Question: Hi Dr. Schultz, My son, late 20's, took a medical leave from work to attend a partial hospitalization program, he had been in therapy and feels stuck. He has been extremely frustrated with himself for not feeling like he could follow through on recommendations. He's been diagnosed with depression, also ADHD (Inattentive type) and anxiety. He tried medication for a little more than a month, then had difficulty refilling the prescription and is no longer on medication. In the meantime, he has lost his job due to downsizing. He no longer receives therapy and has not followed through on a few job leads. I find myself worrying way too much about the situation. I have a hard time not offering support, and find myself trying to help him prevent this situation from getting worse. I need to know the best way to be supportive. Please give me some suggestions...

Dr. Richard Schultz Says...:

Hello
and thank you for addressing these important concerns to me.
 

First,
I wish to say that I am truly sorry to hear about your son's recent struggles,
and about the stressful impact his challenges are having on you. There really is
no way to go through life as a sentient being and NOT encounter such a conflict,
especially if one is living in awareness and is closely connected to others.
 

After
reading your question, I was left with many of my own, regarding family history,
severity of his symptoms, the nature of your relationship with your son, etc. Therefore, in
order to write an appropriate reply, I had to make some assumptions. Where you
find these to be baseless, feel free to disregard that aspect and use what is
helpful.
 

First,
with regard to your son's treatment, there have clearly been too many stops,
starts, misfires, and abrupt treatment changes during these last few months to
reasonably expect a positive, stabilized outcome. This is unfortunately not
uncommon. In addition, no specific treatment plan seems to be in place for him
at this time.
 

So, I'm
thinking it may be a good time for a do-over. Your son's first order of business
is to establish a solid working relationship with a clinical psychologist,
preferably one with a CBT perspective, and one who also knows a thing or two about
meds. A
clearer diagnostic picture (likely involving some additional testing or formal
evaluation) will be of immense help in guiding proper treatment; depression,
anxiety, and ADHD, can all overlap, exacerbate one another, and/or enable the
others. A sharp quarterback/clinician is needed to call the next few plays, to
clarify the sequence at work here, and to identify the next best point of additional
clinical intervention, layered atop the therapeutic base.
 

For
you personally, I urge you to begin practicing constructively entitled self care
immediately, particularly in regard to your son. By setting reasonable
boundaries between you two, you will help you, help him, and help your
relationship with him. You'll do nobody any favors by getting burned out, by
putting up with too much of what you don't need, or by bending over backwards
too far.
 

In
any case, your own efforts are best spent on adding structure to the
arrangement between you and your son; a specific, quid pro quo "behavioral
contract" (and I strongly suggest putting this in writing) that clearly outlines
your individual and collective goals for the near term primarily, and for the
mid-term secondarily. This will outline the resources and contributions each of
you is willing to expend in service of your collective goals regarding your son's general functioning and mental health care, what you are
asking for in return, and what contingencies or consequences will be triggered
by failure of either party to deliver. I don't know what currency
or weight you have in this relationship (residential, financial, or other), but
these are your power chips, and they will most likely require some
leveraging.
 

As
you well know, your role with your son cannot be that of therapist, even if you
were a professional. Any dynamic in which are experienced by him as lecturing,
preaching, shoulding, criticizing, or judging, is destined to do more harm than
good. Even if he does outwardly tolerate such a stance, oppositional or rebellious feelings
and behavior are likely to arise in him, against you, which is counter to the
intrinsic motivation you want to help him cultivate for himself.
 

Aristotle
wrote that "nature abhors a vacuum," and the concept is relevant here. The less
you do to fill the vacuum of your son's unmet needs, the more room and incentive
there will be for him to step forward and do it himself. Avoidance is a key
element in anxiety, depression, and ADHD, so your son is surely experienced at
ways to dodge the rough spots or perceived challenges in his life. Whatever you
do, you don't want to enable ANY such avoidance behaviors as that just makes
"the monster" (which is nothing more than his own pain) even bigger and scarier
for him. So, no ducking, bobbing, or weaving around such monsters, as these
actions only strengthen the anxious thoughts and feelings.
 

Each
time aversive sensations are experienced, humans are strongly inclined to
withdraw. By artificially LOWERING this anxiety level, through any means other
than facing and "habituating to" the feared situation, negative reinforcement
and avoidance behavior will be strengthened. The short term reward of "relief"
determines behavior most powerfully.
 

My
final suggestion to you is to seek out a psychological consultant of your own.
Having your own "go-to professional" will provide you with objective,
behaviorally wise guidance you'll need to stop yourself from filling the vacuum,
while maximizing your son's motivation to do it himself. You will also get
useful instruction on creating and implementing the behavioral contract. Your
own therapist can also teach you to understand how this situation "hooks" you so
strongly and painfully, and help you learn how to unhook yourself from worry,
sadness or frustration about your son.

I do hope that some of what I have written is of help to you. Please do keep me posted on your situation, and feel free to let me know of any additional questions you may have.

Sincerely,

Question: How do you motivate behavioral health change in the family?

Dr. Richard Schultz Says...:

Hello and thank you very much for addressing your question to me. 

As your question is almost word for word the very title of a recent answer I provided to another reader, and because you have provided no detail to your question, I am left scratching my head and a bit confused.

Perhaps you hit send too soon?  Changed your mind? 

In any case, if you would like to elaborate on the question, I will be glad to consider answering it. 

And just in case you did NOT read the previous reply, here it is:

http://www.choosehelp.com/experts/depression/depression-richard-schultz/if-not-for-yourself-then-do-it-for-me-motivating-behavioral-health-change-in-the-family

Sincerely,

Richard E. Schultz, Ph.D.

www.drschultz.org

www.mindsetdopc.com

@mindsetdoc

Question: I have an adult family member who has been diagnosed with severe clinical depression and anxiety. She is very cooperative in terms of going to therapy and taking the prescribed medication. But when it comes to actual necessary habit changing, she doesn't budge. For example, her CPAP sleep apnea machine just collects dust because she says she can't sleep with it on, and she smokes CONSTANTLY - every 10 minutes or so. My questions are: 1) When someone is in such a horrible condition - pretty much comatose 24/7- is it an appropriate time to try to get them to stop smoking? She is very sensitive to even the slightest bit of "stress". So would trying to quit just be compounding her troubles? 2) What do you think of using cigarettes somehow as bargaining chips to get her to use her cpap machine?

