Category:

Psychiatry

World Mental Health Day 2016

I talk about the subject of mental health EVERY SINGLE DAY. Therefore, with today being World Mental Health Day, I thought long and hard about how I’m going to say something any different than what I wrote on this day last year and what I say in my job as a psychiatrist on a daily basis. So here’s what I came up with:

NOTHING.

No joke – I literally sat in front of my computer for hours typing idea after idea, sentence after sentence, complaint after complaint about our mental health system when I decided to scratch everything I wrote and opted instead to free write the following thoughts:

Issue 1: Mental health impacts EVERYONE…whether we choose to acknowledge it or not. The topic of mental health is considered taboo in many cultures and remains highly stigmatized in society. However, in order to break the pattern of silence which gets passed along generations, we must acknowledge our own mental health issues and create a sense of safety within our own families to feel open enough to discuss issues as they arise, thus modeling a healthier way of communicating.

Issue 2: We often tell people “don’t be afraid to ask for help,” yet when they finally decide to seek resources, the first place they may end up is on a long waitlist to see a mental health professional, yet mental health professionals are overworked and becoming burned out trying to meet increased demands and make up for the lack of resources. The bigger issue is that more funding and resources are needed to bridge the gap in order to meet the need.

Issue 3: If you Google ‘World Mental Health Day,’ the top articles on your feed likely consists of links that highlight the Duchess of Cambridge, Prince William and Prince Harry’s public appearance today to raise awareness of mental health and support the mission of Heads Together, the mental health organization they helped create. I love their theme for World Mental Health Day, which encourages people to celebrate anyone who has supported them through a difficult time using #ThereForMe. Support is absolutely necessary for everyone, especially those struggling with mental illness.

Personally, through each struggle I’ve experienced, I have always been thankful for the support I received. Often when my patients are struggling, they feel comforted knowing they have at least one person they trust to reach out to. I hope that someday each one of us could feel open enough to be that person to someone because addressing mental health isn’t something we should have to go through alone. Rather than waiting on legislation to create measures that prioritize mental health, we can each act now by identifying ways to address our own mental health and be more present for those close to us who might be in need of support.

By the way, I realize that I posted this blogpost quite late today, but I suppose there was no real sense of urgency because in my mind, World Mental Health Day is EVERY DAY.

October 11, 2016 8 comments

Psychiatry

Why Minority Mental Health Is Important

written by freudandfashion

As a psychiatrist who is also in therapy, I remember feeling misunderstood when it came to my culture as a filipino-american, but meant a lot to me to have my therapist express a genuine interest in understanding my culture and asking me for details regarding my experience. Oftentimes I believe clinicians don’t prioritize someone’s identity (ethnicity, culture, religion, sexuality) when it comes to health, especially mental health, yet these factors play a significant role in someone’s values and way of life.

July is Minority Mental Health Awareness Month and although today might be the last day, having knowledge of the disparities and struggles that several minorities experience is important if we’re going to eliminate stigma surrounding mental illness. I consider myself as someone who prioritizes cultural competency, yet reading statistics and information regarding certain minorities surprised me and I was happy that this month existed and motivated me to read more about it. Which is the reason why I’m sharing some of the following information with you here on my blog, in addition to some techniques that I use to incorporate someone’s ethnicity/culture/sexual identity, etc into the conversation during treatment (continue reading below).

Statistics:

African American attitudes toward mental illness are another barrier to seeking mental health care. Mental illness retains considerable stigma, and seeking treatment is not always encouraged. One study found that the proportion of African Americans who feared mental health treatment was 2.5 times greater than the proportion of whites (Sussman et al., 1987). (1)
A report from the U.S. Surgeon General found that violent deaths – unintentional injuries, homicide, and suicide – account for 75% of all mortality in the second decade of life for American Indian/Alaska Natives (U.S. Dept of Health & Human Services Office of Minority Health)
Southeast Asian refugees are at risk for post-traumatic stress disorder (PTSD) associated with trauma experienced before and after immigration to the U.S. One study found that 70% of Southeast Asian refugees receiving mental health care were diagnosed with PTSD (U.S. Dept of Health & Human Services Office of Minority Health)
Western culture makes a distinction between the mind and body, but many Asian cultures do not (Lin, 1996). Therefore, it has long been hypothesized that Asians express more somatic symptoms of distress than white Americans (1).
Mexican immigrants who lived fewer than 13 years in the United States, or Puerto Ricans who resided on the island of Puerto Rico had lower prevalence rates of depression and other disorders than did Mexican Americans who were born in the United States, Mexican immigrants who lived in the United States 13 years or more, or Puerto Ricans who lived on the mainland. This consistent pattern of findings across independent investigators, different sites, and two Latino subgroups (Mexican Americans and Puerto Ricans) suggests that factors associated with living in the United States are related to an increased risk of mental disorders (1).

The following are a few questions I ask to promote discussion of someone’s identity and incorporate someone’s culture, race, ethnicity into treatment (some of these may sound so simple, yet raising the questions can feel awkward at first especially since the subject of someone’s identity might be perceived as a sensitive subject):

What is your ethnic background?
For someone who is mixed race: Is there a specific ethnicity/culture/race that you identify with most?
What is your sexual identity?
How has your cultural identity influenced the way you approach current issues in your life?
How does your family cope with issues related to mental health?
Tell me what are some of the most misunderstood aspects about your culture that you wish people could better understand?

