From the Education Committee:

Clinical Corner Topics...
Just what is CBT? How does it work?
Internet Resource for Pharmacology
Teen Suicide
What is CBT?
The 5 goals of a PACT team are to 5/5/04
Personality disorders
Antidepressants and Sex  (updated)
PTSD Criteria
Relaxation as Therapy
Brief Intervention Can Help Alcohol Abusers
Antisocial Bipolar Patients
CM or ACT?
Treatment Team Resources on the Web
Advances in Childhood Schizophrenia
What is EMDR?
Treatment for Lygophobia
Clinical Corner:  PANIC!!
RECOVERY in Mental Health
Principles Guiding the Recovery Process
Principles of Recovery
Principles of Recovery Part II
TCSC Day ProgramThe Stages of Recovery
Peer Support & Relationships in the First stage of Recovery
Domestic Violence Doesn’t Discriminate by Alexandra Price
Clinical Corner: IED and ODD
Antisocial Personality Disorder
Empowerment Model of Recovery from SMI
Seasonal Affective Disorder: Real & Treatable
Screening for Alcohol in the ED & Trauma Center
ADD- Attention Deficit Disorder
Guidelines for BPAD in Children

Management Topics...
Management Matters: The Summary of the Story "Who Moved My Cheese?"
Management Matters: Motivation Technique #1: Delegate effectively
Management Matters: Motivation Technique #2: Assign incremental tasks
Management Matters: Motivation Technique #3: Generate enthusiasm
Management Matters: Motivation Technique #4: Use praise and criticism
Management Matters: Motivation Technique #5: Generate enthusiasm
Management Matters: Motivation Technique #6: Promote integrity
Management Matters: Motivation Technique #7: Maintain your humor
Gaining Cooperation from Others
Characteristics of A Good Working Group #1
Characteristics of A Good Working Group #2
Characteristics of A Good Working Group #3
Characteristics of A Good Working Group #4
Characteristics of A Good Working Group #5
Characteristics of A Good Working Group #6
Ten Commandments For Conducting Meetings
6 ways to say 'No' and mean it
End Procrastination
Effective Leaders
Believing the Right things for Success
Managing Time, Info, Stress
Believing the Right things for Success - Point #2
Odorific! How to deal with employees' smells
The Art of Delegation by Gerard M Blair
Managing stress: a few simple techniques
Theory
What's Wrong With A Messy Desk?

Now that everyone has been trained in the treatment of Post Traumatic Stress Disorder (what! you haven't seen the 4 part series? Better sign up today, it's mandatory!), here are the four essential features the experts say are necessary to diagnose the condition:

First, the person has been exposed to a traumatic event in which both of the following were present:

1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and

2. the person's response involved intense fear, helplessness, or horror. NOTE: in children, this may be expressed instead by disorganized or agitated behavior.

Second, the traumatic event is persistently re-experienced. For example, recurrent and intrusive distressing recollections or dreams of the event, acting or feeling as if the traumatic event were recurring, intense psychological distress at exposure to cues that resemble an aspect of the traumatic event, or physiological reactivity on exposure to cues that resemble an aspect of the traumatic event. NOTE: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed; there may be frightening dreams without recognizable content; trauma-specific reenactment may occur.

Third, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma).

Fourth, persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response

Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association

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Cognitive behavior therapy* combines two very effective kinds of psychotherapy - cognitive therapy and behavior therapy.

Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.

Cognitive therapy teaches you how certain thinking patterns are causing your symptoms - by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.

When combined into CBT, behavior therapy and cognitive therapy provide you with very powerful tools for stopping your symptoms and getting your life on a more satisfying track.

http://www.cognitivetherapy.com/basics.html

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The Summary of the Story "Management Matters: Who Moved My Cheese?"

The story of Who Moved My Cheese? is a simple parable that can be interpreted as you like, depending on where you feel you are -- at work or in your life. In the story, four characters -- who represent parts of ourselves -- live in a "Maze" and look for "Cheese" to nourish them and make them happy. Two are mice named "Sniff" and "Scurry." And two are little people named "Hem" and "Haw," who are the size of mice but look and act a lot like some people.

"Cheese" is a metaphor for whatever you want to have in life -- job, relationship, health, peace of mind. And the "Maze" is where you look for it. The story shows what happens to the characters one day when the Cheese has been moved to another part of the Maze. Some are prepared for it and do well. Others are surprised by it and have a difficult time. As you watch what they do, you may see a part of yourself.

When Haw is finally able to see what he is doing and laughs at himself, he moves on and finds "New Cheese", while Hem remains hemmed in by his comfort and fears and is left behind. As Haw progresses through the Maze, he uses the walls to write what he has learned about change, hoping his friend Hem will find his way. The story ends with Haw realizing that when you can read the "Handwriting on the Wall," you can do well in changing times.

From: Ramita Bonadonna, PhD, RN

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What is CBT?
Cognitive behavior therapy combines two very effective kinds of psychotherapy - cognitive therapy and behavior therapy.

Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.

Cognitive therapy teaches you how certain thinking patterns are causing your symptoms - by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.

When combined into CBT, behavior therapy and cognitive therapy provide you with very powerful tools for stopping your symptoms and getting your life on a more satisfying track.

For more information about CBT, see the website:

http://www.cognitivetherapy.com/basics.html

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The 5 goals of a PACT team are to 5/5/04

1. lessen or eliminate the symptoms of mental illness,
2. improve or monitor functioning in social and employment roles,
3. reduce hospitalization,
4. lessen the family's burden of providing care, and
5. enhance the client's ability to live independently in his/her community.

For more information on PACT, see the NAMI website:

From Dave Shiel: In other words, " to maximize the potential for Recovery ! " Thanks Sarah.

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Personality disorders

Personality disorders (PDs) are pervasive, persistent, usually life-long patterns of maladaptive behavior that are not attributable to Axis I disorders, specific organic factors or cultural role difficulties. In general, the PD patient typically lacks empathy for others and tends to externalize blame. Thus, the old joke about the narcissist's retort to his therapist: What do you mean I'm grandiose? If I were, do you think I'd choose a loser like you for a therapist?

The PD patient typically shows a certain rigidity of function. No matter how many times the old ways of behaving have failed, the patient resists changing them. It is usually pressure from family, spouse or employer that brings the patient into treatment. Speaking of spouse or employer, if ever a patient failed Freud's test of mental health, which included the ability to love and to work, it is the patient with severe personality disorder. This brings up the egosyntonic quality of most PDs, it is usually not the identified patient who is bothered by the behaviors in question, but someone else who must endure them.

Reference: http://www.mhsource.com/expert/exp1020397d.html

Q. A physician has asked me to provide her with the name of an antidepressant that will not decrease sexual libido in her patients. Serzone and Wellbutrin have a low incidence of such effect. Is there a better choice?

http://www.mhsource.com/expert/exp1031698c.html

Here's an update about last week's Clinical Corner from one of our Advance Practice Registered Nurses, Madelyn Myers:

"Serzone has recently been withdrawn from the market due to cases of sudden liver failure. Trazadone is another med. that may be helpful. Taking up to a 2 day holiday from Zoloft is another method that I have heard is helpful to decrease side effects ( the week- end drug holiday!!)"

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Medications are an important part of the treatment plan for most of our consumers. It is a challenge for clinicians to stay up-to-date with the latest information and teach consumers what they need to know to use medications safely and effectively. The South Carolina Department of Mental Health has made an excellent Internet resource available to employees, called "Clinical Pharmacology", and here's how you can find it:

1. Access Clinical Pharmacology online by first going to the South Carolina Department of Mental Health Intranet site at http://dmhhome then clicking on "Clinical Pharmacology" (listed on left side of screen).

2. Enter a search term in the Search Entire Site box in the upper right corner. You can enter a full or partial, generic or brand Rx, OTC, herbal or nutritional product name; disease state or condition (e.g., hypertension, headache); classification; or cost.

3. Click the yellow "Go" button.

4. Search results will display in the right frame below the search box. View all links to your term, organized into categories (as applicable): monographs, product information, patient education, indications index, contraindications/precautions index, adverse reactions index, costs index, and/or classifications index.

5. Click on the link for your term under the category you wish to access.

     A continued rise in teen suicide rates is concerning mental health professionals, educators, and youth workers. In the past 25 years, while the general incidence of suicide has decreased, the rate for those between 15 and 24 has tripled. It is generally considered to be the second or third most common cause of death among adolescents, even though it is seriously under reported. No one has advanced a good theory explaining why teens are taking their own lives in greater numbers, but it's important for everyone to be aware of the problem.

     No talk of suicide should be taken lightly. It indicates the need for professional help. Any suicidal gesture, no matter how "harmless" it seems, demands immediate professional attention.

