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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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

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?
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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

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.
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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.
LoseWeight
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).
MedicalIssuesInsomnia
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.
SealsSleepWexlerPsychiatry

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 05

When you lose a parent to suicide

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

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

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

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

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

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

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

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

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

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

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

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

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

Jan 01

More suicides during the holidays?

PeaceWinter2By Dr. Micaela Wexler

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

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

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

Preventing suicide is a good New Year’s Resolution.

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

If you are wishing you were dead yourself, you must get help immediately. Call 911 if you don’t know what to do. Or, call one of the following numbers:
1-800-SUICIDE
1-800-273-TALK

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

Websites where you can go for help:

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

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

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

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

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

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

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

Dec 10

When you call a girl a slut

By Dr. Micaela Wexler
When I say “girl,” I am talking about females who have not yet reached adulthood. Girls start being subjected to this abuse starting at the age of 10, if not earlier. By “slut,” I am not just referring to the actual word, but also to any language that shames a girl for expressing her sexuality. And, when I say “you,” I am limiting myself to the adults in girls’ lives who do this who are supposed to be supporting and nurturing these girls: parents, step parents, parents’ girlfriends, aunts, older sisters, teachers, neighbors.

This behavior is so wide spread that a word defining this behavior is now part of our lexicon: slut-shaming. Slut-shaming is defined as “publicly or privately insulting a woman because she expressed her sexuality in a way that does not conform with patriarchal expectations for women.” As a child psychiatrist, I hear slut-shaming several times a day. And, sadly, it is usually women who engage in this behavior. Examples I have heard include:

- a teacher I spoke to about a bullying incident said, of the 12 year old in question, “excuse my language, but if she didn’t dress like a slut . . . ”
- a woman, speaking about her stepdaughter: “she is 15, and she’s already a slut”
- another stepmother, speaking of her husband’s 14 year old daughter, “she goes prancing out the door with skirts up to here, make up that makes her look cheap, to hang out with a bunch of kids to do who-knows-what. I don’t like that sort of behavior around my 12 year old son. You should see how he looks at her. I wish she would just go away.”
- a woman whose boyfriend has a 16 year old: “instead of making her babysit (their one year old), he let her go out with her friends. All she does is go out and screw everyone she sees.”

The implications behind this slut-shaming behavior is that these girls are unworthy of our love, support and protection. In each of these examples, the girls’ behavior was being used as a rationale for not considering her needs. In the first example, the teacher is absolving herself of any responsibility for protecting a 12 year old girl because of how she DRESSES. The other examples all involve stepchildren. So, not only do the girls in question have to suffer the calamity of their parents’ divorce, but they now have a new slut-shaming person in their lives.

In every single example, the needs of the girls are completely ignored. The 14 year old girl mentioned above is entitled to safety in her own home regardless of how she dresses. The 12 year old son would benefit from being taught to respect females rather than watching the behavior that is undoubtedly being demonstrated. If it really is true that the 16 year old is “screwing everyone she sees,” that is a tragedy, not an opportunity for derision.

As a child psychiatrist, I have to think that the women in these slut-shaming examples, and others like them, do not truly wish these girls harm. The teacher chose a helping profession and has dedicated several years to serving middle school children. All the mothers in these examples are incredibly nurturing to their own children.

So, why do you do this? One reason, in my opinion, is that you are truly overwhelmed by the daunting task of shepherding girls through these turbulent years. Raising teenagers, both boys and girls, has become very complicated. Families face constant intrusion from the world at large, through the media, social media, as well as from economic pressures that expose families to risky situations. Many of you are the products of a society that gave you negative images and limited opportunities. You live in a world that offers your family very little support.

I have to believe, also, that you are unaware of the damage this behavior causes. Slut-shaming causes deep, long lasting damage to a girl’s self perception. When girls are slut-shamed by the adults in their lives, they are shunned, isolated, left to navigate the dangerous waters of the teenage world alone, without protection, information and support. This places boys at risk, as well. Slut shaming leaves boys without any meaningful tools they can use in communicating with girls. They are being asked to view potential friends and romantic partners in a negative, one dimensional fashion which ignores who they are as people.

When we make negative comments about how a girl dresses, we are are objectifying that girl, and teaching her, and her male peers, that her value is based on how she looks. Whenever we slut-shame, we make it harder for these girls to defend themselves against rape, child molestation and relationship abuse. We also make it difficult for these girls to develop a healthy sexual identity. Some girls react by exaggerating this behavior. Other girls react by shutting down their sexual side, acquiring negative attitudes about their sexual feelings.
By slut-shaming, you are adding to the turbulence all teenagers face. Since I know that this is not at all your intention, I ask, for the sake of all teenagers, that you examine this behavior and why you engage in it. Next time you get the urge to do this, instead find out what the girl’s behavior means about how she feels as a person. Reach out to her and help her navigate the treacherous waters she and all teenagers find themselves in.