If you’ve had any positive/negative experiences with clinicians in regards to addressing your health/mental health, please share and comment below!

Source:

1. Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug.

Photo collage credit: Patrice N. Douglas

July 31, 2016 12 comments

Medicine Psychiatry

Why I Chose Psychiatry As My Specialty

written by freudandfashion

{Rancho Cucamonga, California}

I am often asked why I chose psychiatry as my specialty, yet as one of my readers pointed out, I’ve never described my reasoning in a blogpost! So here goes my short story of why I chose the path to become a psychiatrist…

The time to solidify your choice in medical specialty and apply for residency training programs occurs during the Fall of the 4th (and final) year of medical school. Students have various reasons for choosing a specific specialty, some knowing which specialty they wanted to go into since childhood, others typically contemplative until right before application season. Some people even change their minds in the midst of residency training and decide to switch specialties.

As a medical student, I attended most class lectures, yet spent majority of the time passively writing notes while chatting on instant messenger. However, when it came to psychiatry, I woke up every morning with excitement to attend each lecture (quite unheard of since I practically dragged myself to every other lecture series), paid attention (and even turned off my instant messenger), thoroughly read the textbook, diligently took notes, and excelled at every exam.

During third year of medical school, students start clerkships, which consists of rotating through various primary care specialties (typically family medicine, internal medicine, Ob/Gyn, pediatrics, psychiatry, and surgery). When interacting with patients during each rotation, regardless of the specialty I was assigned, I ALWAYS spent more time with my patients asking about their psychological and social backgrounds. As a result, I eventually became identified by my senior resident and Attending physicians as the student who would generally be assigned the patients with a history of mental illness or medically-related psychiatric issue. Also, if a patient was admitted to the hospital for physical symptoms, yet the extensive medical workup failed to determine any causative explanation for the symptoms, I was told to assess if there were any emotional issues that might be contributing to a patient’s intractable symptoms (such as cyclical vomiting syndrome, intractable pain, etc).

I specifically remember one patient — a young woman with intractable nausea/vomiting, who was unable to keep down food and fluids. Her medical workup was normal and the medical team could not identify a cause. While the medical team spent only a few minutes to check in on her (to do a quick medical exam and see if she had eaten), I went to visit her after rounds to chat. My intuition told me that there was more to her issue than solely a physical complaint. She was quite shy and spoke only a few words, yet after a few minutes of engaging in conversation, I believe she saw that I wholeheartedly cared about her wellbeing. As it turned out, she experienced ongoing stressors at home due to a recent move with her boyfriend and often felt isolated since she was often home alone with no friends in her new area of residence. I promised to check in on her after daily rounds and she thanked me for taking the time to speak with her.

On the third day, I saw her untouched food tray, and after a few minutes of talking, I asked if she liked ice cream. I brought her vanilla ice cream from the supply in the nurses’ station. We talked about how she missed her family back home. After several minutes into the conversation, I watched her open up the ice cream cup and slowly start nibbling on small scoops. After eating 25% of the cup’s contents, she politely asked for a cup of water. I quickly got up to pour ice water and asked about her little brother as she took a few sips from a straw. Before I left the room, I closely watched her for a few minutes to observe if she’d vomit the contents. She appeared comfortable with no sign of nausea.

The following morning, I viewed the nurses’ report, which noted that she had no episodes of vomiting overnight and even ate a jello snack. I said ‘goodbye’ to her that morning since our medical team informed her that she’d likely be discharged home after lunch. I couldn’t help but wonder if she’d be okay returning home to the same environment that triggered her symptoms. However, the empty plate on her breakfast tray was an indicator that she ate that morning, which reassured me.

Others docs may feel this way about their own specialty, but in my view (currently and as a medical student at the time), there is an art to psychiatry. There are no labs to rely on and although psychopharmacology is of importance, I immediately noticed the value of a therapeutic connection and communication necessary to fully understand an individual’s situation and the context of their symptoms. Despite such a strong emphasis on pharmacology during medical school, I recognized early on how much certain symptoms (even physical) could not be improved solely by medications and standard treatment alone. I recalled reading The Diving Bell and the Butterfly as a medical student, which inspired me to try various different creative ways to communicate with other patients who struggled to verbalize their needs, and had a bit of success with many.

I have several other reasons that contributed to my decision to pursue psychiatry, but wanted to emphasize how much the nature of my connections with patients empowered me as a medical student. The psychological components of a person’s history are often not prioritized when it comes to a patient’s medical care. Throughout medical school, I often felt inferior particularly because I didn’t achieve the highest grades compared to my classmates. However, I knew one thing for certain when the time came to apply for residency: as a psychiatrist, I could play a vital role in emphasizing the importance of an individual’s psychological and social background in order to fully address health and wellness. And I felt confident that I’d do whatever I needed to be damn good at my profession.

Photo by Marlon Santos

March 18, 2016 24 comments

Psychiatry

6 Things To Say (And Not Say) To Someone Who Is Grieving

written by freudandfashion

{Na Pali Coast, Kauai, Hawaii}

I always struggle with grief this time of year. Among other stressors, this month also marks the 14th year death anniversary of my grandfather, whom I was extremely close to. You’d think that after fourteen years, the grief wouldn’t hit me so hard, yet it still does. Grief is one of the most difficult emotions we experience as humans, yet is also one of the most commonly misunderstood.