Indicators of developing depression in adolescents include:

• Unhappiness

• Gradual withdrawal into helplessness and apathy

• Isolated behavior

• Drop in school performance

• Loss of interest in activities that formerly were sources of enjoyment

• Feelings of worthlessness, hopelessness, helplessness

• Fatigue or lack of energy or motivation

• Change in sleep habits

• Change in eating habits

• Self-neglect

• Preoccupation with sad thoughts or death

• Loss of concentration

• Increase in physical complaints

• Sudden outbursts of temper

• Reckless or dangerous behavior

• Increased drug or alcohol abuse

• Irritability; restlessness

More imminent danger signs include:

• Talking about death and wanting to die

• Suicidal thoughts, plans, or fantasies

• Previous suicide attempts

• Friends who have attempted suicide

• Giving away personal possessions

• Telling a friend about suicidal plans

• Writing a note

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TEENAGERS WITH EATING DISORDERS

Overeating related to tension, poor nutritional habits and food fads are relatively common eating problems for youngsters. In addition, two psychiatric eating disorders, anorexia nervosa and bulimia, are on the increase among teenage girls and young women and often run in families. In the United States, as many as 10 in 100 young women suffer from an eating disorder. These two eating disorders also occur in boys, but much less often. The child and adolescent psychiatrist is trained to evaluate, diagnose, and treat these psychiatric disorders which are characterized by a preoccupation with food and a distortion of body image.

Parents frequently ask how to identify symptoms of anorexia nervosa and bulimia. Unfortunately, many teenagers successfully hide these serious and sometimes fatal disorders from their families for many months or years.

Parents should be on the lookout for various symptoms and warning signs of anorexia nervosa and bulimia:

A teenager with anorexia nervosa is typically a perfectionist and a high achiever in school. At the same time, she suffers from low self-esteem, irrationally believing she is fat regardless of how thin she becomes. Desperately needing a feeling of mastery over her life, the teenager with anorexia nervosa experiences a sense of control only when she says "no" to the normal food demands of her body. In a relentless pursuit to be thin, the girl starves herself. This often reaches the point of serious damage to the body, and in a small number of cases may lead to death.

The symptoms of bulimia are usually different from those of anorexia nervosa. The patient binges on huge quantities of high-caloric food and/or purges her body of dreaded calories by self-induced vomiting and often by using laxatives. These binges may alternate with severe diets, resulting in dramatic weight fluctuations. Teenagers may try to hide the signs of throwing up by running water while spending long periods of time in the bathroom. The purging of bulimia presents a serious threat to the patient's physical health, including dehydration, hormonal imbalance, the depletion of important minerals, and damage to vital organs.

With comprehensive treatment, most teenagers can be relieved of the symptoms or helped to control eating disorders. Treatment for eating disorders usually requires a team approach; including individual therapy, family therapy, working with a primary care physician, working with a nutritionist, and medication. Many adolescents also suffer from other problems; including depression, anxiety, and substance abuse. It is important to recognize and get appropriate treatment for these problems as well.

Clinical Corner: Relaxation as Therapy

Q. Is there any evidence that relaxation techniques (e.g. covert imagery, deep muscle relaxation, etc) may help people with schizophrenia or bipolar disorder as an adjunctive treatment?

A. There is some modest evidence for the use of such relaxation techniques in patients with schizophrenia; I am not aware of similar studies in bipolar patients. Lukoff et al (Schizophr Bull 1986;12(2):274-82) compared a 10 week inpatient "holistic" health program for male schizophrenic patients with an equally intense social skills training program. The holistic program included meditation and stress-reduction techniques. Both groups showed similar reductions in psychopathology, but the use of medication and a token economy milieu confounded interpretation. Puente and Peacock (Percept Mot Skills June 1988) did not find that relaxation response training improved attentional deficits in patients with schizophrenia.

However, Stein & Nikolic (Am J Occup Ther March 1989) found that a stress management training program, including muscle relaxation and biofeedback, did decrease anxiety in a 26 year-old male with schizophrenia. Since stress is known to play a role in psychotic relapse, such research is worth pursuing. Supportive and educational approaches to bipolar illness are generally viewed as very important in the overall well-being and prognosis of the patient; Kay Jamison PhD has written extensively on this.

According to national surveys, nearly a third of Americans consume more than the FDA-recommended two drinks a day. In the last two decades, treatment professionals have realized that reaching these potential alcohol abusers is important. The August issue of the Harvard Mental Health Letter examines brief interventions for this large segment of the population.

Known as problem drinkers, this group probably accounts for most of the problems caused by alcohol, including family problems, accidents, illness, and injuries. They rarely think of themselves as alcoholics or seek standard treatment for alcoholism. However, recent studies suggest that a little advice and encouragement can help problem drinkers cut down or eliminate their drinking. An estimated 75% of alcohol abusers recover without professional treatment or 12-step groups.

The source of advice could be a physician, counselor, or lay person who is knowledgeable about alcohol. The helper can ask about alcohol consumption and compare it to the norm. Too often, people define "moderation" as the amount they themselves drink. The helper can provide a self-help manual, give a brief talk about the consequences of alcohol abuse, suggest choosing a goal and keeping records of drinking patterns, and make professional treatment referrals if necessary.

Intervention can begin by screening large numbers of people for alcohol problems. The August issue of the Harvard Mental Health Letter provides the following widely used questionnaire entitled CAGE (Cut down, Annoyed, Guilty, Eye-opener) that has been estimated to identify 60-70% of alcohol abusers. A person who answers "yes" to even one of these questions may have a problem that a closer examination will reveal.

* Have you ever felt that you should cut down?

* Have people annoyed you by criticizing your drinking?

* Have you ever felt guilty about your drinking?

* Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

The Harvard Mental Health Letter is available from Harvard Health Publications, the publishing division of Harvard Medical School. You can subscribe to the Harvard Mental Health Letter for $59 per year at http://www.health.harvard.edu/mental or by calling 1-877-649-9457.
 

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Antisocial Bipolar Patients

Q. Bipolar patients without psychotic symptoms seem to be just like antisocial patients. When the bipolar patient is on lithium or a mood stabilizer they often become the person you knew was in there.

I realize there is a lot to it, but it seems so many adolescent patients who are ADD (attention deficit disorder) or ADHD (attention deficit hyperactivity disorder) are now also bipolar. By the time they are 18, they now are borderline or antisocial. I am a nurse and I am not sure how to differentiate the lot of them. Can you help?

A. You are raising some interesting and complicated questions. I agree that some bipolar patients may show antisocial features, but this is usually true during manic or hypomanic phases of the illness. A classic paper entitled, "Playing the Manic Game." [Janowsky et al, Arch Gen Psychiatry 1970; 22:252-6] noted that manic patients may often behave in a manipulative, "gamey", or antisocial manner--but again, these are usually not in evidence when the patient has regained their normal (euthymic) mood state.

In fact, the euthymic bipolar patient often looks back with considerable guilt at his or her antisocial behavior during the manic phase--a feature that clearly distinguishes the bipolar patient from the truly antisocial personality disordered patient.

On the other hand, Faraone et al (Am J Med Genet 1998; 81:108-16) have found evidence of a three-way association among attention deficit hyperactivity disorder (ADHD), antisocial traits, and bipolar disorder-suggesting, perhaps, some common genetic factor underlying these conditions. (Perhaps a generalized impulsivity is common to all three?)

In general, though, I believe that aggression and impulsivity in bipolar patients are linked with states of hyperarousal rather than with antisocial personality traits (Swann AC, J Clin Psychiatry 1999; 60(suppl 15):25-28].

I agree, however, that in younger patients, it's sometimes hard to tease out Axis II pathology (borderline or Antisocial PD) from normal adolescent turmoil; from ADHD; from bipolar disorder! One clue is family history: if this is heavily loaded with bipolar disorder, it raises my level of suspicion in the identified patient.

In theory, ADHD and personality disorders are not phasic conditions; i.e., they are always expressed, to some degree, with minor variation depending on the psychosocial environment. In contrast (again, theoretically) bipolar disorder is phasic, with discernible cycles and periods of normal mood. However, in reality, this distinction doesn't always hold up in younger bipolar patients, who may show ongoing mood instability that does not always fit into neat periods of mania, hypomania, or depression (J. Wozniak MD, Bipolar Options conference, 5/9/03).

Recently, my colleagues and I (notably Dr. Nassir Ghaemi) have developed a screening instrument called the Bipolar Spectrum Diagnostic Scale (BSDS) that we believe is helpful in screening for the softer end of the bipolar spectrum; however, we have not yet tested this in ADHD or Axis II diagnosis populations. You may find a copy of this scale at the website http://www.mdf.org.uk/about/BSD.pdf.

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Treatment Team Resources on the Web

Helping clients with mental illness is your top priority. And the more resources you have, the easier that is. This Web site provides a range of materials to help you educate and work with clients, as well as fuel your own professional growth. While some sections have "Schizophrenia" in the title, the information is generic, designed for our population, and can be helpful to people with any severe, persistent mental illness, with any sort of treatment plan.

