LONELINESS

Many years ago I treated a patient who was suffering from a near fatal case of loneliness.

 

No, I am not exaggerating for this person would later confess that she had come to me in a last-ditch attempt to resolve her problems while promising herself that if I couldn’t help she would hang herself. She was a 20-something attractive and very modestly dressed woman who did indeed look very despondent with the psychomotor retardation and furrowed brow characteristics of clinical depression. When I asked her why she was there to see me, she hung her head, stared at the floor, and tearfully responded that she had been shunned.

 

She went on to tell of how her infraction of the church’s rules (one that most of us would consider a minor infraction) had resulted in her being officially designated as one with whom the entire church should have no contact whatsoever. You may be thinking: “Big deal go find another church.” But her story was more complicated. She had grown up attending this church. It was the center of not only her spiritual, but also her social and family life. Since the church doctrine insisted that only members of their church were true Christians, the members were warned about the dangers of consorting with people outside the church, apparently convinced that sin was contagious. Thus, when alienated from the congregation, which to make matters worse, included her entire family, she found herself totally alone.

 

Such stories are not new as evidenced by Nathaniel Hawthorne’s tear-jerker, THE SCARLET LETTER, but give witness to the importance of relationships and the pain of loneliness. Many religions have used banishment of varying degrees of severity to punish wayward members. The Catholic Church’s policy of excommunication appears to be less stringent and is viewed by the church as a means to save souls whereby one can return to the fold and regain salvation by repenting. Such tools are powerful and their use can have long lasting effects. For example, I recently discovered that my Great, Great, Great Grandfather was shunned and ejected from the Quaker church. It occurred to me that if he had toed the line, I might be a Quaker.

 

AND YOU THOUGHT SMOKING WAS BAD

Solitary confinement has long been used as a means to enhance the discomfort of imprisonment, and is agreed by many to be a form of torture. In a previous blog, WHAT’S LOVE GOT TO DO WITH IT? I contended that our need for relationships is encoded in our DNA, having evolved long ago as a major contributor to the survival of our species. If one were to accept that premise, it would be logical to assume that loneliness could be a major problem for us. Indeed, according to Vivek Murthy, M.D., the former Surgeon General of the U.S., loneliness has become “a growing public health crisis.” He has said that loneliness is a more effective agent in reducing longevity than obesity, and that its toxic effects are worse than smoking 15 cigarettes per day. Recent research into the prevalence and effects of loneliness tends to confirm Murthy’s assessment. Last year Cigna released a report on a study of 20,000 people age 18 and over as measured by the UCLA loneliness scale.

 

Nearly half reported loneliness as a problem, but even more concerning was that 27% felt no one understood them, and 43% admitted they felt their relationships were not meaningful. One in five felt they rarely or never felt close to others or that there was anyone they could talk to. It was also noted that Generation Z (those born after 1996) were the loneliest of all the generations measured.

There have been a number of studies which confirm the effects of loneliness on physical and mental health. It is not surprising that it could result in affective disorders such as depression, and may help explain the increase incidence of suicide as mentioned in my previous blog, but there is also evidence that loneliness can cause or aggravate innumerable maladies including: hypertension, coronary artery disease, dementia, inflammatory diseases such as arthritis, impairment of immune systems, and even some malignancies to name a few.
A study in the Archives of Internal Medicine sponsored by the National Institute of Health followed 1604 people over the age of 60 (average age 70) for 6 years and measured their physical decline and mortality rate. Their stark conclusion was: “Among participants who were older than 60 years, loneliness was a predictor of functional decline and death.” Need I say more about our need to engage with our fellow man?

 

WE ARE NOT THE ONLY LONELY

It turns out that we are not the only nation where loneliness has become a problem, both from a public health and productivity perspective. Great Britain’s parliament has recently appointed a commissioner to investigate remedies for what has been called a silent epidemic after a study showed that 20% of Brits reported they were lonely most or all of the time. It appears there are similar studies in progress in other European countries. It would be helpful to know if loneliness is a worldwide problem or peculiar to our culture.

NOTHING ELSE TO DO

If one accepts the premise that loneliness is a significant problem, the question arises as to how did we get this way and what can we do about it. Prior to the industrial revolution, multi-generational families provided a sense of belonging. Relatives galore, including parents, siblings, cousins, grandparents, aunts, and uncles usually lived in close proximity. With the switch from an agrarian to an industrial society, there had been a migration to cities where houses were built close together, which resulted in the development of neighborhoods usually composed of people with common interests. There was the inevitable clustering of children who interacted with only minimal adult supervision, and stay-at-home moms who could relate to each other in a very personal way. Neighbors were evaluated based on certain standards including friendliness and mutual respect. The lack of air conditioning and television made front porches very popular especially on hot evenings, and provided an opportunity for informal socializing. The only taboo subjects were sex, religion, and politics.

 

BETTER THINGS TO DO?

Soon after World War II ended, front porches began to disappear from neighborhoods, and there was a wild rush to the suburbs where large green lawns were treasured and families had fewer opportunities to be “neighborly.” On hot summer nights, it became more comfortable to be inside the house (with air conditioning) than outside. There were also new-found entertainment devices available – first radio, then TV, movies in the VCR and then DVD Player, video games, and then the internet which gave us social media and streaming. One could go for months or longer without ever having face-to- face contact with one’s neighbors. There was no longer danger of an errant foul tip sending a baseball through someone’s window. Privacy became important, and it was no longer considered a snub to build a fence between houses.  There were no kids playing hopscotch on the sidewalks, as a matter of fact, there often were no sidewalks in these new neighborhoods.

Competing Schedules and Activities

As more mothers joined the workforce and children were exposed to more structured extra-curricular activities, long-held family traditions changed. There was concern about the “latch key children” so named because they would come home to an empty house. The evening meal, often the only time in which the entire family came together, was often disrupted due to conflicting schedules. This led to the so-called crock pot families where the family meal was available to all who passed by…making it easy to just grab a bite and be on your way without any hassle (or conversation).

