“THE MIND CONNECTION”November 2014 Column: Treatment Plans Vary for Chemical Dependency
By John Hartsock
No two people who struggle with chemical-dependency issues descend into addiction with exactly the same personalities, substance-abuse histories, or type and severity of problems. Therefore, it stands to reason that the treatment plan for every individual battling chemical dependency will differ to some degree. The question of whether a client’s substance-abuse issue requires inpatient treatment is contingent upon a number of factors.
“A client’s ability to maintain safety in a lesser level of care (is considered),”said Erin Miller, who is an inpatient counselor at Pyramid Healthcare, a drug-and-alcohol treatment facility on Plank Road, Duncansvile. For clients who require 24-hour care/supervision and support to maintain sobriety, Miller said that “inpatient treatment provides structure, more intensive therapy, group/fellowship support, and safety measures not provided at the outpatient level of care.”
Miller said that the duration of inpatient treatment depends upon a number of issues. “Duration is dependent on client needs and can range from 14 to 90 days,” Miller said. “A client’s funding, mental health diagnoses/emotional stability, age of onset of use (of substances), living skills, number of attempts for sobriety/relapse history, motivation for treatment, and recovery environment are considered when determining length of stay for each individual client. “Miller said that clients seen most recently at Pyramid Healthcare have struggled with dependency on alcohol, heroin, or crack cocaine. “Substance of choice appears to come and go in waves,” she said. “Recently, most common substances noted have been heroin, crack, and alcohol.”
Each individual who arrives at Pyramid Healthcare follows a different treatment plan. “Treatment is more dependent on disease severity, length of use (of substances), consequences, and underlying factors of use while at the inpatient level,” Miller said.
In certain cases where a client has become severely physically dependent on alcohol or another drug, detoxification is necessary to purge the substance from the person’s system. “Detoxification is needed when the client is medically unstable and requires medical intervention to maintain sobriety and well-being as substances are cleared from his/her system,” said Jesse Hertzler, who is a detoxification specialist at Pyramid Healthcare. “Detox services at Pyramid include: medical monitoring/supervision; comfort medications to ease withdrawal symptoms and prevent dangerous medical consequences of [complications such as] seizures, elevated blood pressure, and dehydration; and group (therapy) sessions to address harm reduction, benefits of sobriety, and benefits of ongoing drug and alcohol treatment.”
Miller said that inpatient clients at Pyramid Healthcare participate in both individual and group counseling and therapy.
These types of counseling and therapy, along with the type of intervention that clients experience in 12-step recovery programs like Alcoholics Anonymous and Narcotics Anonymous, emphasize a need for the chemically-dependent individual to acknowledge his or her addiction to substances, and to surrender the sense of denial that is an impediment to recovery. “Clients often minimize disease severity and find it difficult to accept treatment recommendations and after-care,” Miller said. Ideally, inpatient settings foster the sense of need for treatment in clients, Miller said. “Introduction of structure and rules, and gaining acceptance of a need for treatment,” were the biggest hurdles that inpatient clients generally face, according to Miller.
A variety of factors come into play in determining if, and when, an individual is ready to leave the type of structured environment that an inpatient treatment facility provides. “Treatment progress, ability to identify/utilize healthy coping skills, diminishing cravings, ability to recognize and address triggers for use (of substances), development of (a) relapse prevention plan, identification of (a) healthy support system or where to create one, and (availability of) funding (for continued treatment),” are all factors in whether a client can, should, or will leave an inpatient facility, according to Miller.
Relapse is a constant and life-long concern for individuals battling chemical dependency, and a relapse- prevention plan for those leaving inpatient treatment is essential. Such an after-care plan often involves 12-step recovery programs such as Alcoholics Anonymous and/or Narcotics Anonymous, as well as placement in halfway houses, Miller said. “After-care is dependent on an individual’s needs and funding,” Miller said. “Most common recommendations are for halfway-house placement for those in need of ongoing intensive treatment or structure, or (the) Intensive Outpatient Program (IOP) for those who do not require that level of support/supervision. “All clients are recommended to participate in 12-step programming, and (to) identify a home group or sponsor,” Miller said.
Ahead for the December 2014 column: A look at the societal scope of the substance-abuse problem.
“THE MIND CONNECTION”October 2014 Column: Substance abuse requires thorough treatment
By John Hartsock
Substance abuse -- an addiction to alcohol, drugs, or both -- is a chronic, progressive and potentially fatal disease that requires treatment which encompasses the body, mind and spirit. Addiction to alcohol and/or drugs is considered a disease because, while initial use of substances often begins with experimentation, real physical and psychological dependency can ensue in which brain chemistry changes and a true craving for the substances actually occurs.
The Home Nursing Agency’s main Blair County office at 500 East Chestnut Avenue in Altoona provides assessment and counseling services for people affected by substance abuse, or chemical dependency. The Home Nursing Agency does not provide inpatient treatment for drug and alcohol abuse, but does make referrals to other Blair County agencies such as Pyramid Health Care and Cove Forge that do provide inpatient care.
Kristen Barr, adult clinical service manager at Home Nursing Agency, said that the process of assessment gets the ball rolling for treatment. “Assessment is open-access here,” Barr said. “[Clients] can just come in, sit down with one of our assessment counselors, and there’s a gamut of questions to be answered [that includes inquiries] like when the individual started using [substances], how often, and if the individual has been the victim of any trauma in the past.
The Home Nursing Agency provides counseling treatment for individuals struggling with alcohol abuse, drug abuse, and co-occurring addictions. “The two biggest things that we’re seeing are heroin and alcohol, and a lot of our clients are court-ordered to be here,” Barr said. “We’re also seeing abuse of benzodiazepines (medications used to treat anxiety), and Suboxone, a drug which is used to treat addiction to opioids like Percocet and Oxycodone.” The Home Nursing Agency has also seen an increase in clients with driving under the influence (DUI) charges for having been impaired by substances other than alcohol. “We’re seeing a ton of DUIs from prescription drugs or things other than alcohol,” said Barr, noting that the agency provides group treatment for DUI clients on Monday nights.
