Why are People so Interested in the DSM-5?

There is a lot of internet buzz about the approval by the American Psychiatric Association’s (APA) board of trustees of its fifth edition of  the Diagnostic and Statistical Manual of Mental Disorders (DSM-5.)

The APA press release notes “the trustees’ action marks the end of the manual’s comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries.”

The approval was announced on Saturday, December 1 (was the APA trying to keep it quiet?) with publication of the DSM-5 scheduled spring 2013.  For a book that has no plot or characters, its pending publication has caused great excitement.  True, it is a sequel, but it is not the latest installment of Harry Potter or the Twilight Saga.

Though the DSMs have not reached the volume of sales of a Harry Potter (so far),  the paperback edition of the last version of the DSM had a sales rank of 261 on Amazon.com.  This is remarkable for a book that is over 900 pages in length and written for professionals.

Besides being bestsellers, the DSMs have inspired games and even music awards. DSM-IV the Game is available for free online.  It is described as “beautiful way to engage and learn about yourself, family, and friends and as an ice breaker at your next holiday gathering.”

Several years ago, Dr. Jill Squyres, a clinical psychologist in San Antonio, created the DSM-IV Music Awards for her professional society’s fall social.  The  DSM-IV Music Awards are modeled on the Academy Awards. She chooses categories based on a DSM diagnosis and then nominates songs that are reflective of disorders such as Major Depression (Jagged Little Pill by Alanis Morisette,  King of Pain by the Police), Mania (Wake Me Up Before You Go Go by Wham, Life in the Fast Lane by the Eagles), Obsessive-Compulsive Disorder (I’m In Love With My Car by Queen, Pinball Wizard by the Who), and Borderline Personality Disorder (Isn’t life Strange by Jim Morrison, Addicted to Love by Robert Palmer).

How does a medical book about psychiatric disorders inspire games and awards let alone become a bestseller? There are not enough medical professionals or people with vested interests, such as the pharmaceutical or insurance industries, to account for these sales figures. What is behind the fascination with the DSM among the general public?   I believe it is because our mental state goes to the core of who we are as human beings and our fascination with the link between mental illness and creativity.

Mental illness went “public” long before cancer and AIDS. Although mental illness is still considered a stigma by the general public, writers and artists have been talking publicly about their bouts of depression and struggles with alcohol and drugs for hundreds of years.  Ernest Hemingway, Virginia Woolf, Sylvia Path and Vincent van Gogh committed suicide. The poets T.S. Eliot and Ezra Pound were committed to mental institutions. The 27 club is comprised of  musicians who died at age 27; Janis Joplin, Jimi Hendrix, Brian Jones, Kurt Cobain, and Amy Winehouse.  The public breakdowns and rants of Mel Gibson, Alec Baldwin, Lindsay Lohan, Charlie Sheen and Mel Gibson have been televised and viewed by millions on YouTube.

The style and language of the DSM is another reason for its popularity. Unlike most medical textbooks , there is relatively little medical terminology and diagnoses are described in terms that are easily understandable to the nonmedical reader. Each diagnosis includes a list of symptoms, referred to as criteria, that typify the disorder. The list of symptoms is exhaustive, but not all symptoms necessarily occur in the disorder. The format and clear non-technical language invite the reader to examine and apply this new knowledge to themselves and others. A parent who worries that his child might have Attention Deficit Hyperactivity Disorder (ADHD) or a spouse concerned that their loved one is displaying symptoms of Alzheimer’s disease can easily look up these disorders and review the symptom check list.

Psychiatric disorders consist of behaviors that are extreme. The same behaviors occur with less intensity or frequency in everyday living. A key symptom of Major Depression Disorder is anhedonia, a failure to find pleasure in everyday life. Anhedonia was the working title of Woody Allen’s movie Annie Hall, which won four Academy Awards including Best Picture. In mild or moderate degrees, most of us have experienced “mild anhedonia” (a.k.a being in a funk) at some point in our lives.

Obsessive-compulsive disorder (OCD)  is an anxiety disorder marked by obsessions, which consist of unwanted and repeated thoughts, or behaviors, and compulsions that make those with OCD feel compelled to perform a behavior to lessen their anxiety. Although most of us are not paralyzed by OCD, we all have some traits. We go back and check to see if we locked our doors or left the tea kettle on. And although we might wish to have the detective skills of Adrian Monk or the writing skills of Jack Nicholson in As Good As It Gets , these fictional characters inability to cope with OCD causes them great anguish and the inability to have significant relationships.