Click on the following link to find downloadable patient information in English and Spanish as well as instructor's manuals. You may have seen these materials in binders called "Team Solutions" and "Solutions for Wellness". This website is your on-line source for the same materials.

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CM or ACT?

In Adult Services, we have two types of team approaches to caring for consumers: Case Management (CM) and Assertive Community Treatment (ACT). How does ACT differ from traditional case management?

• Traditional case management uses a “brokered service” approach where the case manager links the client to services rather than directly providing them, as ACT teams work to do. An example would be linking the client to Vocational Rehabilitation versus teaching job readiness skills.

• With ACT, caseloads are smaller in order to allow delivery of intensive services.

• ACT teams share responsibility for the intervention rather than the client being assigned exclusively to one case manager.

Since ACT teams serve clients who, at baseline, have a high degree of impairment and usually a history of multiple/long-term hospitalizations, outcomes such as reduction in hospitalization rate, decreased symptomatology, and increased independent living lead to substantial cost savings, compared with looking at these same outcomes in a much less severely ill population.

Reference:
Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners: About Understanding and Implementing Evidence-based Practices. Hyde, Falls, Morris & Schoenwald

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Advances in Childhood Schizophrenia

Q. What can you tell me about childhood schizophrenia? Have there been any recent advances in treating this illness?

A. Childhood schizophrenia is an area of active investigation, with much work being focused on neurologic and other physical markers for this condition. Increasingly, schizophrenia looks to be a neurodevelopmental disorder, with subtle evidence visible even early in childhood, though not always manifest clinically prior to the age of 12. For example, when compared with normal and ADHD children, children with childhood-onset schizophrenia may show a higher blink rate (see Jacobsen et al., Biological Psychiatry, December 15, 1996, pp. 1222-9).

This same group has also found higher rates of abnormal eye movements in children with schizophrenia (Biological Psychiatry, December 1, 1996; 40(11):1144-54). A recent review of the demographics of childhood schizophrenia appears in an article by Thomsen, Acta Psychiatrica Scandinavica, September 1996. Finally, you may want to check the web site for the National Alliance for Research on Schizophrenia and Depression at: http://www.narsad.org.

Clinical Corner: What is EMDR?

Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories (Shapiro, 1989a, 1989b). Shapiro's (2001) Adaptive Information Processing model posits that EMDR facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution. After successful treatment with EMDR, affective distress is relieved, negative beliefs are reformulated, and physiological arousal is reduced. During EMDR the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. Therapist directed lateral eye movements are the most commonly used external stimulus but a variety of other stimuli including hand-tapping and audio stimulation are often used (Shapiro, 1991).

Shapiro (1995) hypothesizes that EMDR facilitates the accessing of the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. These new associations are thought to result in complete information processing, new learning, elimination of emotional distress, and development of cognitive insights. EMDR uses a three pronged protocol: (1) the past events that have laid the groundwork for dysfunction are processed, forging new associative links with adaptive information; (2) the current circumstances that elicit distress are targeted, and internal and external triggers are desensitized; (3) imaginal templates of future events are incorporated, to assist the client in acquiring the skills needed for adaptive functioning.

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Treatment for Lygophobia

Q. I have a 17-year-old old female client with lygophobia - fear of the dark. She has been afflicted with this for a number of years. In the last six to eight weeks it has begun causing her serious problems, such as inability to go into the garage to do laundry by herself or to go out alone after dark to perform tasks. She is not currently taking medication. I would appreciate reference to any text or article which might help me formulate a treatment plan. I am aware of exposure therapy.

A. My first question is why things have gotten worse in the last 6-8 weeks. Has there been a recent stressor? Do you have a formulation regarding the origins of this phobia? Could there have been some traumatic event that set this pattern off?

Beyond some reports in the child literature, there does not appear to be much research on fear of the dark. In a review of children's nighttime fears, King et al (Clinical Psychology Review 1997;17[4]:431-43) postulate that severe night-time fears are probably due to a complex interaction of biological, environmental, and cognitive factors. Behavioral interventions and cognitive-behavioral interventions are evaluated, with the latter showing the most empirical support. Giebenhain and O'Dell (Journal of Applied Behavior Analysis, Spring 1984, pp. 121-25) examined the effectiveness of a manual to teach parents how to help their children overcome fear of the dark. The main components included desensitization, reinforcement and verbal self-control statements. They also discuss the use of a rheostat device that helps the child "dose" the amount of light vs. darkness he/she experiences at night. This might be adapted to your patient's needs.

Another paper by Freidman and Ollendick (Journal of Behavior Therapy and Experimental Psychiatry, June 1989, pp. 171-78) discusses the use of relaxation, reinforcement, and cognitive self-instruction for night time fears. I hope these references get you started. You might also consider contacting the Phobia Self-Help Group (East Post Rd. and Davis Ave, White Plains, N.Y., 914-681-1038) to see if they have any more literature or suggestions. Finally, I would certainly consider a trial on an SSRI, such as fluoxetine or sertraline, based on the utility of these agents for other phobic disorders.

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Clinical Corner: PANIC!!

Panic Disorder!!!!
Core Problem: Brief, Unprovoked Attacks of Panic

Associated Problems:
- Drug or Medication Abuse
- Alcohol Abuse
- Phobia (Excessive Fear of Specific Things)
- Obsessive Thinking or Compulsive Rituals
- Prolonged Anxiety, Tension, or Worry
- Sad or Depressed Mood
- Poor Sexual Interest or Ability
- Overly Dependent Behavior
- Poor Physical Health

Problems When Severe:
Risk of Harming Self is low, if no superimposed major depression or substance abuse

Illness Course:
- Onset is usually in early to middle adulthood
- More common in females than males
- Frequently associated with agoraphobia and major depressive disorder
- Outcome is good for two thirds of patients (but only 10 20% completely recover)
 

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RECOVERY in Mental Health

Many of us know what "recovery" means in terms of alcohol and drug dependence. But what does "recovery" mean in Mental Health?

The Ohio Department of Mental Health developed a Mental Health Recovery Model, and I'll be describing parts of that model in this and future Clinical Corners.

There are 12 Guiding Principles used to develop the Recovery Process Model. Let's look at the first three:

Principle I

The consumer directs the recovery process; therefore, consumer input is essential throughout the process.

Principle II

The Mental Health System must be aware of its tendency to enable and encourage consumer dependency.

Principle III

Consumers are able to recover more quickly when their

-Hope is encouraged, enhanced, and/or maintained;

-Life roles with respect to work and meaningful activities are defined;

-Spirituality is considered;

-Culture is understood;

-Education needs as well as those of their family/significant others are identified;

-Socialization needs are identified.

Do any of these principles surprise you? Do you use these principles to guide your practice?

Reference:

Townsend W, Boyd S, Griffin G. (2000). Emerging Best Practices in Mental Health Recovery. Ohio Department of Mental Health, 30 East Broad Street, Columbus, Ohio 43266-0414

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Principles of Recovery

And the last 4 are:

Principle IX

Clinicians and consumers collaboratively develop a recovery management plan. This plan focuses on the interventions that will facilitate recovery and the resources that will support the recovery process.

Principle X

Family involvement may enhance the recovery process. The consumer defines his/her family.

Principle XI

Mental Health services are most effective when the delivery is within the context of the consumer’s community.

Principle XII

Community involvement as defined by the consumer is important to the recovery process.

Reference:

Townsend W, Boyd S, Griffin G. (2000). Emerging Best Practices in Mental Health Recovery. Ohio Department of Mental Health, 30 East Broad Street, Columbus, Ohio 43266-0414

Did you know that the TriCounty Crisis Stabilization Center (a program of the Charleston/Dorchester Community Mental Health Center) has a Day Program?

The TCSC Day Program is designed for adults who are experiencing crisis but are not in need of residential services. The day program is also suitable as a step down for hospital and jail discharges.

For example, if your client is going to be released from jail and will need a structured environment for a while to adjust to community living, the TCSC Day Program might be an important part of the treatment plan for short-term intensive support.

Consumers in the Day Program participate in treatment groups and receive monitoring to increase coping skills. Lunch is included, and some transportation can be arranged.

The program runs Monday through Friday, 8:30 AM to approximately 3:30 PM and consists of scheduled groups throughout the day.

Questions about referrals can be answered at 958-3530.

Referrals can be faxed to 958-3525.

During the recovery process, individuals are either aware or unaware of their condition. This Recovery Process Model accounts for the individual’s movement and degree of awareness within and across the following four stages:

1. Dependent/Unaware
2. Dependent/ Aware
3. Independent/Aware
4. Interdependent/Aware

Let’s look at the Stage I. Dependent/Unaware:

It is understood that multiple factors influence dependency. These include but are not limited to:

1. the degree of illness experienced;
2. the positive/negative impact and/or intervention of others, including the mental health system;
3. an individual’s interaction and/or reactions to experiences with traumatic events, such as hospitalizations, medication reactions, jails, interpersonal relations, and
4. the impact of the illness on their daily lives.