Drug and alcohol treatment provided by the Home Nursing Agency involves individual, group and family counseling sessions.
Depending on circumstances like the severity and/or duration of a drug and alcohol problem, clients are placed into two different treatment groups. One group is called an intensive outpatient (IOP) group, which provides a higher level of care than the other group, which is known as a basic outpatient group. Both groups are held two days a week, with flexible daylight and evening hours to accommodate work and family obligations.
“In addition to counseling, we provide education regarding addiction, recovery issues, and relapse prevention,” Barr said.
Drug and alcohol addiction is a life-long battle, and relapses are a constant concern. “Relapse is part of addiction,” Barr said. “Somebody can relapse in 30 days, 60 days, one year, or one day after undergoing treatment.” Relapse can be prompted by physical triggers, psychological triggers, both, or neither. Like other psychiatric problems, drug and alcohol abuse is a complex issue.
Physical triggers can involve a constellation of problems that make up a list of issues that are known as post-acute withdrawal symptoms. “Post-acute withdrawal symptoms can last up to two years, and increase cravings, [involve] mood swings, sleep disturbances, and anxiety,” Barr said. “In post-acute withdrawal symptoms, a person’s brain chemistry has changed.” Stress, anxiety, and an over-reaction to things can all lead to relapse, Barr said. “Any time an addict is facing stress, it could lead to relapse. Or relapse could also occur because of nothing at all. That’s the scary part of the disease.” And associating with people or frequenting places that were part of the addict’s past can also trigger relapse.
A big part of the treatment protocol for the addict includes severing those toxic ties. “Working the recovery plan is essential in preventing relapse,” Barr said. “Addicts need to avoid associating with people with whom they used to use (substances), and doing things which (prompted) them to use.” Identifying warning signs like depression, anxiety, and sleep disturbances, and maintaining a healthy social support system, is also of paramount importance, according to Barr.
Among those vital support systems are 12-step groups such as Alcoholics Anonymous, Narcotics Anonymous, and Dual Recovery Anonymous -- a group which helps people who are recovering from both chemical dependency and mental-health issues.
Many of these groups often meet in churches, which underscores the spiritual aspect of recovery. “There are 12-step group meetings all around Blair County -- Altoona, Hollidaysburg, and Tyrone -- you name it,” Barr said, pointing out that meeting times for the various groups can be obtained on-line or by contacting the Home Nursing Agency.
Detoxification treatment to combat certain physical symptoms of substance abuse is not available at the Home Nursing Agency. This type of treatment can be obtained at many inpatient facilities. Regarding treatment for substance abuse or chemical dependency, there is no “one size fits all” format, Barr said. “Each person is different,” Barr said when discussing duration and type of treatment. “Each person’s needs are different.”
Ahead for the November 2014 column: A further look at treatment for substance abuse
“THE MIND CONNECTION”September 2014 Column: Substance abuse complicates mental-health problems
By John Hartsock
The world of Hollywood is replete with tales of glamour, glitz, and ... tragedy. This year alone, two Oscar award-winning actors, Philip Seymour Hoffman and Robin Williams, became the latest in a long list of celebrated screen legends to die from the effects of substance abuse, mental illness, or a combination of both. Seymour’s death last February from a heroin overdose and Williams passing in August as a result of an apparent suicide prove than no amount of fortune, fame, or talent can immunize a person from the devastating effects of drug addiction and/or severe mental illness.
Addiction to illicit drugs and/or alcohol is a devastating, progressive medical disease in and of itself all over the world. But when people suffer from both substance-abuse and mental-health issues -- as was the case with Williams -- their very lives, as well as their well-being, are placed at much higher risk. People with mental-health disorders like depression may use alcohol and/or illicit drugs to self-medicate, but their use of substances usually worsens the underlying psychiatric problem.
Alcohol is actually a central nervous system depressant. While one or two drinks may initially temper or lighten a dark mood, excessive use of alcohol almost always deepens depressive symptoms, while leaving individuals vulnerable to a wide variety of physical maladies including cirrhosis of the liver. Drinking to intoxication may exacerbate behavioral or psychiatric issues, leaving individuals with lowered inhibitions that may result in criminal charges for actions such as driving under the influence, or reckless behavior that may result in damage to property, or injury to self or others.
The use of narcotics in a person with psychiatric illness can, in some cases, cause psychotic symptoms. People begin using alcohol or illicit drugs like marijuana, cocaine and heroin for a variety of reasons -- out of curiosity, or to escape feelings of boredom, depression or anxiety. Some people begin using substances recreationally, and can discontinue their use, or continue to use them in moderation. Other people, because of a genetic or personality disposition, become addicts, and their lives begin spiraling down into a very dark place.
“Nobody sets out to become an addict in life,” said Scott Moyer, program director for Discovery House, a facility based in Duncansville that offers outpatient treatment for individuals dealing with addiction to opiates such as heroin and oxycodone. “Some people start with recreational use, and many people never get addicted and they are able to go on with their lives. But some people, usually over a period of time, develop a habit that is not that easy to quit.”
Substance abuse is a progressive disease that can wreak havoc on an individual’s physical and mental health, finances, and family and social relationships. “It is really disruptive of a person’s life,” Moyer said about the descent into addiction. “There are a lot of losses suffered by addicts. Addiction can affect job performance and ruin family relationships. People need money to support their habits, and they may become thieves and end up in prison.” Moyer said.
Addiction becomes an illness that manifests itself in both physical and psychological symptoms. “Addiction affects the liver and internal organs,” Moyer said. “People come in here looking like physical wrecks. They don’t eat, they don’t sleep right.”