Below are some actions and statements that I’ve found most helpful both personally and professionally in my office when I have patients coping with grief. I initially drafted this post last week while in a combined state of anger and sadness (predominantly anger) related to grief. I contemplated deleting the initial draft, which I titled “Things You Should Never Say To Someone Who Is Grieving.” However, since I try to maintain authenticity on my blog, I decided to leave the section I wrote while in an angered state, particularly because people frequently experience anger, yet often internalize and feel too ashamed to express the emotion. People need to recognize that grief does not consist of only sadness. Grief is a complex emotional roller-coaster that may involve one or a combination of emotions such as anger, rage, sadness, guilt, depression, joy, denial, shock, disbelief, confusion, frustration, exhaustion, apathy, numbness…(I think you get the point).

Since people often feel clueless about what to say to someone who is grieving (trust me, I struggle sometimes with what to say as well), I hope that you will consider the following when you or someone you know is experiencing grief:

Things You Should NOT Say To Someone Who Is Grieving:

1. “It’s been ___ days/weeks/months/years already…you should be over it by now.” Grief has no timeline. The closer a relationship someone has with the deceased, the longer it may take to overcome the painful emotions. As one of my amazing readers (whom I learned a lot from since he shared his experience with losing a child) pointed out: grief never fully goes away, but rather becomes more tolerable.

2. “Just try not to think about it.” Telling someone not to think about losing someone is like telling someone not to be human.

3. “‘So-and-so’ has already moved on…you should too.” Comparisons are terrible because each individual person has their own process of experiencing grief.

4. “Just be strong.” Saying this statement actually does the opposite and evokes a sense of weakness for not being able to overcome such strong emotions that may feel outside of one’s control.

5. “I know how you feel. My ____ died…” Don’t even try to make the difficult situation more about you. I once sought support from a peer and confided in my sadness only to have her shift the focus to herself and her past losses (and she was a psychotherapist!). Though I’m sure her intentions were good, a part of me wanted to punch her in the face for wasting my time and energy.

6. “He/she is in a better place now.” I’m a little mixed about this statement because it can be comforting if used in a thoughtful way, but annoying if said generically as a reflex response. For example, when my grandmother passed away, I felt comforted when a relative said “She’s in a better place now with your grandpa in heaven” because my relative knew of my grandparents’ enduring love for each other having been married for >50 years, in addition to our spiritual beliefs. However, when an acquaintance says the statement in a generic manner, it doesn’t feel genuine at all.

Bottom line — don’t say anything to someone who is grieving unless you truly, wholeheartedly mean it. If it doesn’t feel authentic to you when saying it, then it most definitely won’t feel authentic to the person who is grieving. And if you’re not good at verbally communicating your thoughts, then read on to see how your actions can be just as helpful (if not more).

Helpful Things To Do/Say To Someone Who Is Grieving:

1. Just be present. Actions speak louder than words, especially during such a difficult time when grief tends to be a very isolating experience. Being present shows that you’re aware of how difficult the experience is and that you won’t let them go through it alone.

2. Give a hug. Several years ago, I was sitting in a lecture during residency when I received news that my grandmother passed away. During the state of shock, I truly appreciated when my co-residents gave me hugs especially knowing that there was nothing they could say to make me feel better at that moment. Giving me a hug showed that they acknowledged the news and wanted to show that they cared.

3. “If you ever need to talk to someone, I’m here for you.” Again, showing your support and offering your help when needed demonstrates that you care.

4. “I’m so sorry to hear the news” or “I’m so sorry about your loss.” Often, when people don’t know what to say, they may avoid saying anything at all to the person grieving. Avoidance is one of the worst things to do to someone who is grieving because one might assume that you don’t care, which most likely isn’t the case. Saying something as simple as this statement acknowledges that you’re aware and recognize the impact of the person’s loss.

5. “I’ll be thinking/praying for you and your family/ (anyone else known to be deeply impacted by the loss).” Expressing that your thoughts (or prayers if the person is religious/spiritual) are with someone shows that you know this is a difficult/tough time for everyone involved.

6. “I know I can’t say anything to take the sadness away, but just know that I’ll be here to support you.” This is such a true statement — nothing you say can bring the deceased back to life nor take the pain away, so offering your support and presence speaks volumes to someone who is struggling during bereavement.

February 23, 2016 22 comments

Medicine Psychiatry

4 Reasons Why I Don’t Wear A White Coat

written by freudandfashion

I absolutely love this post written by Dr. Kristin Prentiss Ott about why she believes we shouldn’t wear white coats to work. To carry on with her sentiment, I thought I’d write a few of my own reasons why I personally chose to ditch my white coat even when required to wear one since completing my internship (except for professional photos, of course). Aside from the fact that I’m a psychiatrist, you’d be surprised to know there are still some hospitals where psychiatrists wear their white coats on the unit (the psychiatric hospital where I did my internship was one of them). I used to think it was a bit odd to wear white coats on the psych ward because the look can be intimidating, but I was an intern at the time so I complied. And yes, I recall asking one of the supervising psychiatrists the reason why white coats were worn and remember being told it was by choice? I may have also been delirious and sleep-deprived at the time, so don’t quote me on that.