During this stage, individuals are most often unaware of their dependency. As well, the mental health system is often unaware of behaviors and interventions necessary to affect recovery; therefore, it acts, through inappropriate service delivery/interventions, to maintain dependency.

Now let’s look at Clinical Care during Stage I. Dependent/Unaware:

Consumer’s Status:

• Cannot identify personal needs
• Uninformed of resource opportunities;
• May be angry, anxious, distrustful, and unmotivated;
• May not accept diagnosis;
• Symptoms, treatment, and stigma may interfere with motivation;
• May experience shame & stigma concerning illness;
• May lack experience in developing trusting relationships.

Doesn't this sound familiar? How many people in your caseload are at Stage I in the Recovery Process?

Clinicians’ Roles:

• Demonstrates hope and achievement when interacting with consumer;
• Promotes acceptance as first step to recovery;
• Explains illness, symptoms, courses of treatment and hope for the future and begins to teach consumer about the use and benefits of a personal Relapse Prevention Plan and Advance Directives;
• Informs consumer of benefits of active treatment;
• Engages family and/or significant others and refers them to available community supports and education.

Which of these roles feels most comfortable for you? Which roles do you need to develop?

Community Supports’ Roles:

• Makes available family and consumer peer support, consumer enrichment and engagement activities;
• Makes available, especially to families and consumers, information and education concerning mental illness.

Reference:

Townsend W, Boyd S, Griffin G. (2000). Emerging Best Practices in Mental Health Recovery. Ohio Department of Mental Health, 30 East Broad Street, Columbus, Ohio 43266-0414

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Peer Support & Relationships in the First stage of Recovery

Let's look at Peer Support & Relationships in the First stage of Recovery (Dependent/Unaware):

Consumer's Status:

• May have lost contact with peers;
• Lacks self-esteem and sense of self;
• May have limited knowledge of supportive resources and medical management;
• May experience spiritual and/or cultural conflict;
• Views self as an object;
• May feel hopeless and helpless;
• May be withdrawn and avoids contact with others.

Clinicians' Roles:

• Makes consumer aware he/she is not alone;
• Offers hope & friendship;
• Encourages consumer to remain active;
• Identifies support and provides access to peer support;
• Helps consumer develop reciprocal relationships;
• Assists consumer in recognizing strengths and valuing peer support experiences;
• Fosters advocacy and assists consumer in taking control of his/her illness;
• Provides consumer with information about how to obtain access to services;
• Encourages the development and/or maintenance of social, family and personal relationships
• Encourages consumer to maintain or seek supportive spiritual/cultural activities.

Community Supports' Roles:

• Makes peer support groups available and accessible;
• Involves peer support groups in treatment sessions when appropriate;
• Provides personal assistance;
• Offers hope through peer supporters making non-threatening visits;
• Peer Support group participates in community activities (i.e., food drives, community clean up).

Reference:

Townsend W, Boyd S, Griffin G. (2000). Emerging Best Practices in Mental Health Recovery. Ohio Department of Mental Health, 30 East Broad Street, Columbus, Ohio 43266-0414

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Domestic Violence Doesn’t Discriminate by Alexandra Price

Domestic violence doesn’t discriminate. It happens in every type of relationship. It happens to people of every race and economic background. It happens to teens and adults. It happens every minute of every day.

The next time you stand in line at the grocery store, mall or movie theater, take a look around you. Chances are that just about everywhere you go; you see the faces of victims of domestic violence.

Experts estimate that more than 4 million American women are physically abused by their partners each year. According to the National Institute on Domestic Violence, a woman is beaten in the United States every nine seconds. Domestic violence is the leading cause of injury to U.S. women -- more than muggings, rape and auto accidents combined. Many of these incidents are not reported to the police, and the abuse continues.

Domestic violence creates devastating emotional and physical wounds -- and sometimes it kills. According to the United States Department of Justice, one out of three females who is murdered in the United States is killed by a husband or boyfriend.

Although men are also victims of domestic violence, women are 10 times more likely than men to be victimized.

Recognizing Domestic Violence
Domestic violence occurs when an intimate partner or a former intimate partner -- a husband or wife, or boyfriend or girlfriend (or an ex) -- uses physical force or other abusive tactics to coerce or control his or her partner.

If your partner does things like push, bite, kick, slap, punch or throw things at you -- even just once -- it is physical abuse.
Domestic abuse can also be sexual or psychological. Sexual abuse means being forced to have sex or to perform sexual acts against one’s will. People sometimes think sexual abuse usually happens between strangers, but it often happens between people who are dating or between married couples.

Threatening or intimidating a person, preventing her from seeing her friends and family, are examples of psychological abuse. So are criticizing, insulting, yelling at, manipulating, ignoring or publicly humiliating someone.

Elaine Weiss, Ed.D. of the Department of Family Preventive Medicine at the University of Utah School of Medicine is author of Surviving Domestic Violence: Voices of Women Who Broke Free.

Dr. Weiss recommends thinking twice about continuing a relationship if your partner:
• ignores your wishes
• makes you feel guilty
• acts excessively jealous or possessive
• ignores your personal boundaries
• does not listen to you or disregards your opinions
• has a history of fighting, loses his temper quickly, or brags about hurting others
• breaks or hits objects during an argument
• becomes hostile when you say "no"
• makes you feel sad or afraid

Clinical Corner: IED and ODD

Q. I am the 504 Coordinator for an alternative high school. One of our new students has been diagnosed with intermittent explosive (IED) and oppositional defiance disorders (ODD). I need information about the conditions as well as how to best avert and deal with these behaviors in the classroom. I have found some useful information on the Internet about ODD, but did not find much other than a definition for IED. Any information that you can send or direct me to would be greatly appreciated.

A. Both these conditions--ODD and IED--are quite controversial. Some child psychiatrists consider these as garbage can diagnoses--meaning that kids get thrown into these categories when clinicians fail to uncover the real underlying diagnosis.
For example, ODD or IED may be diagnosed in children who actually have a bipolar disorder. Kids with bipolar disorder may act up, misbehave, or be downright aggressive and violent if they are in an irritable manic period. Intermittent Explosive Disorder is one of the so-called Impulse-Control Disorders, Not Elsewhere Classified in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.)

IED is characterized "…by discrete episodes of failure to resist aggressive impulses resulting in serious assaults or destruction of property…" (DSM-IV p. 609). The degree of aggressiveness is "…grossly out of proportion to any provocation or precipitating psychological stressor". Very often, individuals with IED describe a build-up of tension before the aggressive behavior, followed by a sense of relief after the explosive act, which in turn may be followed by a period of guilt or remorse.

The diagnosis of IED is NOT made if the behavior in question is better explained by another psychiatric (or medical) condition, such as a manic episode, brain trauma, etc. IED probably represents a collection of different conditions with different underlying causes.

For example, some individuals with IED may show nonspecific abnormalities on their EEG (electroencephalogram or brain wave recording), whereas others do not. Some children with a diagnosis of IED may actually have undiagnosed or concomitant bipolar disorder (see, for example, McElroy et al, Are impulse-control disorders related to bipolar disorder? Compr Psychiatry 1996 Jul-Aug;37(4):229-40). So--it's absolutely critical that the new student you describe gets a thorough neuropsychiatric evaluation!

Medication may be both helpful and necessary to manage some cases of IED. However, behavioral strategies may be useful in milder cases. You can get some tips on behavioral management techniques at the website http://www.teachervision. For example, the following advice is given to deal with the argumentative student:

1. Do not confront the student in a group situation.

2. Do not use an accusatory tone upon approaching the student.

3. Evaluate the situation that led to the confrontation.

4. Do not back the student into a corner. Leave room for options.

5. Do not make threats that cannot be carried out.

6. Allow your emotions to cool before approaching the student.

7. Maintain the appearance of control at all times. Use a clear, firm voice.

8. Give the child an opportunity to speak his/her piece.

9. Allow for role-playing, doing role reversal.

10. Try to explore and discover what led to the confrontation. Avoid repeating these circumstances.  If you made an error, admit it!

Clearly, these are very general tips and may not apply to the student in question. I would therefore suggest working closely with the school psychologist and/or the student's own psychiatrist in formulating your management strategy.

http://www.mhsource.com/expert/exp1020204d.html

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Antisocial Personality Disorder

What Is Antisocial Personality Disorder? By Derek Wood, RN, BC, MS

Overview

Antisocial Personality Disorder results in what is commonly known as a Sociopath. The numbers of persons with this disorder are much higher than generally thought, with nearly 6% of men and over 1% of women having this disorder. The criteria for this disorder require an ongoing disregard for the rights of others, since the age of 15 years.

Some examples of this disregard are

• reckless disregard for the safety of themselves or others,
• failure to conform to social norms with respect to lawful behaviors,
• deceitfulness such as repeated lying or deceit for personal profit or pleasure, and
• lack of remorse for actions that hurt other people in any way.