People develop a physical dependency on opiates that involves intense withdrawal symptoms. “People get chills, aches and pains -- the really strong physical symptoms of addiction,” Moyer said. Addiction also changes the chemistry of an addict’s brain, resulting in psychological and behavioral changes. “We see a lot of anxiety and depression [with people addicted to opiates],” Moyer said. “Anxiety and depression can lead to addiction, or it can be the other way around -- the drugs can cause symptoms of depression and anxiety because the drugs change the chemistry of the brain.”
Addiction to legally-prescribed painkillers like oxycodone has become as pervasive and serious a problem in society as addiction to illegal narcotics like heroin.“One is legal and the other is illegal,” Moyer said. “Everyone has a different path to addiction. Some people who have been in an accident and/or have had surgery have a lot of pain. Doctors prescribe painkillers in an effort to help people, but some people get addicted to the painkillers.” Addiction to painkillers can be a gradual, insidious process. “People go back to the doctor after 30 days, because they’re still having pain.” Moyer said. “Then they come back after another 30 days (for more of the pain medicine).”The painkiller may initially do the job of controlling the pain, but when used in higher doses, it can lead to addiction.
People who initially find the financial cost of addiction to legally-prescribed pain-killing opiate pills like oxycodone to be prohibitive may eventually turn to a substance like heroin, which is much cheaper to obtain on the street. “Some start with heroin, and some start with pain pills and later may turn to heroin,” Moyer said. According to information obtained from the Intercept Interventions website, in 1966, the American Medical Association classified alcohol abuse as a disease and in 1974, the American Medical Association classified drug abuse as a disease.
Addiction should be looked at as a medical issue rather than a moral issue. “For those who do become addicted, using opiates is no longer a choice,” Moyer said. Approximately 14 million Americans meet the diagnostic criteria for alcohol abuse or alcoholism, according to the Intercept Interventions website. According to the Centers for Disease Control and Prevention, 9.2 percent of Americans age 12 and over had used an illicit drug in the previous month during the year 2012.
According to the website drugfreeworld.org, while heroin and cocaine use still present significant health problems in the United States, more than 15 million people abuse prescription drugs -- which is more than the combined number who reported abusing cocaine, heroin, and inhalants. According to drugfreeworld.org, prescription-drug abuse causes the largest percentage of death from drug overdoses -- in 2005, opioid painkillers accounted for over 38 percent of the 22,400 drug-overdose deaths in the United States.
And it is facts like these that make the work done at treatment centers like Discovery House so very important.
“We’re striving to protect our citizens, to save lives, and to help those who are addicted to opiates,” Moyer said.
Ahead for the October 2014 column: A look at treatment methods to combat drug and alcohol abuse
“THE MIND CONNECTION”August 2014 Column: Prognosis is promising for phobias and anxiety disorders
By John Hartsock
Phobias and generalized anxiety disorder [GAD] are two of the most common types of mental disorders. Fortunately, they are also among the most treatable. “These are common problems,” said Dr. Joseph Antonowicz, medical director of behavioral services at the UPMC Altoona Regional Health System. “I don’t usually see simple [specific] phobias, but I see a lot of social phobia and generalized anxiety disorder. GAD is often seen with major depression. “The prognosis for generalized anxiety disorder is very good, and people get substantial relief with proper care,” Antonowicz said. “The prognosis for phobias is also very good in most cases.”
Treatment -- which consists of a combination of cognitive-behavioral therapy and, in some instances, medication -- is generally very effective. “The prognosis for the treatment of phobias and anxiety is excellent because of the psychotropic products [medications] that are available, which should be used in conjunction with behavioral techniques such as systematic desensitization,” said Denis Navarro, outpatient supervisor and clinical specialist at UPMC Altoona Regional Health System.
Systematic desensitization is a cognitive therapy tool in which a patient gradually exposes himself or herself to a variety of phobias or anxiety-producing situations ranging from those which create the least amount of distress to those which create the highest amount of distress.
Relaxation techniques are implemented in conjunction with the exposure to anxiety-producing situations. “Systematic desensitization is an excellent method of treatment for phobias,” Navarro said. “This involves establishing a list of images related to the phobia, which range in intensity from a one to ten, and then, through training and relaxation techniques, allowing the person to reduce their anxiety response in relation to the phobia as the list is addressed.” “Generally, there can be a transfer from the therapist’s office into the community through the use of this method,” Navarro said. “In addition, as noted earlier, psychotropic interventions are available.” Antidepressant medications that include selective serotonin reuptake inhibitors [SSRIs] such as Paroxetine [Paxil] and tricyclic antidepressants such as Imipramine [Anafranil] are among the most commonly-used and effective medications for the treatment of phobias, generalized anxiety disorder, and panic disorder.
“The mainstay of treatment is psychotherapy, especially cognitive or behavioral therapy, along with medications such as SSRIs or tricyclic antidepressants such as Imipramine,” Antonowicz said. Other types of medicine are sometimes used in more severe situations. “Just about every study you look at shows the best outcome to be with psychotherapy plus medication, unless the symptoms are mild,” Antonowicz said. “Psychotherapy does fine then. “Antidepressants known as MAO [monoamine oxidase] inhibitors such as Tranylcypromine [Nardil] and Phenelzine Sulfate [Parnate] have also been shown to be effective in treating phobias and anxiety disorders, but certain precautions must be taken when these medicines are used. “In some studies, the best medication seems to be MAO inhibitors, which are a type of antidepressant that requires a diet that restricts foods which are rich in an amino acid known as tyramine,” Antonowicz said. “Tyramine interacts in bad ways with these medications, but these medications can also be used safely if one is careful.”
Antonowicz said that anti-anxiety medications known as benzodiazepines are not good choices for treating phobias and generalized anxiety disorder. Benzodiazepines -- which include Alprazolam [Xanax] -- can become habit-forming, and tolerance to these medications develops quickly, which means that increasingly higher doses of the medications must be used to achieve desired results. “We try to avoid the use of anxiety medications like Xanax and other benzodiazepines because tolerance develops quickly and there are better choices” Antonowicz said. “We often use them for [only] limited periods of time to relieve acute symptoms.”