The following are the reasons why my white coat remains unworn and in pristine condition hanging in my closet:

1. White Coat Syndrome. Yes, such a syndrome exists and is also known as “White Coat Hypertension.” The condition is self-explanatory: a person’s blood pressure is elevated while in the doctor’s office, but is normal in other situations. I was initially quite surprised to learn that anywhere from 15-30% of people experience the syndrome, though I’d have to say the statistic is quite synonymous (frankly, I believe the percentage is even higher) with my own experiences in practice, especially when meeting patients for the first time.

Though one explanation for the fear-based physiologic response might be the association of hospitals/clinics with disease and illness, I believe psychiatric patients are even more prone to anxiety when in the psychiatrist’s office due to disclosures of more personal information and possibly also from bad experiences with previous doctors who weren’t empathetic to their psychiatric issues.

2. Prioritize the doctor-patient relationship. In a study done in an outpatient psychiatry clinic in Upstate New York, 96% of the patient population surveyed preferred that their psychiatrist not wear a white coat, while 58% did not think it would make a difference in their doctor-patient relationship.

Having an aligned doctor-patient relationship is important in any specialty, but even more so with psychiatry due to the personal content discussed. Due to the pressures of time constraints and also the trend of several behavioral health clinics having patients see whomever random psychiatrist has availability, patients are less likely to establish a therapeutic connection, which I imagine would exacerbate anxiety during each visit. I mean, would you want to re-hash your story to a new psychiatrist during each follow-up appointment (but then again, most psychiatrists don’t have enough time to review your whole history, so sessions become mostly limited to a discussion of symptoms only)? Minimizing any factors that can contribute to anxiety (such as wearing a white coat) would at least help a patient feel more at ease.

3. They’re filthy and teeming with bacteria. I have traits of OCD (Obsessive-Compulsive Disorder), yet vividly recall disgusting moments during internship (where I rotated in various hospital departments) when I knew that my white coat was dingy and long overdue for dry cleaning, yet was way too busy to wash it (think buildup of splattered bodily fluids from various orifices and the numerous times that my white coat sleeves probably brushed my face or came into contact with food I’d scarf down during quick breaks…ewwww). Dr. Ott points out in her post that research has shown that a mere 8 hours of routine patient contact leaves white coats teeming with infectious microbes. These days, the average work week of all medical residents is limited to 80 hours/week and most practicing physicians work an average of 40 to 60 hours/week, which equals a heck of a lot of microbial buildup.

4. Sure, a white coat has maintained its iconicism as a symbol of power, prestige, and intelligence, but a doctor’s identity shouldn’t depend on wearing one. Obviously, I was excited when I received my short white coat during my medical school induction ceremony, but later hated being identified as a novice med student as I walked the hallways of the hospital. Meanwhile, other health professionals from various levels of training wore long white coats indistinguishable from those worn by physicians. After graduating from medical school and transitioning to the longer white coat, I was so excited, yet recognized that I formed too strong of an attachment to my white coat. My dependency on an object didn’t sit well with me. I felt as if I had to wear one in order to possess a sense of worth and importance.

By first acknowledging that I attributed much of my value to an external object (the white coat), I took steps to detach myself from it. I began to curate a wardrobe that conveyed professionalism and my individual sense of style. I made sure that I properly introduced myself to patients and staff, especially when I was mistaken for a nurse or psychotherapist. And I’m not going to lie — initially, I was frustrated by having to correct people on a regular basis, but as I gained confidence in myself (yes, psychotherapy helped) and my skills as a physician, to this day I am rarely ever bothered. Interestingly, I am acknowledged to be a physician far more frequently and I believe it’s because I project a much greater sense of who I am, both personally and professionally. No white coat needed.

PS: A special “thank you” to my friends on Snapchat (freudandfashion) for contributing your opinion when I posed the question of whether or not you’d want your psychiatrist to wear a white coat (11% said “yes” to wearing a white coat and 89% said “no” ).

February 9, 2016 18 comments

Psychiatry

Quick Reflections From The Week

written by freudandfashion

{Napa, California}

I’d like to think that I’m quite mindful and reflect on almost anything that stands out in my day causing me to raise an eyebrow or feel that a mini light bulb went off in my head. I truly believe that the more mindful we are and the closer attention we pay to cues and details, the more meaning we can get out of even the most routine of days. The following are some of my own reflections from the week, and I hope to encourage you to reflect and do the same!