Forced Socialization in the Pew

Another effective defense against loneliness was the weekly church service. Traditionally, religious institutions encouraged socializing (and in some cases, demanded it). However, attendance at religious institutions has declined in recent years (one study says church membership in the U.S. has declined from 70% in 1999 to 50% in 2018).

 

WHY SO MUCH LONELINESS?

It is ironic that in this digital age when we have vastly improved modes of communication, that we would identify loneliness as a problem. Facebook’s founder, Mark Zuckerberg, insists that he saw his invention as a tool by which relationships could be fostered throughout the world and help dispel feelings of loneliness and dissention, but it appears that it has done more to promote divisiveness and distrust.

 

With the invention of the telephone we gave up non-verbal cues in our conversations, and the trade-off for its convenience seemed like a good deal. Now kids have largely given up talking on their cell phones in favor of texting. Voices from the internet, news media and politicians all conspire to promote divisiveness and paranoia to the point that it is almost impossible to have a rational conversation about many of the issues of the day.

 
Today people are marrying later and living longer. As reflected in the census figures of 2012, 32 million or 27% of Americans lived alone which was up from 17% in 1970. As you might expect, widowhood is likely responsible for many single occupant households, and in another study it was found that 47% of women over the age of 75 lived alone. With aging, comes the inevitable debilities and limitations. The National Institute on Aging reports that nearly half of all people over the age of 75 have hearing loss, which can be a major impediment to any meaningful social interaction resulting in withdrawal from friends and family.

 

It has been said that Americans are losing faith in our institutions, and our political leanings are often shaped by who we hate rather than who we like. Political discourse has hit a new low. Muck raking is no longer good enough, and has been replaced by personal insults a la grade school rants. Respect for contrary opinions has now gone out of fashion. Divide and conquer is the new strategy, and a tactic that seems to have even been adopted by the news media (Matt Taibbi has written an entire book about it, called “Hate Inc.”). We lack heroes. We frequently hear the term “disenfranchised” these days, a synonym for “left out” and to be an outsider is lonely for any herd critter.

ALL IS NOT LOST (stay with me…a little break from “downer” time)

There is some evidence that there may be some efforts underway to deal with the loneliness issue. I was pleased to see a recent article in Psychiatric News suggesting that psychiatrists are focusing more on loneliness as an underlying psychiatric problem (don’t know why it took so long to figure that out). A former president of the American Psychiatric Association has suggested that assessment for loneliness be part of any evaluation or perhaps become a diagnostic category in the DSM 5 (the shrink bible). There is also a growing awareness of a worldwide suicide epidemic which most would agree loneliness all too often plays a part.  Lonely lifestyles also frequently seem to be common with mass murderers.
lonely quote

LONELINESS VS. BEING ALONE

Proximity to other people is not necessarily a solution for loneliness, for it is not unusual to feel lonely in the midst of a crowd. Obviously, some type of emotional engagement is necessary to dispel lonely feelings. Ordinary discourse involves much more than words. Unfortunately, in our digital world many of the nuances of communication are lost. Not only are the tone, rhythm, volume, and timbre involved, but there are multiple non-verbal cues which can modify or even completely change a communication. As a matter of fact, some very significant interactions may occur without any words spoken. In that vein a text hardly measures up to a face to face encounter as a means to communicate feelings.

 

Emotional tone is less relevant, for even an argument can dispel lonely feelings.
Although, until recently, there have been few attempts to measure the extent of loneliness, there is definitely a consensus among sociologists and mental health professionals that there has been a definite increase. Employers have taken note of recent research which has shown that employees are more productive when they are encouraged to interact with each other. As a consequence, in many cases the traditional office cubical arrangement has been scrapped in favor of a more open environment, teamwork is encouraged, and brief chats at the water fountain are less likely to result in a dirty look from the boss. Since most workers spend nearly half of their waking hours in the workplace such changes could be very beneficial for large segments of society.

 

GO TEAM

The needs for engagement with other humans has long been addressed by the formation of millions of organizations that bring groups of people together with myriad goals, but which also provide an opportunity to relate to others. The sense of belonging to a group is a powerful antidote to loneliness. Young people who feel neglected or alienated are more likely to join street gangs (easier to radicalize for terrorism and/or recruit for “religious” cults*). Athletic events and concerts attract millions, most of whom “show their colors” and cheer as one. One of my all-time favorite TV shows was Cheers which identified the locus of the show as the place “where everybody knows your name.” Organizations of all kinds including sports teams, military, and political groups or for that matter any group of people with a common goal make use of the need to belong which at the end of the day is an antidote to loneliness.

THEY NEED EACH OTHER

AARP sponsors a very interesting and apparently successful program called “Experience Corps” in which volunteer over 50 are enrolled in a program where they are trained to help children develop literacy skills. They spend 6 to 15 hours per week working with K-3 students with spectacular results including as much as 60% improvement in reading skills, fewer behavior problems, improved attendance, and increased graduation rates  The AARP foundation at last report had 2,000 volunteers throughout the country serving over 30,000 students. However; it appears the volunteers may be benefiting more than the kids from the program. A University of Michigan study reported a statistical decrease in depressive symptoms and functional limitations among the volunteers after two years involvement in the Experience Corps. There may also be a secondary benefit in that some kids may learn to venerate rather than denigrate us old folks. (Score 1 for the Old Farts!)

 

BE CAREFUL WHAT YOU WISH FOR

None of this should be interpreted as an attempt to diminish the value of solitude. Certainly, this need to relate can be overdone, and in some cases become pathological. In many cases of marital therapy, for example, too much togetherness can be identified as the problem. In testimony before Congress, Prof. Julianne Holt-Lunstad defined loneliness as ” the perceived discrepancy between one’s desired level of social connection and their actual level of social connection.”  She explained that some people who are socially isolated don’t necessarily feel lonely, and some people who are lonely are surrounded by people who make them feel more alienated.