Though the prognosis for the treatment of phobias and generalized anxiety disorder is very positive, some individuals require a longer period of time than others to achieve success in treatment. “Some people with phobias are doing great after two months of treatment,” Antonowicz said. “Others may take a few years. I have one patient who seemed to make little progress at first, but is doing much better after two years.”
Ahead for the September 2014 column: A look at drug and alcohol abuse as a mental health concern.
“THE MIND CONNECTION”July 2014 Column: Phobias are a Common Mental Disorder
By John Hartsock
While obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) comprise a considerable percentage of the spectrum of anxiety-related mental-health problems that plague mankind, they are not the only types of such difficulties. Phobias are the most common mental disorder in the United States, affecting 11.5 million adults, or eight percent of the adult population, according to the National Institute of Mental Health [NIMH].Generalized anxiety disorder [GAD] is also very common, and panic disorder is another anxiety-fueled malady.
A phobia is an intense but unrealistic fear of a particular situation or object that can interfere with the ability to socialize, work, or capably function in everyday life. Specific types of common phobias may include fear of heights (acrophobia), fear of flying (aerophobia), fear of confined spaces (claustrophobia), and fear of snakes (ophidiophobia).There are dozens of clinically-recognized phobias, ranging from the common to the very unusual and bizarre. Among the stranger, more unusual phobias are venustraphobia (fear of beautiful women), gamophobia (fear of marriage), and catoptrophobia (fear of mirrors).
Along with phobias surrounding specific situations or objects, two other very common types of phobias include social phobia and agoraphobia .People with social phobia have strong fears and experience intense anxiety about being watched or judged by others and/or being embarrassed in public. The effects of social phobia can range from mild to incapacitating. People with severe social phobia may wind up avoiding a variety of social situations that may trigger the anxiety. Work and relationships are often adversely affected.
Agoraphobia -- fear of open spaces -- is the intense fear of feeling trapped and having a panic attack in a public place. In agoraphobia, one episode of spontaneous panic causes paralyzing fears about when the next episode may occur. In severe cases of agoraphobia, people may become totally house-bound.
Needless to say, some phobias are much more constricting than others. A person with an intense fear of snakes can live comfortably by simply avoiding areas and locations where snakes are likely to inhabit. But a person with agoraphobia cannot usually live comfortably by staying in his or her house for 24 hours a day, seven days a week.
Denis Navarro, outpatient supervisor and clinical specialist at UPMC Altoona Health System, said that he doesn’t encounter many people with specific phobias in his practice. “Specific phobias have been less common in my practice, with the exception of social phobia, which tends to go along with generalized anxiety disorder as well as panic disorder.” Navarro said. “Social anxiety is more common than one would expect. There are varying degrees of it, some of which can be very mild, to the point at the other end, where it is incapacitating, such as with attendant agoraphobia.”
The cause, or etiology, of phobias, generalized anxiety disorder, and panic disorder is rooted -- like all other mental disorders -- in a combination of genetic and environmental factors. “The current thinking regarding anxiety disorders is that their etiology is based primarily on a biochemical factor which is triggered by environmental occurrences,” Navarro said. “One of the more common problems is anticipatory anxiety. An anxiety that is common among many people is that of public speaking, which in most instances would not be considered a psychiatric disorder.”
Generalized anxiety disorder is diagnosed when a person worries excessively about a variety of everyday problems for at least six months. People with generalized anxiety disorder worry incessantly and excessively, and their level of anxiety about a given situation is often far out of proportion to what the situation warrants. People with generalized anxiety disorder may also experience a type of distress known as “free-floating anxiety,” in which the specific cause or causes of the anxiety cannot be readily identified. People with generalized anxiety disorder may worry about their jobs, financial states, and/or marriages even when all those areas of their lives are on solid ground.
Panic disorder is a potentially disabling disorder that is characterized by recurrent severe panic attacks. Panic disorder is not the same as agoraphobia, although the two disorders may co-exist. Panic and anxiety differ. Anxiety tends to build up over a much longer period of time, while the onset of panic is usually much more sudden, spontaneous, and intense. Panic may be brought on by specific stimuli -- a mouse, for example -- or occur in episodic intervals that are unprovoked by any specific, identifiable cause.
Common symptoms of a panic attack may include -- but are not limited to -- rapid heartbeat, hyper-ventilation, perspiration, and intense fears such as fears of dying and/or fears of going crazy. Depending upon their severity and whether several different problems and symptoms co-exist, phobias, generalized anxiety disorder, and panic disorder are very amenable to treatment. Without treatment, these problems will almost certainly worsen. “The prognosis for the treatment of phobias and anxiety is excellent because of the psychotropic products [medications] that are available, which should be used in conjunction with behavioral techniques such as systematic desensitization.” Navarro said.
Ahead for the August 2014 column: A look at treatment regimens for phobias, panic disorder, and generalized anxiety disorder
“THE MIND CONNECTION”June 2014 Column: Cognitive Therapy Essential in Treatment of PTSD
By John Hartsock
Cognitive therapy is a central component in the treatment of some forms of clinical depression, a disorder which often engenders false and/or inappropriate feelings of guilt about events in which depressed individuals have limited responsibility and/or control. Some depressed individuals may blame themselves for situations in which they have had limited or no culpability, and these people may ruminate endlessly about things that they could have done differently.
Cognitive therapy with a professional social worker or psychologist, in conjunction with, in some cases, appropriate medication prescribed by a psychiatrist, can help depressed individuals challenge and overcome negative, inaccurate thoughts and recover from depression. Cognitive therapy and medication can also help individuals who are suffering from post-traumatic stress disorder [PTSD]. Les Weiss, social work coordinator for the post-traumatic stress disorder clinical team at Altoona’s James Van Zandt Medical Center for military veterans, utilizes a treatment modality known as cognitive processing therapy [CPT] to help individuals with post-traumatic stress disorder.