The importance of teamwork. As a psychiatrist who values coordination of care and hearing other clinicians’ perspectives, I had the opportunity to connect and discuss cases with an awesome psychologist whom I share several patients with. Being in private practice can feel a bit isolating at times compared to working in a multidisciplinary setting, so I welcome the opportunity to meet and discuss any complex psychological issues that might be impacting my patients. As several of you may know, I place a much stronger emphasis on psychotherapy than pharmaceuticals when treating my patients. Therefore, knowing that therapists value my opinion on psychotherapy just as much (or even more) than my expertise in pharmacology helped me feel connected and valued as a team member.
Be authentic and speak up. Since I posted my latest blogpost on physician burnout, I’ve received amazing responses from people telling me that they could relate to my post. As someone who was always afraid to share my opinion (yes, I’d go to leadership meetings and literally sit there and say NOTHING), it was a testament to how much personal work I’ve done to overcome barriers that got in the way of me voicing my opinion. I think clinicians can be hypocritical by simply telling patients to exercise more, think positive, stop thinking so much, eat healthier, etc, and even worse if they label patients as ‘non-compliant’ for not executing such changes by their next follow-up appointment. As if breaking years worth of habits is that easy. Well, I can say that it took me years to overcome my overwhelming fear of judgment in order to speak up and I’m just happy to have the support of empathetic people who helped me achieve it.
Normal vs Pathological. During sessions with patients, I try to help them discern whether the symptoms they’re experiencing are normal reactions given their circumstances. This week, several patients chose to hold off on increasing medications after recognizing that they were coping with issues in a fairly healthy manner. Often times when people are diagnosed with mental illness, any anxious feeling, sense of fatigue, anger outburst, difficulty sleeping, etc, is automatically perceived as problematic rather than a ‘normal’ response. I’m far more collaborative in my approach, and part of the treatment involves determining whether or not a symptom is ‘normal.’ The decision-making process of determining whether or not to adjust a patient’s med is geared towards first helping my patients gain insight rather than automatically assuming that their symptoms are pathologic.
“To find health should be the object of the doctor. Anyone can find disease.” ~ A.T. Still. I am currently reviewing osteopathic principles for an upcoming presentation, and while reading I came across this quote. There are times during appointments when I’m stuck on which medication to prescribe next, though I noticed that I experience clarity the moment I get an opportunity to practice the above quote with my patients. I have several patients who have tried an extensive list of meds, yet start to observe more improvement when the sessions shift from solely focusing on meds to helping them heal from years of trauma, neglect, medical illness, heartbreak, addiction, etc. Doing so reminds me of the reason I pursued a career in medicine in the first place.

January 16, 2016 5 comments

Lifestyle Psychiatry

New Year’s Resolution Ideas To Enhance Your Mental Health

written by freudandfashion

Not sure about you, but I got tired of writing down the standard New Year’s resolutions on my list (such as losing weight, making more money, etc) several years ago. Research has shown that people typically lose momentum to carry out their resolutions within the first 6 months, so why not make a list that enhances your life and contributes to happiness for the long run rather than relying on a number (ie, pounds lost, money earned, etc) to determine whether or not you succeed?

Achieving your resolution is a process…it has ups and downs…successes and failures. If we learned to embrace the process, we’d likely maintain momentum (ie, “okay so I ate a lot of chocolate and pastries on Valentine’s day — I’m going for a run the next day,” rather than the negative self-talk such as “I’m such a fatty and a failure because I ate a piece of chocolate”). I say, get over it and move on — after all, you’re human. You either have the option of stressing and obsessing about that one piece of chocolate (thus increasing your cortisol levels leading to increased fat storage) or owning up to eating that piece of chocolate and viewing it as fuel for your workout or a well-deserved treat. Perhaps self-love and forgiveness can also be a resolution? Since awareness of the importance of mental health has been gaining more traction lately, let’s make 2016 a year to focus on your overall mental health and well-being.

The following are some ideas that I share with my patients on a regular basis, in addition to some resolutions that I plan to incorporate into my own list for 2016:

1. Improve your sleep patterns. I listed this as #1 because it’s actually at the top of my own list since I stay up way too late despite having to wake up early in the morning for work. Sleep is correlated with your health (insomnia is related to hypertension while too much or too little sleep increases the risk of stroke, for example), levels of concentration, and mood. So how much sleep do you need? You can check out the National Sleep Foundation’s recommendations for amount of sleep here.

2. Substitute some of your least healthy food habits with more nutritious options. It has been shown that those with better quality diets were less likely to be depressed and people who eat higher amounts of processed food was associated with increased anxiety. Here are a couple of substitution ideas:

Instead of soda: try flavored sparkling water, fruit-infused water, unsweetened iced tea. (This is how I quit drinking soda about 4 years ago)
If you eat fast food on a regular basis, aim for an option that perhaps is charbroiled instead of fried (ie, grilled chicken sandwich instead of battered).
If you want to fulfill the craving for fried food, be sure to use oil from healthier sources (ie, coconut, olive, and grapeseed oil).
Instead of snacking on white or milk chocolate, switch to dark chocolate.

3. Make more of an effort to connect with others. This can be as simple as smiling or saying “hi” to people that you walk by on the street to making more of an effort to talk to a co-worker whom you normally don’t speak to, or re-connecting with an estranged family member. Social interactions with those you are close to, in addition to acquaintances, are linked to a greater sense of belonging and happiness.

4. Give back by volunteering. Volunteer work increases social connectedness and has been shown to lower levels of depression, especially for people over age 65.

5. Discover the exercise/sport/gym/physical activity that you love so much it becomes part of your regular routine rather than a chore/hassle. Rather than committing to losing weight, why not first find the physical activity you enjoy and desire to participate on a regular basis? Then, the benefit of engaging in the activity leads to getting in better shape. It’s really all a matter of perspective. If you focus on a specific number of weight to lose, then you’re more focused on the end outcome (and that could entail unhealthy habits such as yo-yo dieting, starving yourself to meet that number, or overexerting yourself at the gym — basically, methods that are unsustainable and add excess stress to your body).