Dr. Richard Schultz Says...:

Hello and thank you for addressing this important question to
me. 

As we Baby Boomers continue
to age (at least us lucky ones!), challenges and concerns such as this, which
revolve around adherence to medical treatment, and the relationship between
family members, caregivers and healthcare professionals, will occur
exponentially more often.  I also
believe that the mental health community can and should be called upon to
help.

I am quite sorry to hear of your family member’s medical and mental
health challenges, and it is easy to understand why this situation is pretty
miserable for you both. She is at perhaps the most deteriorated position of her
life, and you are very justifiably concerned, thus attempting to motivate her to
help herself and heal, and encountering resistance along the way. 

Unfortunately, it does not sound as if your relative is at this
time exhibiting a very strong will to adhere to the lifestyle and behavioral
challenges that would be optimal, given her existing medical conditions and
habits.  This is a delicate and
precarious dynamic indeed, especially when someone so emotionally close to the
patient, such as you, is also trying to be the cheerleader, coach or
motivator. 

In considering the best intervention for helping your relative, I
would want to consider many factors. 
These include: a) the degree to which she is manifesting symptoms of
depression that are NOT being successfully treated by current medications and/or
therapy, b) the degree to which her behavior is a deliberate choice based on her
current existential crisis (for example, she may not wish to prolong her life
and may in fact wish to hasten her death by smoking and not using her CPAP,
among other related behaviors), c)the level of  her accurate and complete understanding
of the deleterious and synergistic effects that her untreated sleep apnea and
continued smoking are having on her; and d) the degree to which her seemingly
rebellious maladaptive behaviors are in some way a reaction to perceived
attempts on the part of others to “fix” her (this last point often termed
“iatrogenesis,” wherein treatment or help actually makes the problem
worse). 

It’s a complex picture, to be sure, and one that must be
holistically considered prior to initiating any new “solution.”  These are the kinds of challenges that
psychologists and psychiatrists face every day, and we ideally bring to the
table a wide repertoire of possible interventions to address them, taking into
account the big picture.

In this case, I would suggest you begin by doing less to solve
these problems.  That’s right, I did
just write that! I suggest you immediately reduce the amount of attention, and
emotional and behavioral energy, you devote to this relative’s challenges.  Think of it as “cleaning the slate” or
“cleansing the palate” in a way, whereby you till the field before making a new
planting.  Based on what you
describe the current dynamic to be, my guess is that doing so will do no harm,
and, more importantly, will actually be helpful to you, your relative, and to
the relationship you share. Sometimes, believe it or not, simply doing less to
fix a problem is, in and of itself, the best fix for the problem. 

After a few weeks of tilling have occurred, it is time to plant! You will begin by approaching your
relative and inquiring as to whether it might be okay with her if you were to accompany her to
at least part of one of her therapy sessions.  You will frame this request as stemming from your love and concern for her well-being, your awareness that your "helping" behavior has probably been at times frustrating or annoying or disrespectful to her, and your desire to do more of what helps and less of what doesn't.  You need not mention the CPAP or smoking issues during this conversation; keep it general and, if necessary, mention a condition or symptoms cluster that you KNOW she wants to change.

I don’t know if you (or any other readers) have ever done this or asked to
do it in regard to a relative’s psychiatric treatment, but such “guest appearances” can
be very illuminating and constructive, IF they are handled sensitively and ethically and at the election of the patient.  Benefits may be experienced by the patient, by the guest, and by the guest's relationship with the patient.  It is possible, I suppose, that the therapist in question (if
indeed true psychotherapy is happening, versus simply medication management and
a very brief, supportive check-in, the difference between the two being QUITE
dramatic as it concerns the influence of the care provider on the patient) is
not even aware of the CPAP or smoking issues, is not focusing on these
areas because the patient seems not to be troubled by them (or is intentionally
avoiding discussing them), or because the patient has expressed a desire NOT to make change in these behaviors. 

And if
your relative is NOT receiving solid, empirically-informed psychotherapy from a qualified
professional, this will ideally be sought out as soon as
possible (perhaps yet ANOTHER motivational challenge; you are going to get good at this!). In any case, the point of participating more actively in the
patient’s treatment is to still demonstrate your concern, but at the same time
to also access the expertise and influence that can be delivered by the care
provider (be it as “expert,” “the only one who really listens to me,” “my
friend,” “benevolent and respected authority figure,” etc.). Let the therapist
and the intervention be "the enforcer" of whatever plan us put in place, given,
of course, that the patient responds receptively to this request to go to
therapy with her. 

Some strong words of advice: Please consider exactly how you will word your request to the patient very carefully before
doing so, and run it past a few others whom you trust, as your first chance will
be your best, and thus the stakes are high.  If any hint of control, punishment,
disrespect, insensitivity, or criticism is present in the request (“I want to
talk to your doctor so that I can tell them what a 'problem child' you are”), it
is likely not only to fail, but to re-exacerbate the dynamic between you and
your relative. This is how therapists are trained to deliver treatment, in a very thoughtful, client-centered manner.  Thus, such Motivational Interviewing (a specific clinical approach that has been widely researched and practiced) is not only an important aspect of helping someone seek treatment, but also a very powerful component of the treatment itself.