CPT involves 12 weekly therapy sessions of 50 minutes in duration for individuals, and 90 minutes for groups.
The focus of CPT rests on identifying how a traumatic experience or experiences have changed an individual’s thoughts and beliefs, and how thoughts influence current feelings and behaviors. Topics that are typically covered in CPT, according to a brochure released by the Department of Veterans Affairs, include an examination of the meaning of the traumatic event(s), identification of thoughts and feelings about the event(s), trust issues, safety issues of power and control, esteem issues, and intimacy issues.
According to the brochure, the goals of CPT include improving the individual’s understanding of PTSD, reducing the distress surrounding memories of the trauma, decreasing emotional numbing and avoidance, decreasing depression, anxiety, guilt or shame, and improving day-to-day living. Cognitive processing therapy has been effective for combat veterans, but it has also been shown to be effective for sexual traumas, childhood traumas, and military sexual traumas. Weiss said. “There are a growing number of men and women nationally who have suffered military sexual traumas, which we call MSTs.”
Talking about and even writing about the traumatic experience or experiences helps individuals to realize what their feelings are about the experiences. Facing the discomfort and pain of those experiences by verbalizing that discomfort helps to facilitate healing. “Talking about the traumatic experience also forces [people] to fight against their own avoidance, because they’re actually talking about what happened,” Weiss said. Individuals with PTSD, just like individuals with clinical depression, can often get mired in certain erroneous modes of thinking. Weiss regards these modes of thinking as “stuck points” from which people with PTSD must disentangle themselves.
“Stuck points are simply those thoughts and beliefs that keep people from recovering from their PTSD,” Weiss said. Among combat veterans with PTSD, guilt and anxiety may be common problems. “Some of them may think that if they had done their jobs better, then others might not have died,” Weiss said. Combat casualties may also bring forth an overwhelming feeling of abandonment. “People may think that if they allow themselves to get too close to another person, they’ll lose that person and be hurt,” Weiss said. “Or people may believe that because of the traumatic events that they’ve experienced, they will never be the same again -- they will never be healthy again.” Most of those beliefs are not based in fact, and must be aggressively challenged to be overcome.
Homework assignments and worksheets to be completed away from the therapy sessions are given to PTSD patients.
“The goal is for them to challenge these unhealthy thoughts and beliefs,” Weiss said. Another type of therapy that is implemented in the treatment of PTSD is known as prolonged exposure therapy, in which people actually tape-record thoughts and memories about their traumatic experiences and desensitize themselves to the trauma by listening to the recordings for a period of time.
Support groups can also be very beneficial for people with PTSD. At the Van Zandt facility, veterans with PTSD have the option of joining an anger-management group, an art enrichment group, and cognitive-behavioral groups for depression and insomnia. There is also a group for individuals with PTSD and substance-abuse issues that is known as the “Seeking Safety Group.” Also offered is a compensated work therapy program in which individuals with PTSD learn job skills and interpersonal skills that will help them to succeed in the workplace. This is particularly important, because individuals with PTSD often have difficulty with both securing and maintaining employment.
“They’ve walked off jobs because they can’t get along with their co-workers and supervisors,” Weiss said. “The idea is to put them into a position where they can be successful.” Stigma and discrimination toward individuals with mental illness in general, and PTSD in particular, create additional difficulties in the workplace.” It’s important to point out that violence is rare among individuals with PTSD, but we still have a lot of veterans who are unemployed,” said Andrea Young, the Van Zandt Medical Center Public Affairs Officer. “[Employers] just don’t understand PTSD and traumatic brain injury, so they’re afraid to hire these veterans.” The post-traumatic stress clinical team that Weiss, a licensed social worker, coordinates at Van Zandt, also includes a psychiatrist, a couple other social workers, a psychologist and military sexual trauma coordinator, a peer specialist who helps to run PTSD support groups, and a certified nurse practitioner.
Medications are also used as part of the treatment program.
“Many of our veterans with PTSD do receive medications,” said Weiss, who pointed out that selective serotonin uptake inhibitors -- also known as SSRIs -- are the best course of medication treatment. “Two SSRIs that are currently approved for the treatment of PTSD are Sertraline [Zoloft] and Paroxetene [Paxil],” Weiss said. “Paxil is a little better for social anxiety, and is probably the medication used most here.” Benzodiazepines like Valium, Xanax, and Ativan are not used to treat PTSD patients at Van Zandt. Weiss pointed out that these medications can have addictive qualities, and that the numbing effect that they create makes it more difficult for patients using them to access their emotions in therapy.
The outlook for the successful treatment of PTSD is becoming an increasingly promising one, especially for younger veterans with the disorder, Weiss maintains. “In my own experience, [treatment] is more effective for the younger population,” Weiss said. “The traumas are fresher, and if services can be provided early, before [symptoms] are allowed to become more chronic, I think people will have a better chance of recovering.” But older veterans with PTSD still have hope as well, Weiss said.
“With the Vietnam [veterans] population, symptoms have become more or less ingrained into their personalities,” Weiss said. “That doesn’t make those symptoms impossible to treat, but it becomes that much more difficult.”
Ahead for the July 2014 column: A look at phobias and generalized anxiety disorder.
“THE MIND CONNECTION”May 2014 Column: Personality, Trauma are Factors in PTSD
By John Hartsock
Combat service exacts an enormous toll on thousands and thousands of military veterans. Soldiers who survive a war often lose arms, legs, and other essential body parts while fighting for their country. Many return home physically scarred, but that doesn’t account for the full extent of combat casualties. The mental and psychological wounds suffered by combat veterans can be just as debilitating, if not more so, than their physical wounds.