Nov 27

Genital warts: what to tell your teenager

By Dr. Micaela Wexler
One wouldn’t expect a child psychiatrist to be writing about this, but it turns out a common source of severe anxiety for teenagers is discovery of a sexually transmitted infection. Genital warts is one such infection, which is poorly understood by teenagers. Once they have it, they hear just two things: 1) it’s forever; 2) it’s transmittable. In most cases, no one has ever sat down and had an in depth discussion with them about genital warts.

First, parents always want to know: HOW do you talk to your teenager about GENITAL WARTS?

Here’s a way I know of that has worked for parents. This is the phrase that you can use for just about anything:
“This may not ever happen to you, but I was reading an article about it, and I want you to be prepared if it does happen to you, or if it happens to anyone you know.”

Practice saying that to yourself, and then practice saying that phrase to your teenager. Start by using it for a topic that isn’t so sensitive, like, how to avoid being pick-pocketed. You can then segue to topics about health, like, how to treat a urinary tract infection, how to avoid constipation, all the way to talking about sex.

Once you’ve used it a few times on these less sensitive subjects, don’t waste your currency. Dive in and use it before it “expires.” You can say, “now that we’re on the topic of things I’ve read about, what do you know about genital warts?”

Here’s the skinny on genital warts.

Genital warts are warts that are located near or in the genital areas. In a female, that means on or near the vulva (the outside genital area), vagina, cervix, or anus. In a male, that means near or on the penis, scrotum, or anus. They look like bumps or growths. They can be flat or raised, single or many, small or large. They tend to be whitish or flesh colored. They do not cause pain. They do not drain or ooze.

Genital warts are caused by a type of virus, the Human Papilloma Virus (HPV). There are 100’s of types of HPV warts, and they infect multiple parts of the body. Some types of HPV cause plantar warts, which appear on the bottom of one’s foot. Other types infect the genital area, and a smaller subset of those can cause cancer.

Typically, a wart will show up between three weeks to six months after exposure. Sometimes warts can take even longer, up to years, to appear; the virus can live in the body for a very long time without causing any symptoms. This makes it difficult to know who gave you HPV.

Because warts are caused by a virus, they need to INCUBATE in order to cause a visual wart. In simple terms, what this means is that the virus needs to take over the cell’s genetic machinery, and then change those cells to become cells that look like warts. This takes time; it doesn’t happen in just a few days. And, while the virus is going through all the steps of creating a wart, our body’s immune system is fighting the virus at each step. So, if a person is healthy with a good immune system and living a stress free life, the body could potentially fight off HPV enough to keep a wart from appearing.
To better understand this, think about chicken pox, which is also caused by a virus which causes skin eruptions. The chicken pox virus is much stronger than the HPV virus: no matter how healthy and stress free you are, you’re going to get skin eruptions after being exposed (unless you have been vaccinated). Chicken pox requires at least 10 days to incubate and cause skin eruptions, ie, it takes at least that long after exposure to get the chicken pox rash.

How contagious are warts?

HPV transmission can be complicated. If you have a wart, or a lesion, then you are very contagious. For women, this can be a problem, because they could potentially have an eruption on a part of the body they can not see, like the vaginal canal, and not even know they have HPV. The male sexual partner could then get the virus on his penis, and then give that virus to another female, and SHE could get HPV. All of this could happen without anyone knowing anyone has HPV. This complicated transmission is a strong case for using condoms. However, condoms are not 100 per cent protective, because a male could have a virus on his scrotum and transmit it to a woman’s vulva.

How dangerous are genital warts?

Some types of HPV can cause cancer. In women, they can cause anal or cervical cancer. In men, they can cause penile cancer. For this reason, they should not be ignored. Because of the complicated transmission described above, ALL women are advised to get annual pap smears. (Pap is short for papilloma.) Men should examine their genital area on a regular basis, including the penis, the scrotum and the anal regions. If they see or feel a lesion, they should have it looked at by a doctor. Some physicians provide “anal pap smears” for people who have engaged in receptive anal sex.

How can genital warts be prevented?

The only 100 per cent way to prevent genital warts is to abstain from all sexual activity. For many people, especially married people, this is highly impractical. There are ways to reduce the risk of genital warts: 1) use condoms; 2) get the Gardisil vaccine; 3) know your sexual partner well enough to examine the genital area; 4) get annual pap smears; 4) let your partner know you have “tested positive in the past for HPV.”

The last one is important. Many teenagers will neglect to tell their partners out of fear that they will be ostracized, or accused of intentionally spreading STDs. However, saying “I have tested positive for HPV” is clinically no different than saying “I have genital warts,” but much easier to get out of your month. If teenagers are informed with the knowledge in this article, they can at least have the proper “ammo” to disclose this important information.

Click here for more information on genital warts.