Additionally, they must have evidenced a Conduct Disorder before the age of 15 years, and must be at least 18 years old to receive this diagnosis.

People with this disorder appear to be charming at times, and make relationships, but to them, these are relationships in name only. They are ended whenever necessary or when it suits them, and the relationships are without depth or meaning, including marriages. They seem to have an innate ability to find the weakness in people, and are ready to use these weaknesses to their own ends through deceit, manipulation, or intimidation, and gain pleasure from doing so.

They appear to be incapable of any true emotions, from love to shame to guilt. They are quick to anger, but just as quick to let it go, without holding grudges. No matter what emotion they state they have, it has no bearing on their future actions or attitudes.

They rarely are able to have jobs that last for any length of time, as they become easily bored, instead needing constant change. They live for the moment, forgetting the past, and not planning the future, not thinking ahead what consequences their actions will have. They want immediate rewards and gratification.

Treating antisocial personality disorder can be difficult as those with this disorder may have little or no desire to change themselves, which is a prerequisite. No medication is available either. Appropriate treatments for antisocial personality disorder include group psychotherapy, having feedback from peers, and constructive confrontation of inappropriate behaviors.

http://www.mental-health-matters.com/articles/article.php?artID=51

Empowerment Model of Recovery from SMI

Editor's Note:

What is an empowerment model of recovery? How is it useful, perhaps invaluable, in the daily practice of psychiatry? What data support it? To get to the core of these issues, Randall White, MD, interviewed Daniel B. Fisher, MD, PhD, Executive Director of the National Empowerment Center in Lawrence, Massachusetts.

Medscape: In your publication "Personal Assistance in Community Existence: A Recovery Guide," you write that the recovery model emphasizes that emotional distress is a temporary disruption in life.[1] Can you elaborate?

Dr. Fisher: Our description of mental illness is a combination of severe emotional distress and an interruption of a person's place in the community and social role -- being a worker, parent, student, a participant in overall community life -- which is not dissimilar from what is considered a mental disorder in DSM-IV.[2] The most important finding in our research is that people who have shown significant or complete recovery from severe mental illness -- by that I mean schizophrenia, bipolar disorder, or schizoaffective disorder -- have cited hope as an extraordinarily important component in their recovery. Part of the recovery was being around people who saw their condition as not permanent, a condition from which they could take increasing control of their life and reestablish a place in society.

Medscape: You also write, "It is much more difficult to recover once a person is labeled mentally ill." How have you found that to be true?

Dr. Fisher: If people don't have the internal capacity, and the severity of their distress is too overwhelming, and they don't have the finances, the education, the social surroundings, and family to help them, they end up with the label of mental illness. The severity becomes greater because, in addition to having to recover from the severe distress that interrupted their capacity, they also have to recover from the role of being mentally ill.

The biggest example of that is Social Security; another is the loss of rights and the trauma that often occur in being hospitalized. For many people, it's very traumatic being hospitalized.

Medscape: Can you talk some more about Social Security?

Dr. Fisher: If you don't have the resources, or if the duration of distress lasts too great a time, a person needs to be on Social Security. I've been on the psychiatrist's side of that and I know that, unless someone is able to get a job that pays up to $16 per hour and has full benefits, it's very hard to duplicate the benefits. I've worked with legislators on the Ticket to Work legislation to try to correct some of the shortcomings of Social Security, one of the biggest being you're either on it or off it.[3] Once you have been on it, there's great fear of going off it because you might not get back on.

Medscape: Your publications make reference to the difference in outcome of schizophrenia in less-developed societies compared with industrialized societies. What does the research indicate?

Dr. Fisher: The evidence is from 2 studies by the World Health Organization (WHO), one in 1979 and the second in 1992, comparing the recovery rate, mostly from schizophrenia, in developing countries with the recovery rate in industrialized countries. In 1979, WHO had about 1800 cases validated by Western diagnostic criteria in developing counties matched with controls from industrialized countries, and they found that the recovery rate was roughly twice as high in the developing countries compared with the industrialized.[4] They were so surprised by this that they said, "Well, this must be a big mistake." So they repeated the study in 1992, and they got the same results.[5]

Medscape: How do you interpret this and what are the implications for us as psychiatrists in industrialized societies?

Dr. Fisher: The implications are profound. It shows that schizophrenia is more pronounced and prolonged in industrialized countries. I've started to gather information from developing countries about how they approach treatment and healing. They have a completely opposite approach from Western countries. They're very socially oriented, and they instinctively recognize the importance of keeping people connected to the community. We have ceremonies of segregation and isolation, which is really what our labeling and our hospitalization process is. They have ceremonies of reintegration and connection.

Medscape: Can you contrast the medical model with your empowerment model in the approach to psychosis?

Dr. Fisher: The first contrast is that we say to the people going through the experience that this is not a permanent condition and that other people have recovered. We try to expose them to people who have recovered and who can be role models. When I'm working with people who are undergoing psychosis or long-term severe mental illness, I share some of my own experience with them and how I too at times heard voices and had the television talk to me.

The second part is that we help them understand that these symptoms are expressions of distress over their lack of a connection on a deep emotional level to the people around them, that they involve loss and trauma and interruption in social development. We go through with them a set of 10 principles of recovery that we have established through our research, which is the qualitative study of people who have shown complete recovery from severe mental illness, mostly schizophrenia.

Through this model we emphasize the reestablishment of personal connections. It's often peers who are the most significant guides for recovery. This is because, if you've been through the experience yourself, you're often able to connect with another person in a verbal and especially a nonverbal fashion that is hard for people to do who have not been through the same experience. That connection is vital to people's recovery.

Medscape: This reminds me of the recovery model of addiction.

Dr. Fisher: We certainly see some similarities to the addiction field. In the addiction field, a person's first-hand experience with addiction is valued; whereas in the mental health field, it's only now starting to be valued. Until fairly recently it was something you didn't talk about. Part of the recovery is society's recovery from placing so much discrimination and stigma on the person who's been labeled with mental illness. It's hard to recruit peers as long as the stigma is so great; people don't want to step back into the system.

I went through this. It was hard for me to disclose. I waited until after my residency, but this is the major resource for the empowerment model -- finding and training people who have shown significant recovery, who can come back and help other people and train other providers, too.

Groups are an important modality in this model because they enable people to share their experiences and see that they're not alone. I do a weekly recovery group at a day program, and what I try to do is put into lay terms what's been learned over the last 50 years about what helps people psychologically in their recovery. In psychoanalysis they've developed a lot of understanding; Carl Rogers did some very good work, as did Harry Stack Sullivan. So in some ways, the empowerment model of recovery is drawing on earlier knowledge of working with people interpersonally rather than exclusively medically.

Medscape: What is the role of medication in your model?

Dr. Fisher: Ideally we would like to see settings provided -- Soteria House you may have heard of -- where people can go when they need more intensive social supports.[6] We expect that if there were more of these settings, there would not be as much need for medication. The need for medication I tend to see as a failure of the person's world and their own internal resources to sustain emotional equilibrium sufficiently to remain in consensual reality, and I don't know whether it's one or another neurotransmitter, but clearly when people are feeling very frightened or confused, it's hard for them to be reached by another person. During those times I do prescribe medication and say, "This is to help you to gain control of yourself and your life. Hopefully, you won't have to take it for a lifetime."

I think it's very important that people hear that it's to be used as a tool. I always point everything toward how can you learn to be with other people, to make friends, to get a job, to go back to school, and to perform adequate self-care. Because if you don't, and I'm afraid I see this a lot of times the way medication is used today, people start to believe that the medication will solve their problems, and that's a kind of magical thinking. And it takes away responsibility, motivation, initiative.

I think that ultimately psychiatrists need to hear that a recovery approach is going to assist them in their practice. We're often asked, "Doesn't an empowerment approach increase risk? If people make their own decisions, doesn't that increase the risk involved in practicing psychiatry?"

Medscape: You mean medicolegal risk?

Dr. Fisher: Yes, medicolegal risk, and the position that I take in my own practice is that the recovery approach is really a risk-reduction approach, because the biggest risk is a rupture of communication between the person receiving services and the person providing. Most lawsuits are the result of bad feelings and poor communication much more than bad outcomes; furthermore, if people lose communication with their caregiver, they're not going to say when they are not taking medication, that they're feeling suicidal, or that they're thinking about hurting somebody.

Medscape: You write that psychotic symptoms may persist after recovery but "those are no longer symptoms of mental illness." How so?

Dr. Fisher: I'll give you an example from my own life. I've developed, for instance, ways of talking myself through frightening periods in ways that normalize them to me. I might, at times, if I'm driving along and see a police car, think, "I wonder if they're following me." Then I'll just think it through -- "Why would they be following me?"

Medscape: What you're describing is cognitive therapy.

Dr. Fisher: Yes, it is in a way, but it's actually what I think people who are not labeled mentally ill instinctively know how to do. We all are confronted at various times in our life with potentially psychotic thoughts. It's just unavoidable. If you're in a new situation and you're uncertain about things, and you can't quite identify the people around you, you can have a misperception. But the difference between misperception and delusion is how you think about it.