 

One’s work may require so much contact with others that it can become oppressive, and some personalities may cause anal pain of the worst kind!  Nevertheless; before you make plans to spend the rest of your life on a deserted island or join an order of non-verbal monks, be careful what you wish for. Time-alone can be refreshing, relaxing and creative, but as with most things in life, it can be overdone. Alone can be good, but lonely can be very bad. In this time in which we are all mutually dependent, it has become even more necessary to have relationships than we did in those days when we needed help to bring down a woolly mammoth. It is difficult nowadays to survive in this world as a loner. We face enormous problems including an increased global population, competition for resources, and degradation of our environment. It is once again time for us to hang together or hang separately.

WHAT MAKES THEM TICK?

The ability of the human race to relate to each other has allowed us to survive and to thrive.  We need to exercise that talent now more than ever.  As I finished writing this, once again two hate-filled young people described as loners committed horrible atrocities within hours of each other. It goes without saying that we need to take logical steps to limit access to those instruments designed to kill people, but the prevalence of these kinds of behaviors also require us to learn more about the milieu in which they occur.  For example: are there genetic influences involved, does our society in some way generate such hatred, are certain personalities more easily recruited to violent organizations, is shyness a precursor, and finally does the hatred cause the loneliness or vice versa?  We need to understand more about how these people end up the way they are if we are to have any success at solving the problem.

What’s Love Got To Do With It?

If you have read any of my recent blogs, you may have noticed the following quote from Lao Tsu, an ancient Chinese philosopher: “to be loved deeply gives you strength, to love deeply gives you courage.”

 

The wisdom of those words explain much about behaviors I observed and attempted to treat as a psychiatrist. Feeling unloved was indeed a common complaint and the cause of a great deal of pain and misery.  Without the experience of feeling loved one is weakened, and thus may lack courage to face even the ordinary demands of life.  This may progress to a conviction that one is not only unloved but unlovable, resulting in self-loathing, depression, thoughts of harming oneself, and according to Anthony Storr, may generate violent aggression which he says is: “a complex mask for a repressed longing for love.”

WHY DO THEY DO IT?

There seems little doubt that we are now in the midst of an era of increased incidence of depression and unsanctioned violent aggression. Mass murders by otherwise ordinary people of all ages are now occurring at a level never before seen in the U.S.  Most perpetrators have a history of relative anonymity.  Neighbors usually describe them as quiet and unassuming, a person to whom they would speak to in passing but never engage in conversation.  Acquaintances when found describe their relationship as superficial, and express profound surprise that the person was capable of violence.  There is little evidence of any closeness let alone intimacy in their lives.  Could such horrible deeds be as Storr said: a result of anger over the lack of love in their life?

THE THIRD MOST COMMON CAUSE OF DEATH

There has been an alarming increase in the number of kids diagnosed with clinical depression which is not limited to those who are disadvantaged or abused.  A recent Center for Disease Control and Prevention survey of young people between the ages of 10 and 24 years resulted in shocking statistics. They report 4600 lives lost each year by suicide (most experts feel the actual number is higher due to a tendency for many to go unreported), and that rate has nearly tripled since 1940.  Emergency rooms throughout the country report 157,000 young people treated for self-inflicted injuries each year.  In their Nationwide survey of high school students, the CDC reported 13% admitted to seriously considering suicide, and 8% actually made an attempt to take their own life.  The report goes on to list a number of risk factors however; at a time in their lives when they are dependent on others to establish an identity and self-worth, it seems to me that relationships deserve to be at the top of the list.  Indeed, many teen-age suicides do implicate such problems as precipitating factors.

MORE OF THE SAME, ONLY WORSE

Rollo May in his 1960’s book LOVE AND WILL, says  “Our culture pushes people toward becoming more detached and mechanical,” but that observation doesn’t come close to what we see now that the digital age has enveloped us.  The addiction of our children to cell phones and other electronic gadgets contributes to their alienation.  Consolidation of schools and overcrowded classrooms have made it easier for kids to fall through the cracks.  Social media has become a convenient vehicle through which kids can be disparaged or bullied.  They are often attacked where they are most vulnerable i.e. their lovability consequently; the common theme “no one likes you” can be devastating to developing minds.  Now we hear there has been a dramatic increase in suicides in recent years among not only teenagers but pre-teens.   Although there is no proof of a link to feeling unloved, logic suggests there often is.

DON’T CARE? SURE YOU DO

There is ample evidence that we are herd animals, consequently; it is not surprising that I spent many hundreds of hours listening to patients with relationship problems, for when people are so very important in our lives, dysfunction can present problems.  Although we often attempt to comfort ourselves by professing to not care what others think, in truth we usually do care more than we would admit.  During all those years I spent in the shrink business I must have seen hundreds of people who were contemplating suicide or had actually made serious attempts.  Although there are obviously many factors that may lead one to seriously consider killing oneself, I recall often hearing: “Nobody cares.”

DO WE KNOW WHAT IT IS?

It would indeed be presumptuous of me to attempt to explain what love is all about.  It has certainly been a popular topic for poets, philosophers, musicians, theologians, and artists, through the ages.  The stories of wonder, ecstasy, and tragedy associated with love resonate in pop culture to this day. There have been myths, and legends and attempts to define love by categorizing it (erotic, agape, filial, spiritual, etc.), but the force responsible for this peculiar phenomenon remains a mystery to me.  My favorite definition of the term is from psychoanalyst Harry Stack Sullivan, as follows:

The validity of such explanations is confirmed by the intense love relationships experienced by warriors throughout the ages.  The myriads of reports of heroic efforts put forth by battle hardened veterans to protect their comrades, even risking or forfeiting their lives in the process gives credence to Sullivan’s ideas.  Indeed, when questioned as to why those who would in other situations have been considered unlikely heroes are questioned about their behavior, they will acknowledge that it had nothing to do with military or political beliefs, or patriotic fervor, but rather their devotion to their buddies (“No greater love hath man……”). That phenomenon has not been lost on those charged with training the military, consequently; camaraderie is encouraged and interpersonal dependency guarantees bonding.  One cannot wonder as to the part that the loss of relationships, solidified by the heat of battle, factor in the alarming rate of depression and suicide among our veterans.  Many report they worry about their comrades who are still fighting which may  also account fir the significant number who volunteer for additional tours of duty with their old outfits in spite of the known horrors they will likely confront.