6. Take up a new hobby. In effort to live a more balanced life, having a hobby can be a healthy distraction away from your everyday stressors. I’ve been meaning to improve my golf skills ever since I first played a round during residency several years ago (okay, maybe I didn’t play all 18 holes, but still). I’ve already bookmarked a few golf courses to check out and plan to go to the driving range in January. Anyone care to join?

7. Spend less time on your smartphone/social media and more time engaging in real conversation (and life in general). Americans have been found to spend an average of 4.7 hours/day on their smartphones. This is going on my list as well because I’m definitely on my phone way more than I should be. Although social media can be a great source of support to connect over mental health issues, it has also been linked to insomnia and increased anxiety in the teenage population. I believe that adults are likely also impacted by social media in a similar manner, so reminding ourselves to unplug more can lead to less distraction and greater productivity to accomplish the other resolutions on your list.

Photo by Marlon Santos

December 29, 2015 26 comments

Psychiatry

The “No Bullsh**” Guide For Getting Through The Holiday Season

written by freudandfashion

Ahhh yes, the television commercials convey cheerfulness and joy with the contrived images of gift giving and preparing for a massive holiday feast, but the reality is that people probably identify more with Ebenezer Scrooge than Martha Stewart. If a part of you feels too guilty and ashamed to admit that you’re not filled with holiday glee, then consider the following questions:

Do you want to roll your eyes when asked how excited you are about spending the holidays with your in-laws?
Do you feel obligated and forced to buy gifts for everyone?
Have you lost loved ones and the holidays serves as a reminder that they’re not present to celebrate with you and the family?
Did you recently go through a divorce or breakup and feel even lonelier now that you have nobody to drag to holiday parties or kiss on New Year’s Eve?
Are you struggling financially and can’t afford much of anything except to spend a quiet, typical night at home?
Are you trying to stay sober and the holidays tend to trigger using again?
Do the holidays cause more anxiety and depression because you’re expected to be happy even though you’re really not?
Do you hate dealing with annoying crowds of shoppers trying to get those last minute gifts?
Do you beat yourself up for waiting until the last minute to buy gifts (and then tell yourself that you’ll get all your Xmas shopping done early next year, yet repeat the same pattern. I’m raising my hand for this one)?
Have you been good about diet and exercise, but worry that Thanksgiving, Christmas/Hannukah/Kwanzaa/”insert celebrated holiday here” and New Year’s will test your discipline and make you gain all the weight you’ve worked so hard to lose?
Would you much rather say “screw it” and purchase an extravagant gift for yourself instead of trying to find the perfect gift for everyone else?

If you answered yes to any of the questions, then you’re definitely not alone. The above questions are just a few of the common issues that I heard from my patients and friends within the last few weeks. I’d say that the majority of my patients and people that I know perceive the holidays as far more stressful than joyful. I recall the holidays being so much fun as a child due to getting time off from school, receiving Christmas presents, building sticky gingerbread houses that were actually made of graham crackers, and going on trips with the family, but the holidays are definitely not as fun when you’re the adult responsible for planning the festivities. If you are one who tends to struggle during the holidays, then the following are a few tips to help you get through the next few weeks until New Year’s Eve is over (then you at least have some time to breathe until Valentine’s Day comes around):

1. Set boundaries, boundaries, boundaries. If you’re a “Yes Man/Woman” (someone who always says “yes” and has a hard time saying “no”), then you not only have to deal with the stress of planning for the holiday, but also the overwhelming pressure to please everyone since you’re the reliable person whom everyone depends on (or the schmuck whom everyone takes advantage of), which leads to internal feelings of guilt, exhaustion, anger, and resentment if you can’t carry out all the duties expected of you, but then blame everyone else for not helping you (you probably also don’t feel comfortable asking for or accepting help, right?).

If you fit some components of the description above, here are a few ideas to try:

Talk to your therapist (and if you don’t have one, you might want to consider getting one because your issues with setting boundaries probably aren’t limited to the holiday season).
Use the Yes/No Method.

2. Don’t overexert yourself if you don’t want to attend so many holiday gatherings. As mentioned in #1, the key is learning to say “no.” Weigh the risk/benefit of attending each event, and attend the ones where the benefit outweighs the risk (ie, attending your boss’ holiday gathering may have more benefit than attending a coworker’s potluck dinner/white elephant gift exchange). And if for some reason you actually have to attend a party that you can’t get out of, then stay for a bit and come up with an exit plan (I used to make up excuses such as “I promised to dog-sit for a friend” or that I’m not feeling well, but now tell the truth because I find that people are generally pretty understanding or can tell when you’re lying).

3. If you know you’re going to eat a feast and have a hard time avoiding all the amazing holiday desserts and egg nog, then plan ahead yet also be realistic. Stressing out about your exercise regimen and what you’re going to eat causes even more stress. Weight gain and disease is not caused by one or a few days of eating unhealthy during the holiday, but rather the trajectory of your lifestyle choices over time. If you eat a lot during Christmas dinner, then utilize those carbs with a good workout the following day, or plan on making healthier food choices thereafter. It’s truly better to move on after a day of indulgence rather than perseverating on the guilt (trust me, it took me over a year of living with my brother, who is a personal trainer/unofficial psychotherapist, for me to get over the guilt of eating unhealthy a few days at a time).

Here’s another article that might be useful for managing your diet/fitness goals during the holidays.

