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.