Further, do not
attempt to discuss these challenges with the care provider without first consulting the patient and securing their informed consent (assuming that the patient possesses reasonable mental competence; if they do not, conservatorship or power of attorney may be needed). No licensed care provider is legally or
ethically empowered to share information regarding the patient with anyone without
such consent unless it is in the context of an acutely emergent and life-threatening circumstance. Perhaps even more importantly, any perceived violation of your relative’s
reasonable rights would be likely felt by her to be infantilizing and would certainly do more
harm than good, for example by only further strengthening her resistance to your suggestions.  In fact, even if
the patient agrees immediately to let you speak with her physician or therapist when she is
not present, I would still recommend that you not do this. The goals here are to help the patient change AND to empower her as the AGENT of such change.  

Once in the room with your relative and her therapist (or psychiatrist or other care provider), you can begin, very gently and
diplomatically, to express some of the concerns you have about the patient's
well-being, speaking ideally about YOUR feelings and concerns versus
making allegations or complaints about THE PATIENT’S behavior and adherence issues.  The care provider can then assess the
situation and guide you and your family member in a clinically valid and
hopefully helpful manner.    

If this first approach does NOT work, and in fact even if it does,
I would suggest you find a therapist on your own, whom you can consult for
further intervention and coping strategies.  Ultimately, you probably have a
miniscule amount of control over what this relative, or any other person,
thinks, feels or does, however you may exert great impact by adjusting your own
stance. I would recommend that you seek out a therapist who is well-versed in
cognitive behavioral therapy, management of geriatric challenges, and someone
who also has grounding in family or systemic work (this situation being VERY
different from one in which an individual such as your relative seeks out a
therapist to address their personal difficulties with the CPAP or smoking
issues).  This clinical challenge
requires of the provider a far more fluid repertoire and understanding of family
and interpersonal dynamics, medical illness, and issues faced by elders than
might be the case in a simpler clinical situation.  This is all the more reason to find the
right therapist for the job.  And
remember, ALL THERAPISTS ARE NOT TRAINED OR CREATED EQUALLY.  Please know this. Perhaps the greatest
benefit to seeking your own consultation is that you can talk freely with the
therapist about the situation without worry of hurting your relative’s feelings,
making the situation worse, or dealing with the bias or allegiance of her
existing therapist.  This would be
akin to hiring a coach to teach you how to coach someone you love at, say,
pitching a baseball or playing a violin.

Before closing, I will say that your own points regarding the pros
and cons of various interventions are well taken.  Yes, although smoking is quite harmful
to your relative’s general and specific medical health and condition, it may be
far down on her own list of priorities, and the activity of smoking itself may
be a valued coping technique which might not survive the cut in a strict cost
benefit analysis.  Finally, the
concept of utilizing any type of “bargaining chip” to increase desired behavior
is really one best addressed by a qualified mental health professional.  There are a multitude of such strategies
that might be implemented and, although the right one may help, the wrong
attempted “cure” may indeed end up doing more harm than the disease it was
designed to treat is actually causing (see “iatrogenesis”
above).

I do hope that some of what I have offered has been of assistance
to you, and I wish you, your relative, and the entire family, peace and strength
moving forward.  I also want to say
that your relative is lucky indeed to have someone in her sphere with as much
concern for her well-being as you clearly do.  I only wish there were a zillion times
more family members out there than there are who have the caring and judgment to
“Choose Help.”  Nice plug there, eh?
Don’t worry, this is not a paid gig for me, so that isn’t an ethical violation!
J

Please do feel free to write again with an update on the situation
(I get very few of those, unfortunately), or if you have any further questions
or issues.

Sincerely,

Richard E. Schultz, Ph.D.

www.mindsetdoc.com

www.drschultz.org

@mindsetdoc

Question: Hello, I am a 23 y/o female and I don't know what's wrong with me, l am a big time overeater. The only reason I am not obese is because I exercise. I'm always preoccupied with food. I'm always thinking of what I will eat next. After having my child I started taking phentermine and that has been the only time in my life that I did not obsess over food. l don't know if I'm depressed, have Social anxiety or what my deal is. There is absolutely no time for me to be depressed. I do'nt feel sad. Mostly, I feel like a zombie going through daily routines while shoving processed food down my gullet. 1 also get this weird brain fog that happens when ' believe I'm possibly anxious, like around people. As a nursing student one instructor told me l needed to pay attention and the worst part is I do try but my head sometimes gets cloudy, and 1 will just feel this overwhelming fatigue. I'm going to start a job as a RN soon and feel this foggy brain is going to make everything So much harder. I hate not being able to pay attention, always eating, Worrying I'm going to mess up. I would like to ask my PCP about Wellbutrin but I feel embarrased asking.

Dr. Richard Schultz Says...:

Hello, and thank you for addressing your question to me. 

I am truly sorry for the suffering you have experienced in regard to your relationship with food, and other troubling symptoms of symptoms of anxiety and depression.

Let me first tell you that you are so NOT alone in your struggles. In any given year, more than 25% of the U.S. population will meet criteria for a mental health diagnosis (anxiety being far and away the most common of these).  Although lifetime prevalence statistics are typically underestimated due to a variety of factors (treatment is not sought, diagnoses are not made, and mental health problems are simply under-reported), a great many of which stem from precisely the sense of embarrassment and shame you have described feeling, it is estimated that between 65% and 85% of the global population will experience at least one episode of mental illness during their lifetime. It is sadly puzzling that so many people continue to think of themselves as “defective” for experiencing what almost everybody else ALSO experiences. I suppose we must conclude that feeling strange is a very strong sign of normalcy.

Before writing further, I must advise you that a variety of medical conditions and syndromes can “masquerade” as mental health issues, and visa versa.  So please do get thoroughly checked out by your doc to rule out pharmacological, metabolic, hormonal, neurological, thyroid and other potential conditions that can impact mood, hunger and eating behavior.

So, it’s drill down time. I am now going to address your issues far more specifically. I will err on the side of directness, and I ask for your patience with this.