4. Make sure you set up appointments with your therapist or psychiatrist during the holiday for preventative measures. Although many health professionals are away on vacation during the holiday, plan ahead by setting an appointment before your therapist or psychiatrist leaves to make sure you have enough med refills or to check-in for support and maintenance. There should be coverage in case any urgent issues arise while they’re away, so make sure you have the contact information handy. And, of course, if safety becomes a concern, then call 911.

5. If you have a known seasonal component to your mood, put into action what has typically helped your mood to get you through the year (med and non-med approaches). I wrote a previous post on Seasonal Affective Disorder (SAD) and another post on how to cope with Summer seasonal depression, though the general principles apply to Winter seasonal depression as well.

6. Plan on staying sober during the holidays. Similar to #4 above, I always ask my patients if they’ll need a follow-up appointment with me during the holiday season to check-in and provide additional support to maintain sobriety. The holidays can be quite triggering for relapse, especially if everyone around you is inebriated by the plentiful cocktails, champagne, and spiked egg nog. The following resources provide great tips for getting through the holidays sober:

5 Ways to Survive The Holidays Sober
HOME Podcast by Holly (of Hip Sobriety) & Laura (of I Fly At Night): The Holidays

7. Coping with grief. I found this post quite informative for the bereaved during the holiday. One tip that I found most valuable was the importance of surrounding yourself with those who support you the most rather than undergo the exhaustion of trying to suppress your grief and sadness at numerous social gatherings.

8. Treat yo self. Okay, I admit it — the first few items I bought while Christmas shopping were for myself, but I couldn’t help it! It’s far more anxiety-provoking trying to come up with which item to buy for someone else than it is for myself (I mean, at least I know that I’ll appreciate what I bought for myself, whereas I have to risk feeling butthurt (this word is actually in the dictionary) if someone returns an item that I bought for them). To some degree, buying myself a gift is a form of stress relief in addition to a reward for getting through the entire year. And if buying something for yourself is not within budget, then deduct the cost from the gift you planned to buy the person you like the least.

If you have any other tips to cope with the stress of the holiday season, would love to hear from you! And rather than saying the generic “have a happy holiday,” I’ll end this post by saying “Hope your holiday is low-stress and may you enjoy (or tolerate) the season as much as you possibly can.” 🙂

Photo by Marlon Santos

December 11, 2015 9 comments

Psychiatry therapy

Tips To Control Your Angry Mood

written by freudandfashion

{Monterey, California}

Up until I graduated medical school, I used to be irritable and impatient on a regular basis. Not many people would think I had anger issues (particularly due to the way my anger manifested, which was mostly unassertive and passive, see below) except for those who received the brunt of it, which is often the case for most people. I also used to feel guilt and shame for having an angry temperament as a child, until I opened up about the issue during individual and group psychotherapy. It was quite therapeutic to hear that several group members (whom I least expected given their present demeanor) reported being angry during childhood as well, and even more helpful to gain the insight needed to identify triggers for my anger, in addition to more productive ways to express and cope with it.

We’ve all experienced anger before, and there’s various ways it can present itself. The spectrum of anger can manifest as brief, subtle annoyance to full-fledged rage. Though anger can be constructive (ie, used as motivation to create change or solve a problem), the more problematic expressions of anger are more outward via yelling, physical aggression (punching and throwing things, etc), or violence. Others may also express anger in an unassertive way (which can also be quite volatile) by isolating, holding it in, and not expressing the anger at all which often leads to more passive-aggressive and pathological forms of coping such as taking it out on others via hurtful comments, putting people down, being vengeful by indirectly trying to get back at people without communicating the reason why, etc.

Developing healthier ways to express anger has many benefits, which include health (anger is known to be associated with increased risk of having a heart attack, hypertension, diabetes, migraines, self-medicating with substances such as alcohol, etc), improved communication in relationships, and a gained sense of control over your emotions. Though the origin and persistence of your anger can be quite complex to fully understand (I tend to formulate my patients’ issues psychoanalytically, which can be theoretically confusing to many (including myself) except Sigmund Freud, who first laid out the theory), the following are some concrete strategies that can help keep your anger in check, which I also teach my patients and use on myself:

1. When your anger gets triggered, slow your response rather than reacting on impulse.

When anger gets triggered, our brain perceives the situation as a threat and automatically reacts by going into fight or flight mode and the response is believed to last less than 2 seconds. Therefore, since we can go into a rage from 0 to 100 instantly, we can take control of our behavioral response by using tactics that allow us to regroup and think through how to respond. Some tactics include the following: take a couple of deep breaths, count to 10, step away and excuse yourself briefly, grab a drink of water, etc.

Another similar example/situation — Have you ever received an email or text message that was so upsetting that you immediately started aggressively typing a hostile reply? I’ve reacted this way many times (and have also typed blogpost drafts out of anger), yet the rule of thumb is do not send content that is typed in a heated, angry state of mind, but rather to wait and respond when you’ve cooled down because you might send something you’ll regret (and an email/text message is a permanent record that you can’t take back).

2. Recognize your initial signs of anger.

I often ask my patients to identify the initial signs they experience when anger gets triggered because being mindful can put a stop to the progression to an outburst or response they might regret. Utilizing Tip #1 above is even more useful if we can quickly recognize our body’s initial response to anger.