I believe that today’s films and TV shows that portray mental illness are popular because they present characters we can relate to, unlike earlier films such as Psycho, a film that scared people so much they stopped taking showers. We laugh at the neurotic mother-son relationships portrayed in Everyone Loves Raymond and Seinfeld because we can relate to them. And we worry about our children. Are we pushing them so hard that they will end up like Natalie Portman’s crazed ballerina in the Black Swan?

Brain scans have shown that that creativity and “madness” light up similar pathways in the brain. However, the overwhelming majority of mentally ill people are not artists and most artists are not mentally ill.  Edgar Allen Poe, Vincent Van Gogh and Ernest Hemingway were gifted artists who happened to be mentally ill. Their mental illness did not make them artists. In fact, mental illness interferes with the artistic process.  William Styron was not able to write in the throes of his depression. The mathematician John Nash did his greatest work before he was diagnosed with schizophrenia.

I have no doubt that some gifted people are able to function by “throwing themselves into their art.” However, their legacy is their work, not their mental illness. People may fantasize about being able to play guitar like Jimi Hendrix, write like Hemingway, and sing and dance like Michael Jackson. But they don’t fantasize about being clinically depressed, overdosing on drugs, being homeless, or being institutionalized.

To answer to my question of why we are so fascinated by the DSM, I believe it is because it presents and explains extremes of behavior, related to and connected with the more normal levels of behavior we experience. We read the DSM to find ourselves in its pages.

Images: Vincent Van Gogh; Janis Joplin; MONK cover by author.

Chicago Expert Says ‘Anxiety’ Is A Major Challenge Facing New Moms

/PRNewswire/ — Postpartum depression has long been seen as a problem, but mental health providers say anxiety – not just depression – seems to be a major challenge facing new mothers today.  Mental health experts in Chicago are identifying an increasing number of patients who are experiencing severe anxiety and obsessive compulsive symptoms after childbirth.

“We’re seeing moms with disabling anxiety, not just depression after giving birth,” says Vesna Pirec, M.D., Ph.D., the chief medical director of Insight Behavioral Health Centers and a leading expert in the field of women’s mental Health.  “The presentation of anxiety symptoms varies from overwhelming thoughts and images of something bad happening to the baby, to fears that they could somehow harm their newborn. These thoughts can lead to a full blown anxiety attack and a decline in normal functioning,” says Dr. Pirec.

According to recent studies, 16% of postpartum mothers experienced pure anxiety symptoms, while only 6% had pure depression; 4% of the sample had comorbid anxiety and depression. Many experts in the mental health field feel more research is needed. 

Pregnant and postpartum women are often not adequately screened for anxiety even though they are considered an at-risk population for developing new anxiety disorders, or exacerbation of preexisting anxiety symptoms.

“We need improved awareness for perinatal anxiety among both the general public and health care providers,” says Dr. Pirec.  “In some cases, symptoms can start in pregnancy and continue in postpartum, which could affect either fetal or child development.”

Symptoms of perinatal anxiety can include:

  • Excessive worrying –  A persistent focus of a specific anxiety, such as excessive fear of sudden infant death, or a developmental issue which may or may not be objective.  These fears can lead to hyper-vigilance by the mom.
  • Severe insomnia – Most new moms lack sleep, but this would involve the inability of the woman to fall asleep or stay asleep even when the baby is resting.
  • Obsessions during pregnancy – The patient could be plagued by thoughts and images that something bad will happen to the baby, such as worrying about the baby falling or being contaminated by food or medication.
  • Obsessive compulsive symptoms in postpartum period – Examples include obsessively worrying about harming the baby, possibly to the point that the mom would avoid the baby.  Rituals could be created in the caring of the baby and could result in a decline in overall functioning.

Treatment of these issues is often adequately served with intensive out-patient services that would include individualized and group treatment, as well as medication management when appropriate.

Insight Behavioral Health Centers recently launched a comprehensive program tailored specifically towards mood and anxiety disorders in peripartum women.  The program includes individual and group therapy, with more than ten treatment groups for women covering a wide range of issues and experiences.  It focuses on assessment and treatment that is tailored to the patient’s specific needs.

“If left untreated, perinatal anxiety can progress into more severe forms of mental health illness,” says Dr. Pirec.  “If family members and health care providers can identify the signs early, we can take steps to ensure better health for mom and baby.”