WORTH THE TROUBLE?

Obviously, love has been a major contributor to the success of the human race.  Humans isolated from their kind rarely survive.  Sullivan posits that love is caring for others as for oneself and the old Chinese dude says as a result of love for each other, man gained the strength and courage to take on woolly mammoths and those guys in the next village who were trying to muscle in on their territory.  It is the latter part of that statement that has caused a lot of problems.  We seem to know a great deal as to the effects of love, but little about from whence it comes.  The neuro-physiologists and brain mappers continue to look for specific love loci, and geneticists will likely say that it is in our DNA, but I doubt that CRISPR will ever be able to install a love gene.  It would be great if such could be done, for we currently have little treatment for those who seem incapable of love, i.e. psychopaths.

I KNOW IT WHEN I FEEL IT

It may be that love is like the dark matter of our universe in that we know it exists and feel its effects even though we are unable to see, hear, smell or touch it.  Could it be that love is simply a product of evolution?  If so, how could we have survived long enough for natural selection to kick in?  The creationists insist that God snapped his fingers and we instantly appeared on the scene fully equipped.  Atheists on the other hand think the whole thing was an accident.  Others see love as spiritually endowed.  There are 4300 religions in the world with Christianity leading the pack and Muslims close behind.

WHAT ABOUT RELIGION?

Since I have been reared as a WASP, I have very little understanding of the other religions of the world or in particular where they stand on the love thing, but am pleased that love is at the core of Christianity.  When it comes to Biblical scholarship, I am a dunce, but I do find inspiration in those first few pages of Corinthians which are all about love.  The first 2 of the 10 commandments are also about love, and love is said to be the greatest of all, never fails, and is even better than faith or hope.  There is also that thing about loving your enemies and turning the other cheek, but most of all were the teachings of Christ who was all about love.  Of course, many see an inconsistency in a loving God who lets crappy things happen in spite of being all-powerful.  Since Christians are people it is not surprising to find they have found ways to subvert the love philosophy, and resort to violence with all sorts of rationalizations.

Loving others as much as oneself is a great idea, but very difficult to implement on a grand scale.  Excessive cheek turning is guaranteed to result in a lot of broken jaws.  Nevertheless, there have been many attempts to use love as a mechanism to provide peace and tranquility, which has been met with success in some instances.  In a rare instance of wisdom, our government eschewed the policy of gathering the spoils of war after WWII.  Instead they initiated a policy aiding even our enemies to rebuild their virtually destroyed countries which lead to their becoming our closest allies.   Of course, I was also around during the “love ins” of the sixties.  Although they seemed to have emphasized the erotic rather than agape version of love, they did call attention to long neglected human rights issues and war mongering.  There was also Nelson Mandela and Martin Luther King who both emphasized reconciliation and learning to love each other.

We certainly could use more love in this world, but the chances of EVERYONE following the Golden Rule seem to be unrealistic.  Nevertheless, when I look back on our history it seems there has been some progress in the love department with more emphasis on inclusivity and acceptance.  Although it may seem that love is in short supply, it is alive in well and we can only hope the day will come when The Golden Rule is ever present. Even as millions of our fellow humans face horrors each day, there are millions of people who devote their lives to helping others individually and through organizations, which gives credence to the dictum that love never fails.

Corinthians 13:4-8 gives tells us everything we need to know: “Love is patient, love is kind. It does not envy, it does not boast, it is not proud.  It does not dishonor others, it is not self-seeking, it is not easily angered, it keeps no record of wrongs.  Love does not delight in evil but rejoices with the truth. It always protects, always trusts, always hopes, always perseveres. Love never fails…”

THE GUN BATTLE – Watch the Just the Facts Video

All those guys whom we elected to debate issues our country face have been locked in an adolescent food fight for several years. They are our employees, and are paid reasonably well. I contend they are not doing the job for which we pay them, but we don’t seem to be able to fire them. Statesmanship and decorum is lacking. Their so called debates have even included personal insults. It reminds me of the debates we had in grade school which were not designed to determine who or what was best, but rather who was worse. Most polls suggest that our congressional representatives are tied with each other for the honor of being the most inept, as they are the most unpopular congress in our history.

Independent thinking and deliberation are a thing of the past. On most substantive issues members of each party vote the “party line” with no apparent questioning of what is the most rational position on an issue. Since all Republicans think one way and all Democrats agree with each other, the whole lot would appear to fail the test suggested by Walter Lippmann that when “all think alike, no one thinks very much.” In that sense, they are more like a gang than a deliberative body.

It now appears that this august body has reached a new low in cynical disregard for the people who they are sworn to represent. The leadership has refused to deliberate or vote on a bill which is very important to a majority of their citizenry, apparently in order to avoid taking responsibility for their position. It is understandable that they would want to keep their positions secret since even a vast majority of republicans want a vote on this bill. The only logical conclusion is that the will of the NRA is more important than the will of the congressional representatives’ constituents.

But let us not forget the Democrat’s role in this subversion of the will of the people. Both parties will blame the other for refusing to negotiate in a civilized respectful manner, but no matter who is to blame (I suspect both are ) they don’t seem to talk to each other anymore. The Democrats have said to hell with decorum and are engaged in a sit in within the house chambers. Perhaps this is progress, an indicator that they have matured beyond preadolescence  and have adopted a strategy more popular with college age kids.

The current situation could possibly be resolved by luring the Republicans into the house chamber with the Democrats and locking the door with the admonition that could not come out until differences were resolved. There is the risk; however, that that this could degenerate into an out and out physical brawl which has some precedent in other countries.

Since facts about the issues surrounding guns are hard to find if one only listens to the politicians, I found a video that presents “just the facts.” Enjoy, and let your representative know what you think.

Indeed, a government by the people needs to hear from the people in order to be effective. Email, write, call your congressional representatives. Click this link for contact information.