To give an example, the following is my usual pattern of response that occurs when my anger gets triggered: eyes get wide, chest tightens, heart races, facial muscles tense, fists tighten.

I’ve practiced this technique numerous times and have become far more mindful and self-aware in the last few years (therapy and yoga helped) to the extent that once I notice my chest tighten and heart race, I quickly take deep breaths to calm down. So next time you get angered, pay attention to how your body responds.

3. Once you’re in a calm state of mind, express your anger.

When people hold in and suppress their anger, it often becomes internalized (and may experience depression by directing the anger inward) or builds up to the point that it leads to an eventual huge, uncontrollable outburst. I used to cope this way with anger as well where I’d yell and scream hurtful things and bring up anything and everything that upset me in the last few months. Once you’ve calmed down in the moment, try to assert and state your concerns in a clear, direct way rather than waiting until you’ve reached your boiling point.

I admit that I used to also react by either saying nothing or passively turning to someone next to me and saying mean, hurtful things that were loud enough for the person who upset me to hear (yes, I know this response is sooo high school circa Rachel McAdams in Mean Girls), so I felt awkward at first when practicing to be more direct at communicating my anger. However, just like with anything in life, you have to keep practicing and eventually you’ll learn to successfully express yourself and get your point across in order to feel understood and heard.

4. Identify the underlying cause of your anger in the moment, and if the issue is minutiae, let it go.

Numerous things can trigger anger (a negative comment, criticism, lack of sleep, not getting your coffee fix, drugs, depression, medications, anxiety, stress, grief, kids not doing their chores, your sports team losing, bad luck with fantasy football picks, a friend wearing the same outfit as you, a pimple, tardiness, misinterpretation of a text message, someone lying to you, PMS, delayed flight, someone cut you off on the freeway, etc, etc — I think you get the point). If the trigger is something small and trivial (ie, getting cut off in traffic), recognize that reacting in anger won’t solve the issue (that’s right — stepping on the gas and tail-gaiting the SOB will not make the situation any better…I only know this through experience) and expends so much energy that can be more productively utilized elsewhere. However, if the underlying cause might be a major issue you’ve struggled with throughout your life (for example, having social phobia and being extremely sensitive to judgment and criticism) then please refer to #6 below.

5. Diffuse your anger by getting some exercise or channeling that energy into a workout.

This point is pretty straightforward — anger triggers increased stress and exercise is always a good way to lower stress and expel the anger from your system.

6. Seek professional help.

If your anger is causing substantial impairment in your life (work, relationships, etc), then don’t be afraid to seek help from a professional (psychotherapist, your regular medical doctor, psychiatrist, anger management, etc). I mention numerous times in my blog how much psychotherapy has helped me personally and those I’m closest to can vouch for the noticeable improvement in the way I manage stress and anger.

November 13, 2015 13 comments

Medicine Psychiatry

Reach Out And Connect With Someone

written by freudandfashion

{Rancho Cucamonga, California}

I’m approaching a new phase in my life by moving on to a new practice, which will be my second job out of residency. As excited and hurried as I was to leave my first job and move on to the next, with this being the last week in clinic, I’d have to say that I’m quite sad. I’ve had several friends tell me that they don’t get along with their coworkers, that they haven’t developed friendships with anyone on staff, that they mostly are “in and out” of clinic to see their patients and get all the documentation done while minimally interacting with their peers. How fortunate am I to have developed a sense of family and strong teamwork with those whom I work with?

I hear that one of the drawbacks of going into private practice is a sense of isolation not having a team of professionals to bounce ideas off of or interact with on a daily basis. However, I do know that the practice I’m joining will provide valuable experience learning what it’s like to practice psychiatry in a different clinical setting. And even cooler is that the actions and morale of the group I’m joining have given me enough confirmation to prove that I’ve made the best choice for myself and my career.

If you notice a theme in several of my posts, it’s the concept of “family” and teamwork. I have several patients whose stress levels and depression gets triggered or exacerbated by a sense of loneliness and isolation due to lacking the friendship, camaraderie, sense of belonging, and the support we as humans need. Numerous studies have found that social relationships provide emotional support and contribute to stress relief and better quality of life. The following are some examples of how social support enhances mental and physical health:

Addiction
- Recovery from substance use often leads to the dissolution of former friendships that were associated with an individual’s propensity to use drugs or alcohol. Therefore, recovery-oriented support (such as 12-step programs) are critical early in treatment as someone begins to build and develop a healthier network of support. Higher levels of social support are linked to decrease in substance use whereas lower levels of social support prospectively predicted relapse.

Post Traumatic Stress Disorder (PTSD)
- for childhood sexual abuse survivors, a combination of self-esteem and appraisal support (an individual’s perception of being valued by others and that he or she is capable of getting advice when coping with difficulties) was useful in preventing the development of adult PTSD.
Cancer
- Supportive group intervention for women with metastatic breast cancer has been associated with lower mood disturbances and less maladaptive ways of coping with terminal illness.
Work Stress
- Social support at work has been shown to have direct benefit on workers’ psychological well-being and productivity.

THOUGHT OF THE DAY: Identifying and building your own support network can take quite some time and effort, but the enhancement on your quality of life will make it well worth it. Which supports do you identify as being most integral in your day to day life?

October 22, 2015 21 comments

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