Medscape: Would you say that this kind of cognitive-therapy approach is a part of your model?

Dr. Fisher: It is, actually. In fact, part 2 of our PACE [Personal Assistance through Community Existence] program is a cognitive model.[7] We've taken 10 of the major principles of recovery and framed them within a cognitive-behavioral approach.

For instance, a misapprehension might initially be, "I have a permanent condition and I'll never recover from it." Having another person around you who can help you understand through their life that other people have been through it and you're not alone plays a huge role in shifting that misperception to a new understanding.

Medscape: Can you briefly describe your personal journey to doing the work that you're doing?

Dr. Fisher: It's a very significant part of my reason for becoming a psychiatrist -- wanting to bring to the field what I wish had been there when I was going through my psychosis. I very clearly remember thinking, during my second hospitalization, "If the people who are talking to me had only been where I am right now, they'd know the way to communicate with me so that I would feel once again part of the world around me." I also hoped there'd be a way to be helped short of having to be involuntarily hospitalized, which I went through 3 times.

In my second hospitalization, I decided that I would become a psychiatrist and try to change the way mental health is provided. I was lucky -- I was able to find a psychiatrist who was able to provide me with many of the principles we find have worked in recovery. He believed in me. When I told him, several months after coming out of the hospital the second time with a diagnosis of schizophrenia, that I wanted to go to medical school and become a psychiatrist, he said he would be at my medical school graduation. And about 7 years later, he was there.

My life's work is here at the National Empowerment Center, which I helped start 13 years ago, and that resulted in my being a member of the President's New Freedom Commission on Mental Health. I think I played a significant role in getting "recovery" into the national lexicon by my role there. I see my role as a bridge between the consumer movement and the rest of the mental health system. Through my credibility in both worlds, I've been able to help each world understand the other.

References

Ahern L, Fisher D. Personal Assistance in Community Existence: A Recovery Guide. Lawrence, Mass: National Empowerment Center; 1999. Available at: http://www.power2u.org/pace_manual.pdf Accessed December 3, 2004.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

Ticket to Work and Work Incentives Improvement Act, 42 USC ýý 1320b-19 (1999).

World Health Organization. Schizophrenia: WHO study shows that patients fare better in developing countries. WHO Chron. 1979;33:428.

Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1-97. Abstract

Mosher LR. Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review. J Nerv Ment Dis. 1999;187:142-149. Abstract

Fisher D, Chamberlin J. Personal Assistance in Community Existence: Recovery through Peer Support. Lawrence, Mass: National Empowerment Center; 1999.

Daniel B. Fisher, MD, PhD, Executive Director, National Empowerment Center, Lawrence, Massachusetts, d.fisher@power2u.org; psychiatrist, Riverside Community Mental Health, Wakefield, Massachusetts

http://www.medscape.com/viewarticle/496394?src=mp

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Who Gets SAD?

Many women experience occasional periods of the "winter blues" but, when the "winter blues" begin to become more than occasional and become more "seasonal," it may be a case of SAD. Approximately 35 million Americans are affected by SAD to some degree with at least 10 million lives seriously disrupted by seasonal affective disorder and its' effects.

Seasonal Affective Disorder occurs most often in children, adolescents, and women; 75% to 80% of those affected are women usually over thirty.

Symptoms of SAD

• Lack of energy; increased fatigue, increased need for sleep, lethargy
• Increased appetite; weight gain, craving for sugar & carbohydrates
• Withdrawal; difficulty with relationships, loss of sexual desire, anxiety
• Difficulty focusing and concentrating on tasks
• Increasing PMS symptoms
• Depression which occurs seasonally usually during Fall & Winter months

Severe depression requires diagnosis by a physician. SAD is different from depression and different treatments are used. Depression usually is consistent from morning to night in severity, while SAD patients report depression and fatigue which increase in severity during the day.

It's important to be sure it's SAD you are experiencing and not depression; you should not attempt self- diagnosis. See your physician if you're experiencing any symptoms which interfere with your daily life.

What causes SAD?

As many as, 25% of those who live in the northern regions of the United States may be SAD sufferers. The further North or South of the equator, the higher the incidence of SAD.

SAD is caused by the shorter days of winter; the reduction of sunlight to the retina. There's a biological connection: the sun causes the body's' level of serotonin to increase; lack of sunlight causes a reduction of serotonin and an increase in the level of melatonin which, in turn, causes seasonal depression.

During a normal sleep- wake cycle the levels of serotonin and melatonin vary according to time of day, so we sleep at night and are awake during the day; if your brain chemistry is off- balance, your serotonin levels may not increase enough during the short, often cloudy days of winter.

Treatment with lights!

Seasonal Affective Disorder is significantly improved with the use of light therapy. The lack of light causes SAD; increasing light to the brain, through the retina is the effective solution for 60% to 80% of patients who've tried this therapy. Significant improvement is usually noted within four to five days of treatment beginning.

Special lamps are used with a preferred power of 10,000 lux; the equivalent of five to twenty times the normal brightness of your home or office lighting. Patients are instructed to sit, in front of these lights, from 30 minutes to two hours per day. It's not necessary nor recommended to look at the light; you may read, watch TV, or do whatever you wish during this time.

Most patients use their lights as soon as, they wake up in the morning; for some it's more effective with use at night. Some patients may also find it helpful to set an automatic timer to turn on the lamp two hours before they wake up, as a natural sunrise would occur.

Tips to reduce SAD

• Follow a low- fat diet; avoid excessive protein, eliminate carbohydrates, & sugar...
• Vitamins with magnesium, B complex, & minerals may be helpful.
• Eliminate caffeine from your diet; coffee, tea, sodas, chocolate...
• Exercise; walk, jog, aerobics activities increase levels of dopamines & increase your energy level!
• For milder cases try increasing your household lights; take walks and everyone should spend extra time outdoors on sunny days!

Remember, if your symptoms are causing a disruption in either your personal or professional life; it's important to see your physician for a positive diagnosis. Sometimes anti- depressant medications or counseling are helpful. Don't self- diagnose!

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Screening for Alcohol in the ED & Trauma Center

Today's selection is an editorial from Medscape, an electronic medical journal that I find an excellent source of health information.

You might want to subscribe, it's free! http://www.medscape.com/medscapetodayhome

The famous robber Willie Sutton, when asked why he robbed banks, is said to have responded, "because that's where the money is." One's chance of success when fishing is enhanced by the number of fish near your bait and hook. Medical screening for any disease is much more likely to be fruitful in a population with high prevalence. That's simple arithmetic. Therapeutic intervention in alcohol abuse can be successful, especially when one has the patient's attention. Alcohol frequently underlies episodes of trauma, be they attempted homicide, suicide, or unintentional injuries (such as falls and motor vehicle collisions). Because the prevalence is as high as 50% in trauma centers, blood alcohol levels there can be a very efficient method of case finding that can then be turned into a successful intervention.[1] But would you believe that barriers to this common-sense approach have been created by some health insurance companies and some state legislatures? Some will not pay the bills for trauma care if there is a positive blood alcohol, claiming that the injury is self-inflicted and thus not covered -- talk about short-sighted policy working against both the patient and the public interest. A leading trauma specialist, Dr. Larry Gentilello of Dallas, Texas, has taken on this problem -- big time -- as has Physicians and Lawyers for National Drug Policy.[2]. State law changes may be the necessary solution. I urge Medscape readers to become informed about this ridiculous situation in your communities and take the lead to change it. That's my opinion. I'm Dr. George Lundberg, Editor of MedGenMed.

Readers are encouraged to respond for the editor's eye only or for consideration for publication via email: glundberg@webmd.net.

References

Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol intervention in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473-483.

Physicians and Lawyers for National Drug Policy: A Public Health Partnership. Policy priorities. Available at: http://www.plndp.org/About/Policy_Priorities.html Accessed November 18, 2004.

http://www.medscape.com/viewarticle/494068

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ADD - Attention Deficit Disorder

Attention Deficit Disorder tends to focus predominately on children, leaving the ADD adult population largely under served. Most of the information presented about Attention Deficit Disorder focuses on children, parenting and school issues. All but one ADHD medication currently on the market achieved FDA approval for adult Attention Deficit Disorder treatment.

Attention Deficit Disorder simply was not in vogue when the adult of today was a child decades ago. While today many express concerns of over diagnosis of Attention Deficit Disorder in children, many also acknowledge the under diagnosing of adults with Attention Deficit Disorder.

Yet, the hurdles of Attention Deficit are often the same, whether in a child or an adult. The ADD adult might have trouble with staying on task, staying organized and procrastinating, just as the Attention Deficit Disorder child does. The Attention Deficit Disorder adult might have trouble maintaining relationships and controlling their mood, just like an ADD or ADHD child. The main difference between the ADD adult and the ADD child is that the adult with Attention Deficit typically has more sophisticated coping mechanisms.