Separation Anxiety + Mental Health

LincolnLincoln is a very large black Labrador retriever, who has bonded to my son-in-law. Bonded does not adequately describe this relationship for it is as if Lincoln is attached to Jim by a very short invisible rope. Recently, during a visit to my daughter’s home I had the opportunity to witness a hilarious demonstration of this attachment. Jim was mowing his yard with Lincoln at his heels, and when he turned to push the mower in the opposite direction Lincoln followed. This continued with Lincoln following back and forth until the job was done. In a similar manner, he is rarely separated by more than a few feet from his master. When Jim leaves he is frantic, constantly watching the door, pacing back and forth, obviously quite agitated. Lincoln would seem to be the poster child (excuse me, poster dog) for the diagnosis of separation anxiety.

According to the ASPCA web site, the condition is not uncommon among dogs, and is most common among those rescued from kennels, and those who have been moved or have lost their major guardian. In other words, it seems that dogs know when they have a good deal and worry that they might lose it. Lincoln fits that category as he had been given up by his family and given to Jim. Watching Lincoln started me wondering if we humans are all that much different from him.

Most of us can recall at least one incident when we experienced “homesickness.” In my own case I remember vividly very intense feelings when left to stay with my Grandparents.   I never have been able to find words to adequately describe those feelings, but have likened it to a kind of psychological amputation in that a part of one’s self is missing. Those who have experienced it will understand how painful it can be.

Leaving for college is a common precipitant for it represents an abrupt breaking of many of the bonds attached to things familiar and to those upon whom we are dependent. My youngest daughter Maggie (currently my editor and the one who bears total responsibility for talking me into writing all this stuff) was the most memorable example of this phenomenon; although, her siblings also experienced it to some degree. Maggie was eager to fly away from the confines of a boring small town to gain freedom from parents who continued to treat her as if she were a child and to subject her to all kinds of stupid rules. As a matter of fact she was so convinced that geography would be the solution to her discontent that she refused to consider any school within her home state.

The vision of that skinny little girl surrounded by huge limestone buildings gently sobbing and feebly waving a goodbye as we pulled out of that parking lot has never left me. Little did she know the effects her mother and I felt from that poignant scene, for we were heading home to an empty nest. Nothing would ever be the same. Maggie was a prime example of the wisdom of the admonition that one should be careful what he/she wishes. She lost nearly 20 pounds during her first two weeks, and was barely able to function according to her roommate who called us to express her concern. Barb and I resisted our impulse to go save her from this horrible fate, and as one would expect she soon had a spontaneous remission, and went on to excel.

Homesickness vs. Separation Anxiety Disorder

What Lincoln and Maggie have in common is that they have both experienced separation anxiety; although in Maggie’s case the condition was temporary but for Lincoln it became chronic, which qualifies him for a diagnosis of separation anxiety disorder. Although they share the same symptoms, Maggie’s reaction would be viewed as homesickness; therefore, benign in its implications while the same problems if persistent are characterized as mental illness.

In like manner, one could make a case that mental illnesses are largely due to quantitative rather than qualitative variations from the norm. Who among us has never experienced an irrational fear, a fleeting suicidal thought, unwarranted suspiciousness, unreasoned feelings of despondency, or a spontaneous episode of anxiety without obvious cause? Such short lived experiences are usually shrugged off, but the realization that these feelings differ from those of a mentally ill person only in their duration can result in self-doubt and feelings of insecurity about one’s mental stability.

The mechanisms we use to deal with these feelings of mental insecurity and self-doubt are all apt to contribute to the isolation and discrimination so often seen in our relationships with people who are mentally ill.

Denial

Denial is a powerful mental mechanism characterized by statements such as: “pull yourself together, stop worrying, quit being so sad, or stop acting so crazy.” Such statements deny illness and suggest he only needs to “buck up,” thus, perpetuating the time honored tradition of blaming the victim for his troubles. Of course kicking a person while they are down is not very therapeutic, but it may help us feel immune. Some naysayers even insist that the whole idea of mental illness is a fable.

Avoidance

Avoidance is another method of dealing with one’s insecurities. It operates under the out of sight out of mind premise. When I was practicing there were some people would not visit friends or relatives in our psychiatric ward. Many others were obviously uncomfortable in that environment, and would avoid eye contact with patients. The usual response to someone exhibiting bizarre behavior is for observers to look away after a furtive glance. Avoidance in its extreme form is to be shunned, which is guaranteed to exacerbate most any mental illness.

Ridicule

Ridicule is a tried and true method to avoid ownership. It is said that those operated Bedlam (which was actually named Bethlem Royal Hospital), the infamous insane asylum in England that charged admission for visits to the facility where one could make fun of and taunt the patients, felt it was quite progressive because the fees collected helped fund the “hospital’s” operation. I imagine the taunters felt safe since most of the patients would have been chained to a wall. We are of course much more sophisticated than the residents of jolly old England, yet when we joke about mental illness, are we not engaged in a similar coping mechanism? For the patients and their families, there is certainly nothing humorous about mental illness.

Words

The way we speak often illuminates thoughts buried so deep that we may lack awareness of them. This appears to be true when we discuss mental illnesses, especially the more serious variety. For example when we say a person is schizophrenic, where schizophrenic is an adjective, we seem to be saying what he is, but when we use the term as a noun as “he is a schizophrenic” we are saying who he is. He is no longer a human with the disease, but he is the disease, and his humanity is diminished.  People with schizophrenia have this in common with those suffering from leprosy, who are usually referred to as “lepers.”

The plight of those who suffer from mental illness

The parallels don’t end there for those afflicted with either diagnosis, leprosy or schizophrenia, have suffered the same punishments including: torture, execution, imprisonment, denigration, ridicule, and shunning. Both have been thought to be caused by demonic possession, curses, divine judgments, witchcraft, etc. They have been with us throughout recorded history and probably longer. You may be thinking, “Yes, but we have become so much more sophisticated, enlightened and compassionate.” Yet, thousands of severely mentally ill people are imprisoned. Only recently has there been a movement to mandate psychiatric care reimbursement by third party payers to be equivalent to that provided for treatment of non-psychiatric illnesses. An estimated 70% of the homeless who live on our streets are mentally ill. Our government has diligently worked to deny benefits to veterans suffering with post-traumatic stress disorder, and the list goes on. Incidentally, the last leper colony in the U.S. was not closed until 1999.