One can develop the cyclical pattern of preoccupation, obsession and compulsiveness you describe in regard to just about any other at least temporarily stimulating behavior (drinking, gambling, having sex, working, fighting, shopping, stealing, watching porn, etc.).  Regardless of the circumstances under which you developed such an uneasy attachment to this particular realm of behavior, however, let’s please be clear about the research which states that you were NOT born with this problem, but that you learned it.  And you have been practicing it diligently, daily and during almost all of your waking hours, for a very long time. Well, we get better at whatever we practice, and we are always practicing something.  So, sadly, you are now an expert.  But that need not define you beyond this moment.

With approximately 99% of human problems, overt, active and even aggressive solutions will yield success (getting out of a burning building, selling widgets, moving furniture, protecting yourself from an assailant, getting out of debt, etc.).  When applied to internally driven problems of thinking, feeling and behaving, however, such solutions typically fail, and usually cause these problems to persist and  worsen.  Thus, your attempts to zealously control your weight, via compulsive exercise, taking phentermine, or practicing periods of eating restriction, have all been associated with increasing distress and stuckness. This outcome is wholly consistent with the behavioral principle of negative reinforcement.

You wisely suggest that your own underlying tendencies toward insecurity, depression and anxiety, all of which you seem to want to suppress or negate versus address, are likely related to the eating issue, and to the layer of additional worries and pressures to which it gives rise. Well, I think you are right. You are treating yourself like someone that has no right (or time) to truly allow her painful feelings (no time to be depressed?), so you consequently feel as if you are walking through life like a zombie (which is, in fact, a clearer sign of depression than is crying and feeling sad), and the hungry, otherwise ignored part of you, is fighting back. That which is suppressed will be expressed.

Finally, experiences such as “brain fog” and other related neurologically located phenomena (lightheadnedness, dizziness, mind going blank) are common accompaniments to anxiety and are, in fact the direct result of your central nervous system’s fight or flight mechanism kicking in.  These symptoms typically occur within the context of social anxiety disorder and panic disorder, and generally respond well to empirically-supported psychological treatment when delivered by an appropriately skilled practitioner. 

So, most importantly you need, and will most likely derive significant benefit from, good solid treatment.

Most essential in this regard will be establishing a strong working alliance with a qualified therapist who can help you understand, disentangle and address these problems (which, again, do all appear to be related). I would therefore advise you to seek out a psychologist with a strong cognitive-behavioral perspective, who can demonstrate to you rather quickly (hopefully within the first meeting) that they have a solid conceptual and technical grasp of what has been going on with you, as well as a sound initial treatment protocol(s) to propose in response.  You also need to feel reasonably comfortable and connected to this therapist as the working alliance is a major mover in therapeutic success. 

With regard to psychopharmacological intervention, this is also likely to be at least somewhat helpful, and may give you some relief for your symptoms while you are on the medication.  This may also, in turn, give you greater resources for the work required in psychotherapy. I have worked with WAY too many people on psychotropic medications alone who have not made sufficient progress because they are not supplementing their meds with psychotherapy.  Meds can be great, but they don’t teach us new ways of thinking or feeling.  In summary, medication is not proven to be a sufficient standalone treatment for the condition you describe.

You may begin your search for a provider by consulting your PCP (please give yourself the opportunity to be honest about your struggles; your self will appreciate it!) about behavioral health professionals well-known to the PCP, or from trusted friends and family.  You may also elect to review popular therapist search engines such as those operated by Psychology Today, ABCT, ChooseHelp or the American Psychological Association. 

And to be clear, my advice is for you to begin with a psychologist or other professional trained in and practicing empirically supported cognitive and behavioral methods, and then consider the medication options, if desired and needed, after you have already begun to work with the therapist.  If you do find that medication consultation is indicated, the complexity of your combined symptoms do suggest that a psychiatrist could very likely be more useful than a PCP (as they are in almost every such case due to their knowledge of psychopharmacology that greatly eclipses that gleaned from the relatively brief training in such areas are received by internists or primary care physicians).  When and if it is time to identify appropriate psychiatric providers, you may request a referral from your new therapist, or your PCP.

The good news is that NOTHING in what you describe suggests that you cannot begin making change tomorrow. It doesn’t matter how long you have been suffering, enlightenment can still be yours. Psychological treatment is not rocket science, it doesn’t take forever, and the process is not even all that complicated. But I caution you; it will require very hard work (although not nearly so hard as the work you have already put into trying NOT to have the problems). Your personal motivation for liberation is key, and you will also have to be willing to accept the discomfort that comes from facing what you truly fear.  If you want anything else in your life more strongly than you want recovery, than your chances of healing are greatly reduced.  That’s the blessing and the curse of being free and of being human.

Finally, as a future health care provider yourself, you will be giving your patients a wonderful gift to the degree that you take the time to know and work on yourself, and you can then help others cope with their challenge in the ways that you will learn to cope with your own.

I wish you peace, luck and strength in your journey. Please do write back to update me on your progress or to ask any other related questions.  This may not only enlighten me, but may also provide support to the millions of others on behalf of whom you unwittingly write.

Thank you.

Richard E. Schultz, Ph.D.

www.mindsetdoc.com

www.drschultz.org

@mindsetdoc

Question: If I take SSRIs is there any danger that they will change my brain permanently once or if I stop taking them? Serotonin toxicity? I am terrified of the idea that I will lose myself or my personality with medications and I won’t be able to get myself back.

Dr. Richard Schultz Says...:

Hello and thank you for addressing your question to me.

First, let me respond directly to the content of your question. I will then attempt to address the subtext of your question.

Since the introduction of Prozac, the first widely distributed selective serotonin reuptake inhibitor (SSRI), in 1974, extensive empirical and clinical data have been vigorously gathered on this and related classes of antidepressant and antianxiety agents in regard to effectiveness and safety. Amid this sea of data, there have been no observed trends of statistical significance to support either a) maladaptive and irreversible neurobiological changes, or b) individuals reporting irreversible maladaptive "loss of self" or "loss of personality."