For the better part, the Attention Deficit Disorder ADD ADHD symptom test outlined for children is about the same for the adult, with the word "work" substituted for "school." You can also look at the Attention Deficit Disorder test for children and ask yourself if, as a child, you had such symptoms or currently have such Attention Deficit Disorder symptoms.

Below is an adult symptom test with symptoms unique to the Attention Deficit Disorder adult. This self test is not a diagnostic test but a source of information for the adult trying to determine if Attention Deficit Disorder might be present in their life.

If you experience more than 10 points on this adult ADD self symptom test, Attention Deficit Disorder is likely present.

• An internal sense of anxiety
• Impulsive spending habits
• Frequent distractions during sex
• Frequently misplace the car keys, your purse or wallet or other day-to-day items
• Lack of attention to detail
• Family history of ADD, learning problems, mood disorders or substance abuse problems
• Trouble following the proper channels or chain of commands
• An attitude of "read the directions when all else fails"
• Frequent traffic violations
• Impulsive job changes
• Trouble maintaining an organized work and/or home environment
• Chronically late or always in a hurry
• Frequently overwhelmed by tasks of daily living
• Poor financial management and frequent late bills
• Procrastination
• Spending excessive time at work due to inefficiencies
• Inconsistent work performance
• Sense of underachievement
• Frequent mood swings
• Trouble sustaining friendships or intimate relationships
• A need to seek high stimulation activities
• Tendency toward exaggerated outbursts
• Transposing numbers, letters, words
• Tendency toward being argumentative
• Addictive personality toward food, alcohol, drugs, work and/or gambling
• Tendency to worry needlessly and endlessly
• "Thin-skinned" - having quick or exaggerated responses to real or imagined slights

So you hit a number of points on the adult ADD self symptom test, now what?

First, it is important that a physician rule out conditions like anxiety, depression, hypothyroidism, manic-depressions or obsessive compulsive disorder that can mimic Attention Deficit Disorder symptoms. Hormonal imbalances in perimenopause and menopause can produce foggy thinking, anxiety and exaggerated outbursts. Women should rule out perimenopause if the Attention Deficit symptoms appear in their late 30s or 40s.

http://www.mental-health-matters.com/articles/article.php?artID=463

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Guidelines for BPAD in Children

Another excellent item from Medscape, and there are free CME credits available on this subject, if you want/need them!

Laurie Barclay, MD

Feb. 25, 2005 - A working group sponsored by the Child and Adolescent Bipolar Foundation (CABF) has developed consensus guidelines for the diagnosis and treatment of children with bipolar disorder (BPD). The commentator praises the guidelines, which are published in the March issue of the Journal of American Academy Child and Adolescent Psychiatry (JAACAP), but notes a fundamental change in the definition of the illness.

"Doctors are getting somewhat better at recognizing bipolar disorder in children, but there wasn't much to guide them in terms of treatment," lead author Robert Kowatch, MD, from Cincinnati Children's Hospital Medical Center in Ohio, says in a news release. "It is often necessary to use several medications in combination because these kids are very ill, often suicidal or too manic and depressed to attend school. Stabilizing their moods and allowing them to return to school as soon as possible is critical if they are to lead normal lives."

Based on evidence from clinical studies in children and adults, published case reports, and expert consensus opinion regarding current clinical practices, the guidelines address diagnosis of bipolar I disorder (BPD-I) in children aged 6 to 17 years, and they suggest strategies for treatment of mania and depression with or without psychosis in young patients. The four sections of these guidelines cover diagnosis, comorbidity, and acute and maintenance treatment.

"Far too little research has been done on the treatment of bipolar disorder in youth," says JAACAP editor-in-chief Mina Dulcan, MD. "The Guidelines represent a consensus of existing research results and clinical experience to guide clinicians and families. We hope that the guidelines will not only facilitate clinical care but also inform and enhance new research."

BPD, formerly known as manic-depressive illness, is an inherited condition that can present in adolescence and even in childhood. Symptoms may include grandiose delusions, irritable mood often accompanied by aggression and self-injury, decreased need for sleep without daytime fatigue, pressured speech, flight of ideas, distractibility varying with mood, increased goal-directed activity, hypersexuality, and auditory hallucinations in some patients.

"The disorder runs in families, and children with the illness are at extremely high risk of attempting suicide," says coauthor Martha Hellander, JD. "These kids suffer so badly, and deserve to have evidence-based treatment as early in life as possible. Many respond quickly to mood stabilizing medication, and parents tell us that 'we have our child back.'"

Long-term management strategies for BPD include pharmacotherapy, psychotherapy, and lifestyle modifications, including stress reduction, regular sleep habits, accommodations at school, and avoiding caffeine, alcohol, and illegal drugs.

http://www.medscape.com/viewarticle/500273?src=mp

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Management Forum...

"Management Matters" Technique #1: Delegate effectively

The ability to motivate others has long been an accepted hallmark of the successful leader. This is true of student leaders on college campuses, as well as CEOs of Fortune 500 companies. In an organization where people are motivated, there is maximum productivity, efficiency, and enjoyment.

Motivating others is a leadership skill you can learn, says Harvard U. Professor Roland Barth, if you're willing to consistently apply the Seven T's of Motivation . The T's are seven practical techniques for motivating others.

Technique #1: Delegate effectively

By wisely assigning responsibility, you'll get the majority of the membership involved. It will ease both your mind and your workload. Often, leaders inappropriately delegate time consuming tasks to people who don't have the time to do them. Learn to spread the work around. It reduces the stress and gets more members involved.

See future installments of "Management Matters" for the six remaining motivating techniques, or check the web site:

Motivating others is a leadership skill you can learn, says Harvard U. Professor Roland Barth, if you're willing to consistently apply the Seven T's of Motivation . The T's are seven practical techniques for motivating others.
 

Technique #1: Delegate effectively
Technique #2: Assign incremental tasks

Get everyone in your organization involved, even if its in small ways at first. When you delegate even simple tasks, you draw members into action on behalf of the organization. The more they become involved, the more meaningful their commitment and the more successful the organization.

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Management Matters: MOTIVATION Technique #3

The T's are seven practical techniques for motivating others.

• Technique #1: Delegate effectively

• Technique #2: Assign incremental tasks

• Technique #3: Treat members equally

Everyone enjoys being "in the know". People want to have influence and feel as if they share power within the organization. Show that you value every person in your organization. It'll translate into a more motivated membership.

Motivating others is a leadership skill you can learn, says Harvard U. Professor Roland Barth, if you're willing to consistently apply the Seven T's of Motivation . The T's are seven practical techniques for motivating others.
Technique #1: Delegate effectively
Technique #2: Assign incremental tasks
Technique #3: Treat members equally
Technique #4: Use praise and criticism
Technique #5: Generate enthusiasm
There's no substitute for genuine enthusiasm. Real enthusiasm generates real energy, which can become an irresistible force if you focus it properly. Interact with your co-workers in a positive, energetic manner. Don't complain about personal or organizational issues. Believe in your organization and show some zest. Have confidence in your members. Be enthusiastic. It's contagious!

http://studentorgs.unomaha.edu/Vbrochures/!motivat.htm

The ability to motivate others has long been an accepted hallmark of the successful leader. This is true of student leaders on college campuses, as well as CEOs of Fortune 500 companies. In an organization where people are motivated, there is maximum productivity, efficiency, and enjoyment.

Motivating others is a leadership skill you can learn, says Harvard U. Professor Roland Barth, if you're willing to consistently apply the Seven T's of Motivation . The T's are seven practical techniques for motivating others.

• Technique #1: Delegate effectively
• Technique #2: Assign incremental tasks
• Technique #3: Treat members equally
• Technique #4: Use praise and criticism
• Technique #5: Generate enthusiasm
• Technique #6: Promote integrity

An essential part of your personal development is forming your own set of principles. Practice what you believe is important. It will make your personal convictions stronger and promote similar convictions in your co-workers. People respond to what you do. They don't necessarily do what you say.

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Management Matters: Motivation Technique #7: Maintain your humor

Here, at last, are all the seven T's: seven practical techniques for motivating others.

• Technique #1: Delegate effectively
• Technique #2: Assign incremental tasks
• Technique #3: Treat members equally
• Technique #4: Use praise and criticism
• Technique #5: Generate enthusiasm
• Technique #6: Promote integrity
• Technique #7: Maintain your humor

Take your work seriously, but yourself less so. You'll lead more effectively, be less stressed, and be more fun to work with if you learn to roll with your role. Organizations, by the very diversity of their members, produce amusing situations. Step back once in a while and laugh at the absurdities. You'll keep your sanity -- and your friends -- when you maintain your sense of humor.