The stigma of mental illness

I contend that ignorance is fertile ground for the development of stigmata. We are often most fearful of those things which are mysterious to us. A diagnosis of separation anxiety does not promote much fear in us. We all have some familiarity with and empathy for that problem, but mention psychosis and there will be a different reaction. There are abundant myths regarding psychotic illnesses, and for many that term belongs in the same category as axe murderer. Since early childhood we have been taught to avoid people who are acting strangely, and what we don’t understand is always strange.

Behavior Health vs. Mental Illness / Patient vs. Client: Renaming and Reframing

Another way of dealing with uncomfortable problems is to reframe them by renaming them as something less threatening. In the mental health field this mechanism is used by mental health advocates in a way that I feel undermines their stated goal of de-stigmatizing mental illnesses. One such term which I find totally repulsive is behavioral health which has found its way into the vocabulary of not only the general public, but those charged with treating the mentally ill. While espousing the need for acceptance, they choose to call the condition by a different and totally inappropriate name. A mental illness is no more a behavior than is cancer, but since there is a type of treatment used for less serious illnesses called behavior therapy, the term has now been co-opted to encompass all psychiatric illnesses.

In their zeal to demedicalize mental illnesses, the powers-that-be have successfully substituted client for the word patient when describing people in treatment. This is an issue which sometimes leaves me wondering if it might be time for some more therapy for myself. I have fought this one unsuccessfully for at least 20 years. The word patient is from the Greek meaning “one who suffers” while the word client has to do with a business relationship. Call me a snob, but I feel a doctor patient relationship is more than a series of business transactions. As I have pointed out repeatedly to all who would listen and even those who would not: Accountants, lawyers, and hookers have clients. Physicians have patients.

Shortly before my retirement, I penned a letter on the subject to all the nurses with whom I worked, expecting them to be a bit more sympathetic since they had been medically trained. When I asked one if she had read my letter, she answered in the affirmative, then said “Your next client is here.”

Sadly, the previously described types of reactions to a diagnosis of mental illness occur at a time in a person’s life when he/she is in most need of support and relatedness. Admittedly there has been some progress in educating us about mental illness, and research is opening doors toward more understanding, but society remains relatively uncommitted to dealing with one of our most pressing problems. Hopefully there will come a time when patients will not fear being seen going into their psychiatrist’s office.

From Eshrink’s Editor: What can you do to help?

Get informed. Volunteer.

(Side note from eshrink’s editor: If you think about it, all of the big issues that face our society are just symptoms of a society that has yet to address mental illness and the plight those who are the caretakers for the mentally ill face. As the election cycle gets in full force, pay attention to how few candidates address mental health and mental illness.)

Below are some resources I found helpful.

http://www.nami.org/Get-Involved/Raise-Awareness/What-You-Can-Do

http://www.nami.org/get-involved/raise-awareness

Helpful Tips for Family and Friends

60 Tips

Rebuttal to NY Times Article “Medicating Women’s Feelings”

Note from Maggie, Dr. Smith’s daughter and proud editor of eshrinkblog.com

The minister (pastor, reverend, preacher…I never know the correct title) sent my dad an op-ed piece from the New York Times and asked him what he thought of it. To me, it sounds like they are both very well-read people and enjoy intellectual conversations about issues. Below is my dad’s response. For my part, I see why my dad is so baffled by Dr. Holland’s article. I think what she is saying is that the system is set up to reward male-dominated traits, and there is value in many of the traits females have as a part of their biology. But she doesn’t explain it very well. Instead, she seems to be saying, “Suck it up and appreciate your depressive state. These anti-depressants are just making you like a zombie.” As a person who suffered from post-partum depression after my second child, Prozac was a lifesaver…for me and my husband and children.

Here is the article:

Medicating Women’s Feelings

WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.

These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.

The pharmaceutical industry plays on that fear, targeting women in a barrage of advertising on daytime talk shows and in magazines. More Americans are on psychiatric medications than ever before, and in my experience they are staying on them far longer than was ever intended. Sales of antidepressants and antianxiety meds have been booming in the past two decades, and they’ve recently been outpaced by an antipsychotic, Abilify, that is the No. 1 seller among all drugs in the United States, not just psychiatric ones.

As a psychiatrist practicing for 20 years, I must tell you, this is insane.

At least one in four women in America now takes a psychiatric medication, compared with one in seven men. Women are nearly twice as likely to receive a diagnosis of depression or anxiety disorder than men are. For many women, these drugs greatly improve their lives. But for others they aren’t necessary. The increase in prescriptions for psychiatric medications, often by doctors in other specialties, is creating a new normal, encouraging more women to seek chemical assistance. Whether a woman needs these drugs should be a medical decision, not a response to peer pressure and consumerism.

The new, medicated normal is at odds with women’s dynamic biology; brain and body chemicals are meant to be in flux. To simplify things, think of serotonin as the “it’s all good” brain chemical. Too high and you don’t care much about anything; too low and everything seems like a problem to be fixed.

In the days leading up to menstruation, when emotional sensitivity is heightened, women may feel less insulated, more irritable or dissatisfied. I tell my patients that the thoughts and feelings that come up during this phase are genuine, and perhaps it’s best to re-evaluate what they put up with the rest of the month, when their hormone and neurotransmitter levels are more likely programmed to prompt them to be accommodating to others’ demands and needs.

The most common antidepressants, which are also used to treat anxiety, are selective serotonin reuptake inhibitors (S.S.R.I.s) that enhance serotonin transmission. S.S.R.I.s keep things “all good.” But too good is no good. More serotonin might lengthen your short fuse and quell your fears, but it also helps to numb you, physically and emotionally. These medicines frequently leave women less interested in sex. S.S.R.I.s tend to blunt negative feelings more than they boost positive ones. On S.S.R.I.s, you probably won’t be skipping around with a grin; it’s just that you stay more rational and less emotional. Some people on S.S.R.I.s have also reported less of many other human traits: empathy, irritation, sadness, erotic dreaming, creativity, anger, expression of their feelings, mourning and worry.