Depression, anxiety, and a psychiatric condition known as post-traumatic stress disorder [PTSD] may haunt military veterans years after their combat service has ended. PTSD -- which had formerly been known as shell shock or battle fatigue syndrome -- is a serious condition that can develop after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm has occurred or was threatened.
Combat veterans aren’t the only people at risk for developing PTSD. Individuals who are victims of physical or sexual assaults, serious accidents, or natural disasters can also develop the condition, as can family members of victims, as well as emergency personnel and rescue workers who witness horrific incidents. According to Les Weiss, who is the social work coordinator for the post-traumatic stress disorder clinical team at the James E. Van Zandt Medical Center for military veterans in Altoona, there are three different types of behavior commonly manifested by combat veterans and other individuals suffering from PTSD.
One behavior involves re-living or re-experiencing the traumatic event or events. “People will have nightmares, flashbacks, intrusive thoughts, and memories about the event that are often triggered by current world or national events,” Weiss said.
A second behavior experienced by PTSD sufferers is a sense of hyper-alertness or hyper-vigilance. “Being on guard, being on edge,” was how Weiss described this behavior. “You see that with our veteran’s population, and it’s more profound with the younger guys [coming back from combat.]” Insomnia, irritability, and an out-of-control sense of suspicion often accompany such hyper-vigilance. “They have trouble sleeping, there are more irritability and anger issues,” Weiss said. “They feel like that if they go out in public, they’re scanning for anybody who looks dangerous. They’re even planning an escape route if they do go to a restaurant -- they have to plan and figure out how they’re going to get out if they need to, and they always have their backs to the wall.”
Avoidant behavior is a third symptom that is manifested by people with PTSD. “They’re not real keen on coming in and talking about things,” Weiss said of many of the military veterans affected by PTSD. “And they feel like they don’t want to be re-experiencing these things through telling [their] stories.” Avoidance on the part of individuals with PTSD can also manifest itself in the form of alcohol and drug abuse. We have a lot of veterans with what are known as co-morbid conditions like drug and alcohol or substance abuse problems,” Weiss said. “That’s really a form of avoidance. That’s a self-medicating type of activity that basically helps people to numb their emotions so that they don’t have to deal with what they’re dealing with.”
Some veterans practice avoidance by “spacing out,” Weiss said.
“Their minds kind of get overwhelmed, and their minds shut down,” Weiss said. “They may drive somewhere, and not remember how they got there, or they miss a number of exit signs and end up in another state.” Genetics and individual personality characteristics also play a significant role in the development of PTSD, as well as in the severity of the disorder that one experiences. “Absolutely”, Weiss replied when asked if genetics play a role in the development of PTSD. “A lot about neuropsychology is coming out [indicating that] certain genetic markers may be a factor.” This research, in turn, may eventually determine who is, and who is not, deemed eligible for combat service in future years. “I read somewhere that a simple blood test may someday be used to identify who should and who should not be in combat,” Weiss said.
Denis Navarro, outpatient supervisor/clinical specialist with the UPMC Regional Health System in Altoona, also said that individual personality characteristics weigh heavily in the development and severity of PTSD and other mental disorders. “If you have 10 people in a war zone, two may get PTSD, another may get depression, and the other seven may be OK,” Navarro said. “Or some kids may go through abuse and turn out great, while other kids who are abused turn out with severe mental-health issues. This might be due to genetic factors, or to the stress of being abused.”
There is a particular phenomenon known as “survivor’s guilt” endured by victims of tragedies that occur during war, severe accidents, and natural disasters. “Survivor’s guilt happens to some veterans who served with others who didn’t make it back home,” Weiss said. “In some cases, these veterans feel that they could have impacted the situation in some way, and it would have turned out differently. Many times, this thinking is not accurate, but that is their thought process -- that they should have done more,” Weiss said.
PTSD affects about 7.7 million adults, and children can be affected as well. Women are more likely to develop PTSD when exposed to a trauma than men are, and there is evidence of increased susceptibility to PTSD among members of some families. Although there have been isolated reports of veterans with PTSD acting out and becoming violent, the fact is that the vast majority of people with PTSD and other mental illnesses never become violent. According to a statement released by the Veterans Administration, “The majority of individuals diagnosed with PTSD have no history of aggression, violence, or criminal behavior, although irritability and anger are symptoms. Among individuals who do [act out], minor aggression is more common than severe violence, and episodes of extreme violence are rare.”
But the rare cases of violence involving veterans and others with PTSD often generate a negative public perception about the disorder. “You have one or two cases where something catastrophic happens, and the negative publicity overshadows everything positive [involving advances in the treatment of PTSD],” Weiss said.
Ahead for the June 2014 column: A look at different treatment regimens for Post Traumatic Stress Disorder (PTSD)
“THE MIND CONNECTION”April 2014 Column: The OCD Newsletter Provides a Valuable Resource
By John Hartsock
Over the past 30 years, there has been an increased awareness in this country about obsessive-compulsive disorder, and advances in medical treatment that have made the affliction much more manageable for its sufferers. Along with the medical advances have come a surplus of resources, publications, treatment centers and facilities, as well as organizations which provide valuable information and support to thousands of people with OCD and their families. The International OCD Foundation [IOCDF], with office headquarters in Boston, serves nearly 5,000 members in 26 countries, primarily in the United States and Canada.
Since 1987, the Foundation has produced the OCD Newsletter, a quarterly publication which serves 4,490 individuals and their families, and provides news, information, articles written by leaders in the field of OCD treatment and research, and other valuable sources of support. “In each issue, we publish two feature articles about OCD treatment, in our Therapy Community and Research News sections. “said Carly Bourne, who serves as the director of communications for the International OCD Foundation. These articles are written by leaders in the field of OCD treatment and research, and are often based on the latest research.