1.Acknowledge the importance of other people. "The deepest principle in human nature is the craving to be appreciated." -William James

2.Show enthusiasm and energy. "Enthusiasm is by far the highest paid quality on earth, probably because it is one of the rarest; yet it is one of the most contagious." -Frank Bettger

3.Encourage and facilitate two-way conversation. "Education is a kind of continuing dialogue, and a dialogue assumes, in the nature of the case, different points of view." -Robert Hutchins

4.Ask other people's opinions. "I have opinions of my own -- strong opinions -- but I don't always agree with them." -George Bush

5.Ask questions instead of giving orders. "Never tell people how to do things. Tell them what you want them to achieve and they will surprise you with their ingenuity." -Gen. George S. Patton

6.Show sincere gratitude. "God gave you a gift of 86,400 seconds today. Have you used one to say "thank you?" -William A. Ward

7.Give strength centered compliments. "The life of many a person could probably be changed if someone would only make him feel important." -Dale Carnegie

Characteristics of A Good Working Group

A group that is working well together has 6 characteristics, and the first one is:

1. They know what job they are doing, and everyone thinks it's important. You know this is true because

2. Everyone helps to develop the meeting agendas,

3. The proposed agenda is decided and, if possible, sent out before the meeting,

4. The agenda is realistic,

5. The group checks the agenda at the beginning of the meeting, and makes changes if they are needed. The timing of the items is also considered, and

6. A chairperson, or facilitator, helps to keep the group on task.

Last week we learned that the first of 6 characteristics of a good working group is that they know what job they are doing, and everyone thinks it's important.

The second one is each person feels free to speak out:

• Every member is invited to speak out

• Nobody makes threats or "power plays"

• Timid or shy people are invited to give their ideas

• Group members are honest with each other

• All ideas are welcomed for discussion

• If appropriate, group members take turns being the chairperson

Characteristics of A Good Working Group #3

This is the third installment...do you remember how many characteristics there are?

1. Everyone know what job they are doing, and everyone thinks it's important.
2. Each person feels free to speak out.
3. The group shares the responsibilities for getting the work done:
   • People volunteer to help one another.
   • Nobody is pressured into taking a job they don't want.
   • The group makes use of the talents and skills of each member.
   • At the end of the meeting, the group checks to make sure the jobs are evenly divided.

Characteristic #4 next week!

http://www.ifuw.org/planning/lr_wkgp.htm

There are six characteristics of a good working group. Here are the first 4:

1. Everyone knows what job they are doing, and everyone thinks it's important.

2. Each person feels free to speak out.

3. The group shares the responsibilities for getting the work done.

4. Everyone is clear about what needs to be done, who will do it, and when:

• All ideas are carefully considered before a decision is made;

• The group keeps records of what action, who is responsible, and when;

• The group checks to see what has been done at each meeting, and

• The group takes time to say "thanks" for each person's efforts.

Here's a the 5th of 6 characteristics, plus a review of the first 4:

1. People know what job they are doing, and everyone thinks it's important.

2. Each person feels free to speak out.

3. The group shares the responsibilities for getting the work done.

4. Everyone is clear about what needs to be done, who will do it, and when.

5. Everyone tries to practice good communication skills:

• People listen carefully to one another without interrupting.

• People try to express their ideas clearly.

• People are reminded when they are off-task.

• Everyone is given a chance to speak.

• Group members praise and encourage one another.

• Only helpful criticism is given.

At last, here are all 6 characteristics. How many do you see being used in the groups you work with? Is there one behavior you can introduce to make your group more effective?

1. Everyone knows what job they are doing, and everyone thinks it's important.

2. Each person feels free to speak out.

3. The group shares the responsibilities for getting the work done.

4. Everyone is clear about what needs to be done, who will do it, and when.

5. Everyone tries to practice good communication skills.

6. The group takes time to talk about how it works together:

• When things aren't moving, the group takes the time to discuss the problems.

• People are encouraged to make suggestions which will help the group.

• People listen thoughtfully to suggestions which will help the group.

1. Thou shalt not meet if the matter can be resolved by other means
2. Thou shalt make purpose known to those thou summonest
3. Thou shalt summon only those whose presence is needful
4. Thou shalt start at the time announced
5. Thou shalt not run beyond
6. Thou shalt not wander to other topics
7. Prepare thy thoughts that the minutes not be wasted
8. Schedule not in haste for the day is brief
9. Thou shouldst combine into one those which need not be separated
10. Fear not to cancel if the need disappears

http://www.leadersinstitute.com/resource/meetingtips.html

For some of us, the biggest obstacle to managing one's time is the inability to say "no". Saying "no" is an assertiveness tool, a skill that can and should be developed. Here are some tips to help, taken from an article by Lynn Battle: It is not until we can say 'no', that our 'yes' means 'yes', and our 'no' means 'no'. Saying 'yes' when you would rather say 'no' creates stress, which can cause physical symptoms, such as headaches, shoulder tension and disturbed sleep.

Don't confuse "no" with rejection

Some people who find saying 'no' difficult are confusing rejection of a request with rejection of the person making the request. Saying 'no' doesn't mean you don't like the person, just that you're refusing their current request.

Be honest, calm and polite

It will help you keep control, and avoid escalating the situation or alienating the other person. People are happier to accept an honest 'no', than be faced with indecision and a delayed refusal.

How to say 'no' and mean it:

1. The direct 'no'

When someone asks you to do something you don't want to do, just say 'no'. No apologizing, be direct and succinct. If someone asks you to join them for lunch, simply say, "No, no thank you."

2. The reflecting 'no'

Here you acknowledge the content and feeling of the request, then you add the assertive refusal at the end:

"I know you want to talk to me about organizing the annual department lunch, but I can't do lunch today."

3. The reasoned 'no'

Give a brief and genuine reason for the refusal without opening up further negotiation:

"I can't have lunch with you because I have a report that needs to be finished by tomorrow."

4. The rain check 'no'

A way of saying 'no' to a specific request without giving a definite 'no'. It's a prelude to negotiation, not a rejection of the request. Only use it if you genuinely want to meet the request:

"I can't have lunch with you today, but I could make it sometime next week."

5. The enquiring 'no'

A way of opening up the request, to see if it's something you want to do:

"I can't have lunch today, but is there anything else you want to talk to me about, other than the new proposal?"

6. The broken record

This can be used a lot, in all sorts of situations. Repeat the simple statement of refusal again and again. No explanation, just repeat it. It's necessary to use this with particularly persistent requests:

"No, I can't have lunch with you."

"Oh, please, it won't take long."

"No, I can't have lunch with you."

"Oh, come on, I'll pay."

"No, I can't have lunch with you."

End Procrastination

Procrastination is a huge waste of time and energy. Here are 7 Ways To End Procrastination (By Christopher Knight ):

1.Remember the law of motion; What is in motion, stays in motion. ie: get in MOTION.

2.Stop right now. Write down your 5 most important things to get done right now. Start doing them. Cross off each one as it gets done. When you have what's important to get done in front of you, you give your mind something to focus on.

3.IDENTIFY what is stopping you. Do you hate what you're doing? Simply REMOVE the objects which are blocking you from success.

4.Get yourself into what I call, 'Your Action State'. Best way to do that, is to remember a time, when you were in a state of massive action, and go from there.

5.Put your goals in writing, and plaster them on your walls.

6.The best way to end procrastination, is to decide not to have it.

7.Remember, you can never get enough of what you don't want, which means if you constantly focus on why you can't end procrastinating, you are doomed to get more procrastinating. Make sense?

Did you know that managers are hired because of their technical skills and experience and fired because of their lack of ethical leadership ability?

Of 462 executives who were asked, "What characteristics are needed to be an effective leader today?" 56 percent ranked ethical behavior as an important characteristic, followed by sound judgment (51%) and being adaptable/flexible (47%).

--Source: American Management Association, New York

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Believing the Right things for Success

In his book Why Employees Don't Do What They're Supposed To Do and What To Do About It, Ferdinand F. Fournies says

“…One of the major reasons managers are not as successful as they could be in [managing employees] is because of what they believe about their employees and the people management process. Erroneous beliefs lead managers into the self-destructive behavior of disrupting relationships, rather than helping to improve them. Stated another way, if you believe the wrong things about your employees those beliefs will be the basis for you to do the wrong things to solve problems with them."

And he gives 6 points to summarize this perspective.

Here's Point #1:

"Accept the idea that the management function is getting things done through others. Accept the idea that you need them more than they need you. Recognize that the rewards and punishments you get as a manager are not based on what you do, but on what your employees do; your employees are your score card. No matter what your style or skills or knowledge might be, their success or failure reflects upon you.

If all of the preceding are true, then you will recognize that the only reason for being there as a manager is for you to do everything possible to help your employees be as successful as you need them to be. The last thing you should do before firing someone is to look at yourself in the mirror and say “You failed”, then tell your employee, “You’re fired.”"

Ferdinand F. Fournies is an internationally known consultant, speaker, and former professor at Columbia University's Graduate School of Business. He wrote the books, Coaching for Improved Work Performance, and Why Employees Don't Do What They're Supposed To Do and What To Do About It, bot