Obviously, there are situations where psychiatric medications are called for. The problem is too many genuinely ill people remain untreated, mostly because of socioeconomic factors. People who don’t really need these drugs are trying to medicate a normal reaction to an unnatural set of stressors: lives without nearly enough sleep, sunshine, nutrients, movement and eye contact, which is crucial to us as social primates.

If the serotonin levels of women are constantly, artificially high, they are at risk of losing their emotional sensitivity with its natural fluctuations, and modeling a more masculine, static hormonal balance. This emotional blunting encourages women to take on behaviors that are typically approved by men: appearing to be invulnerable, for instance, a stance that might help women move up in male-dominated businesses. Primate studies show that giving an S.S.R.I. can augment social dominance behaviors, elevating an animal’s status in the hierarchy.

But at what cost? I had a patient who called me from her office in tears, saying she needed to increase her antidepressant dosage because she couldn’t be seen crying at work. After dissecting why she was upset — her boss had betrayed and humiliated her in front of her staff — we decided that what was needed was calm confrontation, not more medication.

Medical chart reviews consistently show that doctors are more likely to give women psychiatric medications than men, especially women between the ages of 35 and 64. For some women in that age group the symptoms of perimenopause can sound a lot like depression, and tears are common. Crying isn’t just about sadness. When we are scared, or frustrated, when we see injustice, when we are deeply touched by the poignancy of humanity, we cry. And some women cry more easily than others. It doesn’t mean we’re weak or out of control. At higher doses, S.S.R.I.s make it difficult to cry. They can also promote apathy and indifference. Change comes from the discomfort and awareness that something is wrong; we know what’s right only when we feel it. If medicated means complacent, it helps no one.

When we are overmedicated, our emotions become synthetic. For personal growth, for a satisfying marriage and for a more peaceful world, what we need is more empathy, compassion, receptivity, emotionality and vulnerability, not less.

We need to stop labeling our sadness and anxiety as uncomfortable symptoms, and to appreciate them as a healthy, adaptive part of our biology.


My dad’s response to the article above

Dear Dennis,                                                                                                                                               March 9, 2015

Thank you for sharing the New York Times Op Ed.  Although there are many points in which I agree, I do fear that the opinions expressed may have the power to cause as much harm as the side effects of the psychotropic medications which Dr. Holland feels are overused.   My concern is that her essay may contribute to the stigma already attached to the treatment of mental illness or emotional problems in general.  Although Dr. Holland does make some valid points, I believe that some of her analyses are inaccurate.   She bases her expertise on having practiced psychiatry for 20 years.  Lest you think it audacious of me to challenge her, I trumpet the fact that I had more than twice that many years as a psychiatrist and prior to that another 10 years practicing general medicine.   In the latter capacity, I found myself frustrated by my helplessness to deal with the emotional suffering of many of my patients.   With this in mind I returned for a residency in psychiatry.

The first paragraph of Dr. Hollands’s piece lists qualities which she presents as gender specific, with which I do agree in general.  She then describes these qualities as a “source of power” and continues by asserting that women are  “under constant pressure to restrain our emotional lives” while denying a pro-feminist ideology.   I fancy myself as a firm advocate of equal rights for women having been well indoctrinated by three assertive daughters, and a wife who has extricated herself from the helpless, dependent role which she had been taught.   As I have stated in a previous blog post, I believe that women will eventually achieve equality or even superiority.  In general, I feel this would be a good thing, although I must confess I do occasionally have some nightmares of that Stepford  Wives  thing, for I realize that paybacks are hell.

In the next paragraph she bashes the drug companies for “playing on fear.” Those of you who have read my previous blogs would agree that I am no big fan of the pharmaceutical industry, and I believe that promotion of prescription drugs to the lay public is not helpful, but then neither is the endless promotion of alcohol on TV.  I have long felt the cost of new medications outlandish, but that is another story.   In their defense I must admit that the tools available for treating mental illness although not nearly perfect are amazing considering what was available to us 60 years ago—even 30 years ago.  She uses the example of Abilify as the inappropriate use of a medication.  She does not seem to consider that it may be used so much because it is effective.  Although it was originally developed as an antipsychotic, it has been found to be efficacious when given in small doses to augment the effect of antidepressants.

She presents further evidence of a stoned female population by noting that 1 in 4 women are taking a psychiatric drug compared to 1 in 7 men.  This would seem to indicate that men are under medicated and women are about right for the INH study shows a prevalence of mental illness of 26.3% of the adult population. The disparity may also have something to do with the fact that women are not burdened by the macho thing and the qualities in women, which the doctor extolled in her opening paragraph, allow them to be more likely to seek help.  Could these same disparities in diagnoses between men and women also have to do with the sensitivity and other valued traits in women?  It does not seem illogical that they might have an increased susceptibility to depression and anxiety disorders as is the case in many  types of illness.  After all “men are from Mars and women from Venus.”

Dr. Holland insists that women are designed to “be in flux” and such things as premenstrual syndrome with its despondency, irritability, and anger are simply part of the normal female physiology and apparently is something that shouldn’t be tampered with.

She should be reminded that biologically premenstrual syndrome (PMS) was not a problem for primitive women, because they avoided the problem by being constantly pregnant.  Modern women have rejected that option, and menopausal symptoms likewise were rarely a problem since few lived to be as old as 40.   When these facts are considered one could safely conclude that treatment of these problems is not in violation of natural law.  On the contrary I have seen many women through the years who have been severely impaired and spend sometimes half of each month miserable.  Then there is the guilt that follows when they later realize the effect their behavior has had on their family, friends and coworkers.   I would dispute her statement that menopausal symptoms can ” sound a lot like depression”, and say it not only sounds like but is depression.   If it quacks like a duck, etc.