“We commonly ask authors of scientific journal articles about OCD to re-write these articles in a meaningful way for our audience, which is a mix of mental health professionals and consumers [individuals with OCD and/or related disorders and their family members],” Bourne added. “Our goal is to make information about OCD treatment and research as accessible as possible.”
The OCD Newsletter customarily ranges from between 24 to 28 pages in length, and can be obtained by purchasing a membership with the International Obsessive Compulsive Disorder Foundation [IOCDF].There is a section in the OCD Newsletter entitled "Affiliate Updates", which lists news and developments from OCD affiliates from around the nation, including the Obsessive Compulsive Foundation of Western Pennsylvania [OCFWPA], whose website is www.ocfwpa.org.
The OCFWPA publishes a quarterly newsletter entitled “OCDirections”, which includes articles, news and information about OCD and its treatment. The cost of membership in the International Obsessive Compulsive Disorder Foundation is $45 per year for individuals, $65 for families or households, and $100 for a professional membership.
Checks should be made payable to the International OCD Foundation, Inc. and mailed to: International OCD Foundation, P.O. Box 961029, Boston, MA. 02196.
The telephone number at the IOCDF office is (617)-973-5801. The International OCD Foundation website is www.ocdfoundation.org.
Comments, questions and suggestions about this article are welcomed and can be sent to firstname.lastname@example.org.
Ahead for the May 2014 column: A look at the Causes and symptoms of Post Traumatic Stress Disorder (PTSD)
“THE MIND CONNECTION”March 2014 Column: Cognitive restructuring vital in overcoming Hoarding Disorder
By John Hartsock
Changing and altering negative patterns of thinking is an important tool in coping with a wide variety of emotional maladies. People suffering from mild to moderate depression can certainly benefit from changing their cognitive worlds and self-talk. So can people with certain types of anxiety problems and obsessive-compulsive disorders.
People who hope to overcome hoarding disorder must also restructure their thoughts and beliefs about the things and possessions they accumulate that clutter their lives. People hoard for a variety of reasons. Some may feel excessive emotional attachments to possessions. Others may feel a crippling sense of guilt about discarding or giving away things which have outlived their use.
Dr. Gail S. Steketee, MSW, PH.D., Boston University, is one of the top experts in the United States on hoarding disorder and its treatment. “The best treatments are individual cognitive and behavioral treatment [CBT] designed for hoarding, as well as group treatment designed for hoarding,’’ Steketee said. “Both are similarly effective and use the same methods to enhance motivation, train skills needed to sort, organize and make decisions, address thoughts and beliefs about objects and their meaning, and help clients manage strong emotional attachments to objects.’’
Clinicians who are treating individuals with hoarding disorder often work with the clients in the clients’ homes. In some instances, clinicians may use video technology like Skype to counsel clients. In some instances of hoarding disorder, people may anthropomorphize objects, or think of the objects that are hoarded as actually having feelings. This mindset makes the process of discarding, selling, or giving away the objects much more difficult.
Therapeutic intervention for hoarding disorder does work, Steketee said. “After 26 sessions of cognitive behavioral therapy, 71 percent of therapists and 81 percent of clients rated the clients as either improved or very much improved,’’ Steketee said. “On more stringent measures, 41 percent were classified as clinically significantly improved, meaning that clients had improved so much that their hoarding severity scores were similar to [those scores] of people who did not have the disorder.”
The use of medications for the treatment of hoarding has not been widely studied at the present time, Steketee said. Some types of both hoarding disorder and obsessive-compulsive disorder may respond favorably to certain serotonin uptake inhibitors, however. Regardless of whether medication is used or not, people with hoarding disorder must work diligently in order to overcome it. “Preferably, CBT-hoarding treatment is done mainly in the home, but treatment will not be effective unless clients actively practice the skills that they learn in their homes where clutter is located,’’ Steketee said.
Comments, questions and suggestions about this article are welcomed and can be sent to email@example.com.
Ahead for the April 2014 column: A look at the OCD Newsletter
“THE MIND CONNECTION”February 2014 Column: Hoarding Disorder May Be Different Than OCD
By John Hartsock
For some individuals, discarding or parting with personal possessions creates a very high level of anxiety and distress.
People beset by this type of anxiety often resort to a behavior that is known as hoarding, or stockpiling personal belongings in their residences, workplaces, or vehicles. Hoarding becomes problematic when the accumulation of possessions in a given area or areas causes difficulty in interpersonal relationships, health hazards, or conflicts with the law.
Hoarding disorder [also known as HD] was long thought to be a subtype of obsessive-compulsive disorder, or OCD.
In some instances, people with some types of OCD may be unable to touch empty food containers or wrappers, leading to a home that is congested with these items. In other instances, individuals struggling with clinical depression can lack the motivation to rid their homes of excessive clutter.
But, according to an article published in the fall/winter 2013 edition of the International OCD Foundation [IOCDF] OCD Newsletter, in the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5], hoarding disorder has been placed in a diagnostic category that is different from OCD. In May 2013, the DSM-5 placed hoarding disorder as one of its diagnoses in its new obsessive-compulsive and related disorders chapter.
According to the DSM-5, there are distinct differences between the difficulties experienced by people with OCD and the problems endured by people with HD. According to Dr. Randy Frost, Ph.D., a member of the Smith College (Mass.) faculty who has done extensive work researching hoarding disorder, people with hoarding disorder experience different symptoms than those with OCD, and patients’ responses to treatment are different with the two disorders.
Whether hoarding is considered a subtype of OCD or not, there is no denying that hoarding disorder can present challenges that are every bit as daunting as those that are seen in the most severe forms of OCD. According to Frost’s work, published in the fall/winter OCD Newsletter article, criteria for a classification of hoarding disorder include:
1.) Persistent difficulty discarding or parting with possessions, regardless of their actual value.
2.) The difficulty stems from a perceived need to save the items and to the distress associated with discarding them.
3.) The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas.
4.) The hoarding causes significant distress or impairment in social, occupational, or other important areas of functioning, including maintaining a safe environment for self or others.