To be sure, side effects occur with the use of SSRI's, as with most medications. These vary quite widely across patients, even when they are on the same medication and same dose. Depending on how bothersome these side effects are, measured against the perceived benefit obtained from the medication, and for how long they persist (most initial side effects tend to reduce or fully resolve across time), the patient may, with or without consulting the prescribing physician, elect to discontinue their medication. I will note that this specific scenario, wherein the patient abruptly discontinues psychotropic medication use without consulting their physician, is responsible for a great many patient crises. It is therefore strongly advised that patients do not execute significant psychotropic medication changes, upward or downward, without consulting their physician, and patients should also take great care to ensure that they do not simply "run out" of psychotropic medication between refills.

Thus, side effects are common with psychotropic medication, it is all but impossible to know what they will be or how severe they will be in advance of taking the medication, and adjustments are commonly made after the patient's reactions to the medication are observed. The pharmacodynamics of SSRI's are not observed within the cerebrospinal fluid until several weeks after initial administration, although both side effects and placebo effects may begin almost immediately. It is also rare for any side effect caused by the medication to remain following a reasonable washout period. Anecdotal concerns and accounts about such lingering "changes" are not well documented or prevalent.

You mention serotonin toxicity. Also, known as serotonin syndrome, this cluster of varied, but often more serious and potentially life threatening symptoms results most commonly from the creation of excess serotonergic activity within the brain and nervous system, typically due to contraindicated drug-drug interactions (as in polypharmacy; this is far more rarely observed in monotherapy, except in overdose). Prevalence data is not available, but a great many cases of serotonin syndrome are simply unreported or unrecognized.

In summary, the concerns you have expressed are not supported by the available data on SSRI's, after more 30 years of monitoring.

As to the subtext of your question, these concerns would appear to be anxiety based. Although this may not be accurate in your specific situation, patients who struggle with anxiety (especially when it has a physiological component as in health anxiety or panic disorder) tend to exhibited heightened concerns about taking psychotropic medications. In part, this may be due simply to the prevalence of the underlying foci of their worry on potential bodily or psychobiological changes. However, this phenomenon may also be intensified further after administration of a new medication. The anxious patient, often thought to exhibit interoceptive sensitivity, may hyperfocus on their internal sensations, thus making them stronger (a well-documented finding on attention to bodily sensations). So, unfortunately, although the medication itself may not be causing any worsening in the anxiety condition it is designed to treat, it can provide a great deal of physiological grist for the anxious psychological mill. It is for this reason that initial dosing should "start low and go slow" for anxious patients, and in depth research into potential side effects is to be strongly discouraged. This is often conducted online and often leads the patient to read mostly negative and often idiosyncratic accounts by others taking the same or similar medications. It can, however, trigger further interoceptive sensitivity and hyperfocus, exacerbating the underlying condition in a manner wholly unrelated to the pharmacological agent in question.

So, I know that I have given you far more information than you requested, however I hope that I have not only addressed your concern, but also provided some understanding to others who struggle with this issue as well. My strongest recommendation to you is to discuss these concerns with your prescriber. Ideally, you will consult a psychiatrist or psychologist familiar with these issues, so that you can receive strong counsel and guidance as you start any new medication.

Please do feel free to keep me posted on your experience, with medication or any related issue, as I will be happy to provide additional information as needed. Also, your account may be of help to others struggling with similar issues.

Sincerely,

Richard E. Schultz, Ph.D.

Question: Is there any problem to trying transcanial magnetic stimulation before medication for depression. My husband has a hard time with sexual side effects of SSRIs. His doctor told him his depression was not as bad as they normally treat with this approach but is there any reason why it would not work for someone with medium grade depression?

Dr. Richard Schultz Says...:

Hi There:

Thank you for addressing your interesting question to me.  For those not familiar with this new form of treatment, TMS (transcranial magnetic stimulation) has been shown to produce changes in neuronal activity in regions of the brain implicated in mood regulation, such as the prefrontal cortex.  Further, sustained treatment using this procedure has been shown to have a significantly ameliorative effect on depressive sypmtoms.

Your question, regarding the appropriate sequencing of TMS in an overall treatment protocol is provocative, as it questions the customary practice of holding back on this intervention until several other options have failed.  Although this is often done, as in the case of ECT, for safety reasons, and for clinical indications of treatment resistance, such is not true regarding TMS; there are very few risks associated with the treatment, and it tends to be more effective with patients who have NOT already failed to respond to other modalities.

The greatest downsides to TMS are it's cost (and unresolved questions regarding third party reimbursement), the time demands (typically at least five treatment sessions per week for 2 weeks), and somewhat equivocal research on its effectiveness.  Some patients are also not candidates due to the prior placement of metallic medical devices implanted within or near the head.  If none of these conditions apply to you, as an individual consumer, then there is nothing stopping you from receiving the treatment.  Although there is a slightly elevated seizure risk associated with TMS, I believe it is still all but miniscule.

I understand that physiological side effects discourage many people from undergoing treatment with psychotropic medication for depression.  If this is a concern, I would hope that you consider consulting a psychiatrist, as opposed to a primary care physician (who prescribe the majority of such medications in the USA), as a specialist will have a greater understand of side effects and how to minimize them.

Further, as a psychologist, I would not be doing my job here if I did not strongly recommend a course of psychotherapy, especially given the mild to moderate severity of the depression.  Of all forms of treatment, this tends to be most user-friendly, causes no side effects, and actually helps the patient learn to think and behave differently; this is particularly beneficial given that the challenges we face in life, inlcuding those that tend to trigger depression, are recurrent.  In particular, cognitive-behavioral treatment can be very effective in bringing relief to depressive symptoms within a relatively short period of time.  If you would like to learn more about this form of treatment, you may begin by obtaining and reading "The Feeling Good Handbook" by David Burns.

I hope this response has been of help to you, and I welcome you to get in touch again to keep me updated on your situation or to pose further questions.

Sincerely,

Richard E. Schultz, Ph.D.