Perhaps it is with her discussion about SSRI’s that I wonder if I really am on a different planet.  I vividly recall the first time I prescribed Prozac, which was the first SSRI.  The patient was a very unhappy young man who had suffered  a social anxiety disorder with depression since the 6th grade.  He had lived in almost total isolation, had never dated,  and worked in a warehouse on the night shift in order to have minimal contact with other people.  After a few visits he appeared to be a bit more comfortable with me, but shuddered at the idea of branching out socially.  After a couple of weeks there was a remarkable change.  He had started out by making conversation with the check out girl at the grocery, and reported he was no longer avoiding acquaintances as he had in the past, but more importantly  he arrived with a broad smile.  He denied any depressive symptoms, and the changes in his persona were so remarkable that I wondered if he had been into something illicit.  I was skeptical this might be a  placebo effect, but the changes persisted and the last time I saw him he had quit his night job, and enrolled in a university to pursue an engineering degree.

At this point I was sold on Prozac, but my joy was short lived when I found that it did not always work as advertised.  It did however offer many advantages over other antidepressants which were available at the time including fewer side effects , less sedation, and non lethality at even huge doses, an important feature when dealing with depression.   There is a significant group who will experience some sexual dysfunction, but most of my patients say that is a price they are willing to pay.  I do not recall noting the zombie like effects that she describes with SSRI’s.  As a matter of fact, my patients usually are more animated and expressive.  Dr. Holland notes that SSRI’s may dampen what she calls ”human traits” among which are irritation, sadness, anger,  mourning and worry.  I don’t know about her patients, but mine would not mind giving up those human traits.

She also lists as side effects that SSRI’s are apt to result in one becoming “more rational and less emotional.”  It is difficult for me to understand how these traits could be labeled as negative effects; therefore undesirable. We are led to believe that emotional stability will make women more masculine with the capacity for leadership, which again we are to assume is a negative.  Her response to patients who complain about the emotional instability associated with the  premenstrual period could be likened  to such macho statements as  “suck it up, play through the pain, stop whining  etc.” consequently I am confused as to exactly what behaviors she thinks are appropriate.

The most puzzling of all to me is the last statement in the article wherein she states “we need to stop labeling our sadness and anxiety as uncomfortable symptoms and to appreciate them as a healthy , adaptive part of our biology.”  I see nothing healthy about depression and anxiety, but only pain.  Nor do I see any virtue in needless suffering.  As a physician, I have always seen as my goal the alleviation of suffering, and nowhere in life is the suffering more extreme than in those afflicted with mental disorders despite the cause.

Where’s Walter Cronkite When You Need Him? The media’s inability to multi-task (among other things)

The Curmudgeon’s Corner

The Media + Robin Williams
August 17, 2014

                It would take longer than the time I have left on this earth to discuss all the complaints I have with our current news media; however last week’s performance exemplifies many of them.  I spent much of my time this last week being dumbed down by CNN.  You might ask ‘why didn’t you simply turn the channel?” and my answer is: if I had not watched it I wouldn’t be able to complain, besides where else is a news junkie to go? MSNBC and FOX news function as political propaganda machines rather than as news organizations.  I had some hope for Aljazera USA, but was told by Time-Warner that I must buy a separate cable box in order to get it on the kitchen TV where I prefer to get my morning news.  I suppose it is a coincidence that Time-Warner is the parent company of CNN.

Perhaps you have noticed that CNN only does one story per week; although that story is repeated continuously until something juicier comes along.  Each retelling is presented with great fanfare as “breaking news”.  Occasionally, they might break in to mention some trivial world events such as the numerous wars raging throughout the world, or the plight of the millions of refugees throughout the world facing starvation, genocide or slaughter.  I sense they would prefer to focus on domestic stories for it must be cheaper to use reporters from affiliates than to hire independent foreign correspondents, which the closing of most of their news gathering facilities throughout the world necessitates.

The story to which I am referring mercifully ended in less than a week as it was recently replaced by the shooting in Missouri, which remains at the top of the charts.  This morning there was breaking news that the Governor was planning to visit Ferguson again.  How exciting!  As you may have guessed the suicide of Robin Williams was the story of the previous week.  I have always been a fan of Robin Williams and thought he and Johnathon Winters were the two funniest men in the world.  My wife commented the other day that Robin had “kind eyes”, and watching the clips on TV, I had to agree.  I was also impressed that his humor was not at the expense of others. There is no question that this man was a comedic genius in addition to being an exceptional actor.

Prior to my bitter old man days, I was a psychiatrist and as such have always had an interest in what makes people tick.  I have found the genius thing to be especially interesting.  For example, how is it that the brains of so called savants can perform unbelievable acts of genius when in all other areas  they are so limited? In my younger days I had also done some research into attempting to learn more about suicidal behaviors.  With these sorts of questions in mind, I found myself listening to a parade of so called experts discussing Robin’s life and tragic death.  Physicians generally spend a lot of time attending lectures by various experts; consequently I have had a lot of experience in this area.  I have even pretended to be an expert myself on occasion.  Somewhere along the line some medical truth teller defined an expert as “someone more than fifty miles from home with slides.” I felt a CNN mental health expert could be characterized as “a smooth talker with an agent.”

With the exception of Dr. Oz (really smooth) who did give a short but accurate monologue about depression, I felt the experts sounded like amateurs.  I feel  sure  that it would take any first year trainee in psychiatry about 15 minutes to diagnose Mr. Williams.  His history of depression, and substance abuse, quick, nay lightning fast wit, periods of impaired judgment, racing thoughts, and family history  were absolutely diagnostic of Bipolar I disorder.   Bipolar disorder frequently gets bad press, and I felt this would be a wonderful opportunity to dispel some of the myths about the disease.   Many historians now think that many of our most creative people have been afflicted in some form.   Robin Williams certainly was in that group.

Arthur Miller, the playwright once said that he had not been able to write anything worthwhile since he started on lithium (a mood stabilizer) but he felt wonderful. This is the man who wrote Death of a Salesman in one day. Yes, bipolar patients can be incredibly productive until they  run out of gas and fall into a pit of intolerable hopelessness, and despair.  I don’t believe any of us who have not experienced that pain can truly understand suicide.

Robin Williams paid a big price for his genius, and I can’t help but wonder if in the past I may have stifled some potential genius’s creativity by treating his Bipolar disease.  Yeah, unintended consequences can be a bitch, but I wager that Robin would have gladly traded fame and fortune for euthymia.