5.) The hoarding is not attributable to another medical condition like brain injury.
6.) The hoarding is not better explained by symptoms of another mental disorder.
Objects that are commonly hoarded include books, magazines, old clothing, and newspapers. In cases of extreme hoarding, a person may be unable to discard anything, leaving a home so cluttered that walking from room to room is impossible. In such circumstances, the risk of papers or books catching fire from being placed near sources of heat create fire hazards that may result in intervention from the authorities. Some individuals with hoarding disorder possess enough insight into their condition to recognize that it is problematic, but others do not.
Hoarding disorder and many forms of OCD share at least one common denominator --- the potential to cause serious discord between the person with the disorders and their family members. Interruption of OCD-related rituals can cause intense frustration among members of a household. So can discarding possessions if the person with hoarding disorder is not ready or able to part with them. Some people with hoarding disorder will also hoard animals in their residences or on their property. Published reports of people living in squalor, with residences cluttered with personal belongings and animal waste, provide the more glaring examples of individuals who are afflicted by hoarding disorder.
Comments, questions and suggestions about this article are welcomed and can be sent to firstname.lastname@example.org.
Ahead for the March 2014 column: Examining Treatments for Hoarding Disorder
“THE MIND CONNECTION”January 2014 Column: Refocusing Helpful for Scrupulosity
By John Hartsock
In a world where examples of everyday immorality and man’s inhumanity toward his fellow man are rampant, the problem of excessive scrupulosity represents the other end of the spectrum. Scrupulosity manifests itself in the form of obsessive-compulsive disorder [OCD] in which the obsessions and compulsions center around moral or religious themes. People who are scrupulous in a healthy way lead principled lives in which honesty, decency, integrity and a regard for the rights of others benefit both the scrupulous individual and his or her relationship with God and with society at large.
Scrupulosity becomes a disorder when anxiety relief, rituals, and repetitive behavior supersede spirituality. Examples of disordered scrupulosity may include a person who feels the daily or even hourly need to say a certain number of prayers in an inflexible or repetitive fashion, or another individual who repeatedly confesses his sins to a priest or minister, but feels that he or she has never confessed well enough or thoroughly enough, and therefore, cannot be forgiven by God. Obsessive concerns about eternal damnation in the afterlife often ruin any joy that the individual who suffers from disordered scrupulosity can derive from this life.
“Scrupulosity can hijack any aspect of an individual’s life,” Constantina Bourdovas, licensed social worker and director of social work at the Menninger Clinic in Houston, Tex., said in an article that was published in the Catholic magazine St. Anthony’s Messenger in September 2006. Disordered scrupulosity can paralyze individuals and keep them so preoccupied with anxious concerns and consuming rituals that their everyday lives are put on the backburner. Some individuals who suffer from disordered scrupulosity may practice a certain religion. But many do not.
Religions which stress an adherence to rigid, inflexible or dogmatic beliefs may fuel the development of scrupulous disorders. But the fact remains that the problem of disordered scrupulosity, like other forms of OCD, rests in the chemical imbalances in the brains of those individuals who are afflicted. “No particular religion is going to give you a mental illness, but if you develop a mental illness, the message in religion can get distorted,” said Dr. Joseph Antonowicz, medical director of behavioral health services at UPMC Altoona Regional Health System. “A lot of folks who have rigid, scrupulous interpretations of religion can be manifesting a form of OCD.”
Like other forms of OCD, disordered scrupulosity responds best to a combination of cognitive-behavioral therapy and certain medications. Exposure and response prevention [ERP] involves exposing an individual to the stimulus that provokes the religious obsession, while at the same time, helping him or her to decrease anxiety and develop a healthier reaction to the triggers. Dr. Jeffrey M. Schwartz, M.D., wrote a fabulous book on OCD treatment entitled “Brain Lock”, which was published in 1996.Schwartz likens the individual suffering from disordered scrupulosity to an automobile stuck in a certain gear, and unable to move on to a different, more constructive and favorable position. Schwartz advocates delaying obsessive-compulsive behavior for a period of time, in which the person reminds himself or herself that the disordered scrupulosity is a result of a biochemical imbalance in the brain. Schwartz also advocates redirecting thoughts and actions from obsessions to enjoyable activities like hobbies.
A couple other strategies may involve designating a period of “worry time” -- for example, 15 to 30 minutes each evening -- in which a person will do nothing but concentrate on the obsessive, burdensome thoughts. The goal is for these thoughts to gradually lose their bite, until they actually become boring or monotonous. Along the same lines, tape-recording troublesome thoughts and obsessions on a 30-minute loop tape and playing the tape back until the person becomes desensitized to the anxiety that is caused by the obsessions is another helpful strategy. Still another strategy that may help in the battle with disordered scrupulosity is to cultivate the belief in a merciful, loving God who shepherds his most wayward flock and doesn’t desire eternal damnation for anybody. Such a God offers salvation to all as a free gift.
Selective serotonin reuptake inhibitors [SSRIs] are medications which regulate the brain chemicals involved in the development of disordered scrupulosity and other forms of OCD. Paxil and Luvox are two of the medications in the class known as SSRIs. An important fact to recognize is that treatment protocols for disordered scrupulosity do not desensitize individuals to the point of disregarding that which is truly good, right and correct.
“We’re not trying to desensitize ourselves to good,” said Joseph Ciarrochi, director of pastoral counseling at Loyola College in Maryland, whose book “The Doubting Disease” (1995), focuses on scrupulosity in OCD.
“We’re desensitizing ourselves to the fear of intrusive or obsessive thoughts,” he said while speaking at the International Obsessive Compulsive Disorder Foundation’s national seminar held in Washington, D.C. back in 1999.
Comments, questions and suggestions about this article are welcomed and can be sent to email@example.com.
Ahead for the February 2014 column: A Look at Compulsive Hoarding in OCD