Question: I am on luvox. My depression has lifted but my concentration is still a mess. I will be lucky if I can stay with this paragraph for long enough to finish it…So where was I??? Oh yeah – concentration. I am 9 months into Luvox and I have mostly really good things to say about it. I have heard other people say that it helped them with concentration but honestly mine is as bad as it was at the worst of times. I used to do coding and I took a breather but I have enough goodwill to get some work – unfortunately I just can’t focus enough to trust myself to handle a complex job. So what do I do?

Dr. Richard Schultz Says...:

Hello and thank you very much for addressing your important question to me.

I certainly appreciate the frustration and discouragement you are experiencing as a result of your difficulties with concentration. The task of focusing one's attention on a particular activity of one's choosing, and sustaining mental effort thereupon is a basic aspect of daily functioning for us humans, and yet this endeavor can be negatively impacted by many factors.

In order to better master this challenge, it will be important for you to first understand what is actually getting in your way. I will therefore describe a few of the most basic factors that commonly disrupt concentration and attention, and this will hopefully be of some use to you in addressing this struggle.

1. Anxiety, Depression and Anger:  Even mild levels of any of these common emotional states can cause disruption in the ability to concentrate and attend on tasks and activities, unless of course that activity is being anxious, depressed or angry. When we are triggered by any of these feelings, and the thoughts that accompany them, a significant degree of preoccupation can occur, thereby limiting the brain's central processing unit's capacity to focus on anything else.

With particular regard to anxiety, this preoccupation serves an evolutionary purpose; if you feel/believe that you are at great risk due to Stimulus X (say, a lion in the jungle staring you in the face), it would be maladaptive to then be able to easily redirect your focus to the beauty of the trees and foliage surrounding you, the weather, your feet, or the pretty color's of the lion's eyes.

With regard to depression or anger, the invitation to dwell ruminatively on that which has hurt you, discouraged you or pissed you off, can also be quite hard to resist, although this likely serves a less developmental function, and is more likely a result of simply having such a darned sophisticated brain and cerebral cortex. This is supported by the fact that lingering anger and depression are rarely observed in non-human species. This is why zebras don't get ulcers. Thanks, brain!

Underlying Attentional Deficits:  Another common culprit in the disruption of attention and concentration is a baseline level of under-activation in the frontal lobe, sometimes called the "executive functioning" area of the brain. This anatomical structure is responsible for helping us to think through complex concepts, generate necessary steps and sequences for problem solving, and execute upon these. When such under-activation is present, distraction is far more likely, and abrupt stopping and starting of these processes can occur, thereby limiting one's ability to follow through on one's goals. The role of stimulant medication (such as methylphenidate) in such a condition is to activate these under-active areas and thus bring functioning to within normal levels. You did not specify a pre-existing vulnerability in this area, but I cannot take that to mean it is not the case.

Drugs and Alcohol:  To state the obvious, the use of substances, sometimes in even very small quantities, can erode our ability to attend to, and focus upon on tasks, ideas and activities. The threshold of disruption varies greatly among individuals and substances, so it is not possible to make broadly generalizable statements here. Even prescription medications can, in some cases, impair attention and concentration in some people (I'll not mention specifics here as I have no desire to negatively feed into the suggestibility of humans and their medications).

Luvox, which is an SSRI that has been around for 20 years, and which was initially touted for its effectiveness in treating obsessive-compulsive-disorder, is relatively unlikely to be the cause of your attentional problems. Your description of pre-existing concentration problems supports this. In addition, as an anxiety disorder marked by intrusive, preoccupying thoughts, the underlying condition of OCD may be related to the difficulties you are experiencing (although you did not mention whether you had ever struggled with this, in addition to depression). The medication may be helping with some of the symptoms of the condition, but not all.

Based on what I have written thus far, I would make the following recommendations to you:

1. Pay attention to your inability to pay attention. Yes, this sounds a bit paradoxical, but I am intending to suggest that you gather more information about your difficulties with concentration. When, where, and under what circumstances does this manifest? Where doesn't it? What helps and what makes it worse? Is there a time of day, a location, or fluctuations in energy level or other physiological factors that correlate with instances of inattention? Write down your observations in this regard and do some detective work. You may have some useful realizations. Further, are there any areas of particular focus at the times when you are unfocused (this goes back to the CPU example above)? Where does your mind go when it goes? Are there any particularly popular areas of preoccupation (sorry for the alliteration!) that are sucking up your bandwidth and your focus? Identifying and addressing these can be extremely useful. Further, you may wish to read Hallowell's "Driven to Distraction" to determine if you have underlying attentional problems (although most individuals who do would have likely experienced related previous obstacles during their education). Of course, you can also consult a qualified psychologist or psychiatrist with this question.

2. Get some tools. As they say, those who fail to plan, plan to fail. Given the complexity of current life, and the fire hose of data coming at us every moment, we ALL need ways of de-cluttering, prioritizing, and managing our time and resources. Failing to do so can be overwhelming for anyone, depressed, anxious, angry, attentionally-challenged, or not. There are many good resources available for improving attention and concentration, and you may wish to peruse books or programs recommended by the American Psychological Association (www.apa.org). One book that I have used successfully with patients is "Mastering Your Adult ADHD" by Safren et al. This volume describes a multi-prong approach for dealing with problems with attention and concentration that involves some basic education on the subject, practical strategies for planning and managing your time and tasks, and cognitive methods for dealing with the frustration and hopelessness that often accompanies such difficulties. I don't know anyone that wouldn't benefit from this material, whether they have ADHD or not.

3. Consider mindfulness. As a central component of the Third Wave in cognitive behavioral therapy, mindfulness (aka attention training, mind training, etc.) has been identified as an empirically supported intervention for a wide variety of clinical challenges. If you Google "mindfulness and concentration problems," you will learn about how this technique might be useful to you.

4. Consider a medication change. Although I would not suggest this as a first step (since you seem to be otherwise fairly content with the benefit you are receiving from the Lenox), you may wish to speak with your psychiatrist (and if your meds were not prescribed by a psychiatrist, you may wish to consult one) about other options for treatment your depression, or augmentations to the Luvox that might help with the attention issues.