About Insight Behavioral Health Centers In addition to its newly added women’s mental health program, Insight Behavioral Health Centers specialize in treatment for adolescents and adults dealing with mood and anxiety disorders and eating disorders including anorexia, bulimia, and binge eating.  Insight is accredited by the Joint Commission and a teaching affiliate of the McGaw Medical Center of Northwestern University. Insight currently has four locations including Northbrook, Evanston, Willowbrook and downtown Chicago.  For more information, visit www.insightbhc.com, or call 312-540-9955. For media inquiries, please contact Debra Baum at 847/767-1206 or at debra_baum@comcast.net.

SOURCE Insight Behavioral Health Centers

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New TLC special profiles obsessive cleaners in ‘Neat Freaks’

Neat Freaks on TFLNeat Freaks on TFL

This woman spends all day, every day cleaning as it is described on the coming TLC special, ‘Neat Freaks.’

Do you clean too often, and sometimes feel a little embarrassed about it? Just as watching reality shows often improves one’s mood through the schadenfreude of peering into lives that are more disordered, TLC has a new special airing soon that will make you feel comparatively normal. Neat Freaks, a one hour special airing on Wednesday December 5 at 10 p.m. features people who literally spend their entire lives scrubbing their homes.

Meet one African-American character named Alfreta. She is so compulsive in her disinfection regime that she not only scrubs her own bathroom with bleach daily, she also cleans the bathrooms in homes she visits — and public restrooms.

The show follows her as Alfreta does her daily routine of detailing her home from top to bottom. As she explains it, “I clean once a day, but once a day is all day.”

Neat Freaks will also introduce audiences to a man named Caleb, who sprays himself and dates down with hydrogen peroxide before sex, and Christy, who hates having guests over because they might sully her sterile interior.

In keeping with similar hits like Hoarders that profile the mentally ill, Neat Freaks might be a smash if this special is picked up and airs as a series. Yet, while we are shaking our heads at these crazy antics, we must remember that we are watching people caught in the grip of a tormenting condition.

According to the trusted medical resource WebMD, engaging in repetitive rituals such as cleaning as a means of fighting a fear of germs is a symptom of OCD or Obsessive-Compulsive Disorder.

“Obsessive-compulsive disorder (OCD), a type of anxiety disorder, is a potentially disabling illness that traps people in endless cycles of repetitive thoughts and behaviors,” the outlet states. “People with OCD are plagued by recurring and distressing thoughts, fears, or images (obsessions) they cannot control. The anxiety (nervousness) produced by these thoughts leads to an urgent need to perform certain rituals or routines (compulsions).”

In the case of the Neat Freaks cast, cleaning might allay each person’s fear of germs, as the repetition of certain acts becomes a calming activity similar to the predictable nature of a church service. Yet, for OCD sufferers, the respite from anxiety is only momentary.

RELATED: Eating disorders quietly plague black communities

“Although the ritual may temporarily alleviate anxiety, the person must perform the ritual again when the obsessive thoughts return,” the WebMD outline on OCD states. This means that people such as Alfreta and Christy remain trapped repeating acts that keep them from living normal lives.

You may think Alfreta is a rarity among African-Americans with this problem, but, unfortunately there is very little data about the prevalence of the issue among blacks. Many think of the popular main character of the beloved show Monk when germphobia comes to mind, and may balk at the idea that OCD also plagues African-Americans — but people like Alfreta are not an anomaly.

It may be found that OCD affects blacks at the same rates as other groups when sufficient information is collected about this demographic. What is known is that when blacks do suffer from the disorder, they are less likely to seek treatment.

“OCD among African Americans and Caribbean blacks is very persistent, often accompanied by other psychiatric disorders, and is associated with high overall mental illness severity and functional impairment,” relates an abstract from a paper on the subject published by the US National Library of MedicineNational Institutes of Health. “It is also likely that very few blacks in the United States with OCD are receiving evidence-based treatment and thus considerable effort is needed to bring treatment to these groups.”

I am not diagnosing Alfreta with OCD, and watching her scrub her bathroom fixtures with a toothbrush might indeed make for “can’t look away” television. But, a show such as Neat Freaks can’t help but remind us of the symptoms of OCD, which is a serious disease — one that research shows not enough African-Americans receive help with it. Hopefully, this show will be a gateway for more blacks to become aware of its symptoms and lessen the cultural stigma against psychiatric treatment that pervades our community as it entertains.

