feature called “thumb kiss” letting you touch thumbs in real time to get a “love vibration.”

Between is a similar app available for iPhone and android devices, but with the addition of a datebook and note sharing. The datebook is especially helpful for couples with busy lives because you can keep each other informed of your activities.

Icebreak for Couples is an app that couples can use to learn more about each other. It comes with activities they can share based on the answers to these questions.

Right now, my partner and I are using Between. We are loving it! The first thing we see when we open the app is our two pictures and the number of days we have known each other. For us, the calendar is crucial because we both have busy, fluctuating schedules in the medical field. I have the push notifications on, so I get alerts whenever she enters anything. We chat with each other using the app. We can send each other voice memos as well as texts.

If you find that you just can’t put your smartphone down, and are not able to adopt any of these strategies, then you need to examine the root cause of this behavior. You may need to see a therapist or psychiatrist to determine if you have an addiction, or if you have depression or anxiety that your are self medicating with your smartphone apps. You might need to take a good look at your relationship and your life. Behavior that is out of control should never be ignored, especially because help is available.

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

Feb 02

Children of addicts deserve our protection

PhilipSeymourHoffmanBy Dr. Micaela Wexler

As has become common, we were spared no details as yet another beautiful mind was stolen from us by addiction, this time heroin. Given Philip Seymour Hoffman’s frank honesty about his struggles with substance abuse in his youth and his recent relapse, I would like to think he would want the circumstances surrounding his death to serve as a warning to all of us, especially young people.
So what are we to make of this tragedy, and the message inherent behind these graphic disclosures? Are we to focus our anger at the media, for violating his privacy and that of his family? True, his three children deserve protection at this difficult time. But, like all other children with parents who struggle with addiction, they are at heightened risk of future struggles with addictions themselves, and why not protect them, and other young people, by gathering our resources to fight this horrible disease?
We do not, as yet, have a cure for this disease. A person in recovery is like a person in remission form cancer. The threat of a recurrence of their disease lurks over his or shoulder permanently. Our best hope lies in prevention, followed by treatments that have been proven to work.
Prevention must start with targeting the children of addicts. Since it is not always possible to know who they are, given the stigma surrounding addiction, we must target all children by educating them as well as ourselves. Research shows that the best prevention lies in identifying risk factors, and tailoring interventions to strengthen specific protective factors. Risk factors in childhood for eventual addiction include early childhood aggression, genetic predisposition, lack of parental supervision and substance abuse.
Early aggression can be addressed by teaching conflict resolution and addressing the anxiety that triggers this behavior. Genetic predisposition could be addressed by teaching adult addicts how to educate and protect their children. Lack of parental supervision can be addressed by increasing community support of families, as well as educating parents. Find out WHY parental support is lacking, and how that child can be supported.
Substance abuse in children is sadly widespread and oftentimes ignored. There is good research showing that exposure is a common trigger for initiation of drug use. Children are exposed to tobacco advertising from the time they are toddlers standing next to their parents at the convenience store. We advertise alcohol on television. And, now with the increased legalization of marihuana, pot advertising campaigns have introduced a new avenue of exposure. In our zeal to do legalize pot, we have, once again, disregarded the needs of our most vulnerable people. A child with multiple risk factors doesn’t really stand a chance when talk of pot use is on the evening news, all over social media and on the radio.
Substance abuse must be addressed promptly and with compassion. A strong parent-child bond has been shown to be the best prognostic factor; however parents’ high level of anxiety when confronted with their child’s substance abuse often interferes with this parent-child bond. We must support, rather than shun, parents when they are faced with this crisis. We must advocate for positive interventions when children are caught with drugs at school rather than punitive measures, such as suspension.
Adults struggling with addiction are often denied treatments that have been shown to work. A good example is the use of Suboxone in the treatment of opioid addiction, which has been shown to be life-saving. This treatment is sadly very underutilized due to the critical shortage of Suboxone providers. The training required to prescribe Suboxone is not a routine part of medical training. Currently, a physician is only allowed to have 100 patients on Suboxone at any given time. Both these factors contribute to the severe shortage of Suboxone prescribers.
We must increase the availability of this and other successful treatments, and we must do away with the many myths surrounding addiction. For example, let us do away with the idea that addicts are “choosing” their drugs over their families or jobs. This will only happen when we, as a society, accept that this is a disease, and then mobilize our resources the way we have behind diseases like breast cancer and multiple sclerosis.
Philip Seymour Hoffman left behind three children who join countless others who have been orphaned by drug addiction. All of them cry for our protection. Let us use the tragedy of his death to make their world, and ours, safer from addiction.

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

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.
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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).
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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.
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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.
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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.

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