5. See a psychologist. Yes, I know it's odd that I saved this one for last, especially since I AM a psychologist, however it may be helpful for you to spend some time working with a qualified cognitive-behavioral therapist on this challenge.  If you were to work with me, I would help you to navigate all of the options listed above, and to implement these and other strategies. You don't have to go it alone, and medication on its own is rarely the treatment of choice for ANY psychological difficulty.  Just let me know if you need me to steer you in the direction of qualified providers in your area.

I hope that my response to your question has been of some use to you.  I wish you the best of luck with this challenge, and please feel free to keep me posted on your progress, or to direct any additional follow-up questions or responses to me.

Sincerely,

Richard E. Schultz, Ph.D.

Clinical Psychologist

www.drschultz.org

www.mindset.mobi

@mindsetdoc

Question: My girl friend has anxiety disorders, depression and agoraphobia (all formally diagnosed and currently under medical/prescriptive care). She also suffers from some mild OCD habits, though I've seen people with worse symptoms, myself included. The more we get to know each other, the more she shares with me. She doesn't let many people get close, as she has trust issues. Recently, she shared her obsession with death, as in her obsession with wanting to die to end her physical and emotional pain. She apparently journals her thoughts about death and dying frequently. At one point in her life she was a "cutter" but she hasn't done that in a very long time. We've spoken about that specifically and she has assured me that that obsession is in the past and is not a part of her thoughts anymore. I wouldn't have known except that she and her grandmother told me- her scars are not evident because it was so long ago. She couldn't relax the other night as she was totally focused on a death poem she was writing, and paused the DVD we were watching as she finally had the inspiration to finish the poem. Then she insisted on reading it to me aloud, pausing for effect at certain points, like it was a dramatic stage performance. I didn't say a word, and then she put her journal away and we went back to watching our movie. We never spoke about the poem at all since then. I'm not sure what I'm supposed to do- embrace her thoughts, ignore them, or confront/challenge them. She is going to counseling for help with her many emotional issues, and I want to help. This issue concerns me though, and I'm not sure what I should do. Thanks-

Dr. Richard Schultz Says...:

Hello, and thank you very much for writing, and for addressing your question to me.

It is clear that to be human is to struggle and to experience pain.  To be human is also to have connection with others.  So, it is understandable that, as we go through life, many of those with whom we will become connected will also be struggling or in pain.

I very much appreciate your interest in knowing how best to react or respond to your girlfriend's feelings, thoughts and behavior.  Indeed, many of her symptoms do sound quite painful and distressing for her, and they may also at times be quite upsetting to hear about, or to watch her experience.  There may be times when you can understand her quite well, and can be of significant comfort to her, and other times when what she is experiencing will be far more ambiguous or harder for you to grasp or address.  This may be frustrating for you. 

It is clear that you are a caring and sensitive person, with very positive intentions.  Please know that, despite all of the caring, affection and support you wish to offer your girlfriend, the biggest part of her recovery resides with her, and will be driven by her own motivation to adhere to, and engage with treatment, and to work each day to heal from her wounds, and manage her way through life.  Despite this fact, I am sure there are times when what your girlfriend says or does puzzles or frustrates you (such as in the "death poem" scenario you provided, for example), and you may feel motivated to nudge or push her toward thinking or feeling or behaving differently.  This would obviously be a very common experience for one to have in the presence of someone they care about who is in pain.  What I can say to you is that it will be best at such times to maintain a position of "engaged disengagement" or "interested disinterest."  Kind of an in-between place that keeps you warm, but doesn't burn you.  It will be good for you, for her, and for the relationship. 

So, the bottom line is that there really is no answer to the question of what you "should" do, I am sorry to say, because there is NO universally correct standard of how one "should" respond to someone who obsesses about death, is anxious, and writes death poems.  But here are a few more tips:

1)  To be the best friend you can be to your girlfriend is to first and foremost be grounded in yourself.  Give what you wish to give because you already have enough love for yourself to allow the overflow.  Be mindful of when you might be pushing yourself past your limits of generosity or effort, in an effort to sooth or "fix" her, as you may end up resenting her for it, and she may feel the same way back.

2)  When you find yourself at a loss of what "to do" (embrace/ignore/confront/challenge) in response to her, you can simply state the truth; that you are wanting to respond in a helpful way, but are not sure what she is needing at the moment, and perhaps she can give you some guidance.  Try not to assume you know what she wants, and ask her instead.

3)  Please make sure that your own pain and struggle in life is also getting air time in the relationship.  It sounds like it could be easy for her dramatic feelings and behavior to take center stage and leave little room for you.  Don't let this happen, as it will potentially also lead to the consequences described in #1 above.

4)  Finally, observe over time whether the person you are seeing yourself be in the relationship is one you like being.  See if what you need to do to adapt to her struggles causes you to make adjustments or sacrifices that you don't like seeing yourself make.  If this begins to occur, pay attention and make an alteration in your stance.

I hope you have found some of what I have written to be useful.  I understand that these are somewhat broad recommendations, although I believe you will be well served by attending to them.  Of course, if you have any further questions, reactions to what I have written, or would like to update me on the relationship, please feel free to write back.

Sincerely,

Richard E. Schultz, Ph.D.

Question: (1.) I am very scared to tell my parents what i am going through . I don't know whether they would believe me or not . They would probably think that it is an excuse to run away from studies and to hide my weaknesses . They have very high expectations from me. (2.) Also my mood changes from time to time. sometimes i feel sad and sometimes i don't and sometimes i feel casual and carefree. example like past 2 weeks my exams were going on and i felt very casual and carefree. I did not studied a word to prepare because i was not able to concentrate on the books. I know my sadness will come again when I will get to know my marks and there are hardly any chances of getting passed in any subject. (3.) I have lost interest in school and coaching. I just wan't to get locked in my room and do nothing. AM I NORMAL? ARE THESE PROBLEMS FACED BY EVERYONE IN THEIR LIVES OR AM I TOO MUCH EXAGGERATING ? Also suicidal thoughts don't come on a regular basis.