Follow Alexis Garrett Stodghill on Twitter at @lexisb.

(This piece has been edited for clarity.)

Care trumps pills for peace of mind

CHENNAI: Government employee Sudheer Ramakrishnan, 37, was a stickler in many ways. He would step out of his house with a box containing precisely nine betel leaves and one painkiller. Those, he believed, relieved him of his frequent migraines.

One day, on his way to work, he was shocked to find that he had only seven leaves in the box. He asked the bus driver to stop the vehicle but when the driver refused, he turned violent. “Seven leaves instead of nine,” he shouted.

A psychiatrist diagnosed Ramakrishnan’s problem as obsessive compulsive disorder (OCD) and put him on medication which left him drowsy and weak. But Ramakrishnan recently discovered cognitive behaviour therapy (CBT) when he visited a new psychiatrist. The doctor found that his frequent headaches were linked to panic attacks he had as a child in the dark.

The psychiatrist put him through a series of goal-oriented and systematic procedures that rid Ramakrishnan of the connection with the ‘dark’ memory from his childhood. Ramakrishnan now goes to work without the betel leaves and painkiller.

Welcome the new shrink, who does not prescribe medicines. A growing number of psychiatrists in the city are using CBT instead of drugs to cure psychological problems.

Experts say the development will benefit mental healthcare because psychiatrists in the country have all but abandoned talk therapy, the form popularised by Sigmund Freud, and embraced multiple drug treatment. The drugs they prescribe include sedatives, antipsychotics and inhibitors of dopamine, a chemical that acts as the brain’s neurotransmitter. The doctor spends much less time with each patient, and the medicines only stupify patients.

On the other hand, say psychiatrists, CBT is a psychotherapeutic approach that addresses emotional stress and maladaptive behaviour without the ill-effects of drugs. “It helps tone down aggressiveness, fight fears and depression,” says Dr B S Virudhagiri Nathan, director of CARE Institute of Behavioral Sciences, Chennai.

The therapy has been found to be effective for mood swings, psychotic disorders, phobias and attention deficit hyperactivity. “Through conversation and interactive audio-visual tools, CBT specialists help patients think positively,” says Dr Nathan, who runs a CBT training programme in the city in collaboration with University of Manchester.

Psychologists say teachers, doctors and parents should be trained in CBT, which evolved since the 70s. “The training helps when dealing with children who may have fears,” says Dr Deborah McNally, acting director of Salford cognitive therapy training centre, University of Manchester.

However, the city has few CBT specialists. “Our focus should be to teach CBT to counsellors and psychologists, teachers and parents,” says Dr S Karunanidhi, head of the department of psychology, Madras University.

Nearly 7% of India’s population suffers from some form of mental disorder, and doctors estimate more than 7 lakh people in Tamil Nadu require periodic psychiatric care.

Latest cure

What is CBT?

Cognitive behaviour therapy focuses on SUBHEAD changing HERE illogical thought patterns that trigger mental disorder

Symptoms of OCD

Obsessive compulsive disorder is an anxiety disorder characterised by unwanted thoughts and repetitive behaviors, which are often irrational. For example, repeatedly washing of hands fearing contamination, repeatedly checking if the doors are locked and being obsessed with order and symmetry

What does the therapy entail?

The therapist follows the ‘ABC’ pattern – activating event, beliefs about the event and consequences. The therapist traces the event that triggered the disorder and the client’s immediate interpretation of the event, which can be rational or irrational. The train of thoughts and the behavioural disorder triggered by the event is also assessed by the therapist, who then strives to help the client challenge their thought patterns and beliefs through intensive counselling

Symptoms of behavioural disorders among children

Lack of concentration, fear of going to school, temper tantrums, hyperactivity, irrational fears, frequent defiance, low self-esteem

Symptoms of depression

Mood swings, irritability, loss of appetite, loss of weight, fatigue, absent-mindedness, lack of libido, sleeplessness, frustration, suicidal thoughts and magnifying vague physical pains

Why Houston Rockets Massive Gamble on Royce White Will Pay Off

For a Houston Rockets franchise that has been starved of superstar talent since the days of Yao Ming and Tracy McGrady, Royce White‘s combination of size and skill was simply too great to pass up.

They knew about his well-chronicled struggles with his obsessive compulsive disorder and anxiety disorder. They even knew that his fear of flying would open a suitcase of problems given the rigorous travel demands of an NBA regular season.

