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

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
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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

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

Oct 05

College students and mental health

By Dr. Micaela Wexler
As a family psychiatrist, I have noticed this is the time of the semester when college students first face mental health challenges. These can include issues like homesickness, anxiety about exams, alcohol abuse, difficulty with focus and concentration, romantic break ups, roommate conflicts, insomnia and time management challenges. Though these are common, and not considered serious, they can interfere with a student’s progress. These issues are easily treated, and should be addressed by students and the people in charge of supporting them.

The mental stress that is part of the college experience can trigger episodes of serious mental disorders. It is at this time of the semester, when first exam grades have been posted and class withdrawal deadlines are approaching that students with issues like bipolar mood disorder, eating disorders, severe OCD, or more rarely, psychoses or delusional disorders are especially overwhelmed. A significant number of people with these disorders are not diagnosed until early adulthood, so if they are in college when the first episode occurs, they usually find themselves alone, without psychiatric care.

It has become routine on college campus for a review of mental health services to be part of new student orientation. Many colleges offer a number of free counseling sessions to every student. However, when students are faced with an actual mental health crises, their thinking process tends to be derailed and they don’t always know what do to. The most frustrating aspect of mental health care is that oftentimes, even people with severe mental illness may fail to recognize they are at risk and need help.

College students can play an important role when it comes to mental health by being attentive to their peers. Students should trust their instincts and take action when they sense a fellow student is under mental duress.

All students should know 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.

Students do not need to sense a problem is as serious as suicide to take action. If a fellow student seems down, or has stopped eating, is losing or gaining weight rapidly, or getting intoxicated frequently, that person may need help. Help can take many forms. A student could ask a peer directly, “are you ok?” If that feels awkward, a student could bring up the topic in a general way, ie, by talking about something they heard in class, or on the news, ie, “I heard that severe stress in college can trigger (an eating disorder, a drinking problem, severe OCD, hearing voices). What do you think?”

Or, a student could say to a peer, “you have seemed really worried lately. Would you like to talk about it?”

A student should not take it upon themselves to be the sole source of support for a student in need. Before approaching the student in need, a college student should speak to a professor, resident assistant, a mental health provider, just in case the situation is more serious. This can easily be done in a way that protects the other student’s privacy and dignity.

On the other hand, talking with other students about the student having problems without ever offering support to the person who is depressed or behaving erratically is not only unkind, but potentially dangerous. There is still a great deal of stigma regarding mental health issues, and contributing to this should NOT be part of the college experience. Nowadays there are effective treatments for even the most serious of mental health challenges. Taking positive action in the face of mental duress can be rewarding for college students. Preventing mental health tragedies is something which will enhance the college experience for everyone involved.

Sep 10

“Suicide prevention starts with you.”

By Dr. Micaela Wexler
Whenever I say this to people, they think I mean for them to help prevent suicide in other people. They immediately think about their families, friends, co-workers, children, spouses. In most cases, they are eager for tips on how to join in the fight to stop suicide.

“I mean YOU, specifically. Suicide prevention starts with YOU.”

Suicide is something that can happen to anyone. While we all need to help each other in preventing this tragedy, you can’t prevent someone else from committing suicide unless you prevent yourself from committing suicide.

“Well, that’s easy,” people tell me, “I don’t believe in suicide. Suicide is a selfish act; I would never do that to my loved ones.”

It turns out that people who commit suicide were once just like you: they didn’t believe in suicide. Like you, they had children, parents and friends. They loved them very much and did not want to hurt them. Just like you, they had religious beliefs that once gave them strength and comfort. They had goals and dreams and plans. They had crushes. They had love affairs. They had marriages.

So, to prevent suicide, you have to start by examining yourself.

Do you find yourself doing things you never did before like yelling at the grocery checkout person? Are you snapping at your husband? Does your best friend suddenly make you fly into a rage? Are you drinking more than you ever did? Are you in a financial crisis you feel you have no way out of?

Do you find yourself being careless about your safety: being less careful about locking doors at night; not slowing down for yellow lights; driving recklessly on the freeway?

Many people have these thoughts. That doesn’t mean you should ignore their seriousness. Letting thoughts like these pile up can put you on the road to developing a serious depressive episode. That is the most common reason for suicide.

If you are having these thoughts, then you are not taking care of yourself. You are not taking time to enjoy life. You are losing sight of your dreams and goals. Maybe you are not spending enough time with friends who appreciate you. Maybe you are working too much, at the expense of socializing and exercising.

You can do things immediately if any of these situations pertain to you. Right now, take a deep breath and think of something positive you will do for yourself TODAY. It can be something simple like taking a walk, calling a good friend, making plans to go watch a movie, buying yourself a new song, playing a computer game.

Look at your schedule and see what items are on it that make you feel good. How can you add more? You may not be able to get out of your financial crisis, but you can probably find someone to talk to, either about your problem, or something completely unrelated, to take your mind off your crisis.

If you are having the thoughts I’ve mentioned, this is a sign you need to find time to reflect on what is good about you and your life; you need to make it a DAILY practice; you need to refocus on your hopes and dreams. You need to reach out to loved ones, clergy, maybe a therapist, or the employee assistance program.

There are some thoughts that will require much more than than what you can do alone. There are thoughts that are a sign of something serious that needs immediate professional attention.

Do you feel you have no purpose in life? Do you feel completely hopeless? Do you ever find yourself having thoughts about what it would be like to be dead? Do you find yourself thinking that people would be better off without you in their lives? Do you find yourself going beyond simply not slowing down for yellow lights, and actually running red lights? Do find yourself wondering what it would be like to go toppling off the overpass? Do you notice you are preoccupied with the after life?

These are all thoughts that are a sign of serious suicide risk. Do not ignore this. There are several options for immediate help, from calling 911 and talking to the police, to calling 1-800-273-TALK or 1-800-SUICIDE (1-800-273-8255, 1-800-784-3433) or going to the emergency room. Either one of these options will lead to a trained professional who can help determine the type of help you need immediately.

Nine out of ten people who commit suicide had a diagnosable mental disorder. But, only THREE out of 10 people who die by suicide received mental health care in the year prior to their suicide.

So, start preventing suicide by taking a look at yourself. Because, trust me, we need you around.