Dr. Richard Schultz Says...:

Hello again, my young friend. 

I am very encouraged to hear that you have continued to persevere through the struggles of your life, although I am of course also very sorry to hear that you are still in distress.  In respons to what you have written, I will share a few reactions. 

First, I very much understand how fearful you are of telling your parents about what you are experiencing.  I am also glad that you are acknowledging that you DON'T know how they will react.  This is precisely the reason to tell them; so that you can find out.  Experience is a far better teacher than imagination, and you have been living in fear of the unknown for quite some time.  I know it has only distressed you further to avoid confronting your struggles directly by seeking help.  Over time, I can only predict that your problems will build further, and you will feel even less able to face them.  This is the way anxiety and avoidance work.   

So, Pawan, I must tell you today that I CANNOT provide you with the psychological assistance you need at this time, as I am sure you well know.  I have attempted to guide you in the direction of resources and treatment services that seem badly needed, and you have elected not to utilize these suggestions.  As I said in an earlier reply to you, it is not what happens to us in life that determines our path, but how we RESPOND to what happens to us.  The most constructive response to your situation has been and still is to seek assistance from your parents, another trustworthy adult family member, a teacher, a counseling clinic, your family physician, or a member of clergy.  In the absence of your following up on one of these recommendations, your symptoms and situation, which began quite normally and understandibly, will become more pronounced and difficult to cope with.  So, again, I urge you to seek assistance today.

Pawan, as you know, Choose Help has been developed for informational purposes only, and is not intended to serve as a substitute for mental health counseling in any way.  You agreed to these terms when you signed the User Community Rules during registration.  Further, I cannot ethically or legally attempt to provide you with psychological treatment remotely through this forum.  What I can do, I have done, and the rest is now up to you.  Please begin planning to discuss your difficulties with your parents as soon as possible, or share them with someone else who can help.

I am sorry that I have reached the limits of my ability to assist you, Pawan.  I wish you much peace and courage as you face what you fear, and as you grow into a true spiritual warrior.  This does not typically happen until it MUST happen, and it sounds like your moment has arrived.  Good luck.

Yours,

Richard E. Schultz, Ph.D.

BTW, I removed the email address of your relative from your note to me, in the interest of maintaining your privacy and hers.  I trust you understand that it is you, Pawan, who will have to explain the situation to her, not me.  Do feel free, however, to share with her our correspondence and I am sure she will know how to assist you.

Question: Thank you very much for your reply . Due to this I have gained some hope of getting recovered. According to your question I possess attention difficulties.During any lecture in my school, I am not able to concentrate no matter how much I try. During that time some random thoughts come in my mind . My feelings of depression are worst during exam times. Those thoughts of suicide were at peak when my high school exams were round the corner. That time when I thought of suicide, every time the thought of my parents came in my mind so I did not took that step. But the most important thing is that during normal days these feelings of depression comes to my mind at not so much intensity (These are mild and I feel neither sad nor happy ). I also don't think of suicide during normal days (except sometimes). I also procrastinate during normal days thinking about my life and thinking whether I will be able to get out of this situation or not. This leads to a lot of waste of time and I am not able to study anything. Even when I get down to study these feelings don't let me to study. To avoid these feelings I just sit on internet most of my time. Are these normal feelings and normal circumstances faced by teenagers?

Dr. Richard Schultz Says...:

Hello again, my friend:

Thank you SO much for writing back to update me on your situation.  I am very glad to hear that my initial reply was helpful to you, and that you now have some greater hope of recovery.  I am also pleased to know that the frequency of your severe depressive thoughts and feelings have reduced somewhat.  This is great news.

Based on what you have said, however, it certainly sounds as if you are still struggling quite a bit, and the facts that you are still having such difficulty focusing on your work, and do continue to have thoughts of suicide when you think about your life are clear signs that TREATMENT IS STILL NEEDED.  I know that accessing mental health assistance in your country may be more difficult than it is here in the United States, but I have to believe that help IS available to you.

Think of it this way: If one of your parents, a sibling, or a best friend came to you in such pain, I know for sure that you would not hesitate to get them assistance.  Sometimes, however, we have difficulty in showing OURSELVES the compassion and kindness that we would gladly extend to others in need.  So, in this case, I REALLY need for you to be a loving, accepting and nurturing friend to yourself and follow my suggestion to seek mental health treatment. 

I am pushing you to get treatment for several reasons.  First of all, the symptoms you describe, although improved, continue to manifest at a severe level.  Second, many types of anxiety and depression can be very stubborn, and the more we resist addressing them, the more strongly they persist (I'm not sure if the symptoms themselves are so stubborn or if is WE who stubborn in accepting and getting help with them).  Finally, these symptoms are negatively impacting your ability to function and live your life constructively (not able to study, spending lots of time on the internet, and somewhat paralyzed by worry about your future).  The more you fall behind in your work, the more intense your worry and depression may become.  Therefore, with regard to getting help, the sooner the better!

Finally, in answer to your last question, although academic, familial and psychological pressures are commonly experienced by us all as we move into the world more independently, frequent thoughts about ending one's life and severely depressed mood are signs that something more serious than just "being a teenager" is going on.

So, in closing, I will make a direct request of you; that is for you to begin investigating the availablity of treatment as soon as you finish reading this reply.  Maybe just spend 15 minutes talking with a friend or family member about treatment, or investigating local mental health professionals and clinics on the internet (since you are already on the internet a good bit already).  After that 15 minutes, see if you feel more or less hopeful about the future.  I think that seeing yourself get some help will in itself begin to improve your mood and self-confidence.  We like seeing ourselves move forward and we don't like seeing ourselves remain stuck.

Again, I wish you courage and strength as you follow my request.  Please continue to update me on your progress as I very much want to help you get the asisstance you need and deserve.

Sincerely,

Richard E. Schultz, Ph.D.