But, the Rockets thought White—the only player in the nation to lead his team in points, rebounds, assists, steals and blocks—was worth the gamble. 

The fact that White has yet to appear in an NBA game might suggest that he wasn’t.

But Houston didn’t use the 16th pick of the 2012 draft with the season’s first 15 games in mind. They were clearly thinking big picture with this pick, a concept Houston fans would be wise to embrace.

Houston GM Daryl Morey elaborated on his team’s thought process on a podcast with slate.com’s Stefan Fatsis, Josh Levin and Mike Pesca.

In short, Morey said the pick was talent-based, a wise move in such a talent-driven league.

The Rockets faced the reality that the draft pick was more than a typical draft-day crapshoot. They understand that the move is still a gamble.

But, they also know just how unique White’s skill set is.

White’s game has drawn comparisons to everyone from Boris Diaw to Lamar Odom. Truth be told, the NBA may have never seen a player like the former Cyclone.

He’s big (6’8″, 260-lbs.) and he’s strong (Iowa State coach Fred Hoiberg said White bench-pressed 185 pounds 30 times in pre-combine workouts, according to The Gazette’s Rob Gray) and his court vision is nearly unmatched at the power forward spot, NBA and college players included.

He’s also an effective post scorer with a shooting range that extends to the mid-range. He’s active on the glass, securing rebounds or keeping balls alive with tips when he can’t secure them.

Clearly, the Rockets have their work cut out for them with White.

His absence isn’t just a media whirlwind sweeping through their locker room, it’s also chewing up valuable time in the 21-year-old’s development.

Whether or not White ever steps on to an NBA court, he was well worth the gamble.  The Rockets wanted a superstar and found a player with all of the physical tools to be that guy.

OCD in Kids is Difficult to Diagnose

Childhood OCD is a Difficult Diagnosis Obsessive-compulsive disorder (OCD) is an anxiety disorder often characterized by unwanted thoughts or repetitive behaviors. In children, OCD is difficult to diagnose and a definitive diagnosis is often delayed.

A new German study discusses diagnostic and treatment challenges of OCD, in the journal Deutsches Ärzteblatt International. In the article, Susanne Walitza, M.D., and colleagues point out that appropriate early recognition and treatment can positively affect the course of the disease.

Walitza discovered that compulsive washing, the most common obsessive-compulsive manifestation among children and adolescents, is present in up to 87 percent of all patients.

Children may also demonstrate compulsive repetitive behavior and checking, and obsessive thoughts of an aggressive type.

Attention deficit hyperactivity disorder is present in more than 70 percent of patients. Obsessive-compulsive disorder presenting in childhood or adolescence often becomes chronic and impairs mental health onward into adulthood.

Researchers believe the specific manifestations of obsessive-compulsive disorder can be diagnosed early with psychodiagnostic testing.

Behavioral therapy, although time-consuming, has been found effective and is considered a first-line treatment. In behavioral therapy, the patient is confronted with the situation that precipitates the obsessive-compulsive manifestations, while suppressing the manifestations.

Second-line treatment consists of behavioral therapeutic intervention combined with drug therapy.

Despite intensive treatment, the pervasive nature of the disorder often means that patients will need ongoing psychotherapy or combination therapy to prevent a later recurrence.

Experts believe much is still to be learned about the disorder. Currently, researchers believe the disorder stems from a complex, multifactorial combination of psychological, neurobiological, and genetic factors.

Source: Deutsches Aerzteblatt International

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‘My house is my safe zone’


She thinks I look awkward, like I don’t know what to do at her door. She gets that a lot. People wondering, “Should I shake her hand? Should I not?”

She’s used to it. She extends her hand towards me first. A firm, warm shake with a smile to match.

I step into her house, remove my shoes and walk into her living room. I have socks on. She notices all this. Acutely, uncontrollably, compulsively aware. She makes me a cup of coffee. Hands me a mug. We start talking.

Ashley Berry, 27, has lived with Obsessive Compulsive Disorder since she was about nine years old. She’s been hospitalized twice.

She wants people to understand it. To understand her.

“It’s not just a germ thing,” she offers straight up, smiling.

We talk more. She is candid, eager to explain. She started therapy four years ago and is doing better.

Yet, she is still at its mercy.

“My house is my safe zone,” she tells me.

If I would have walked on her floor with shoes on, or bare feet, she would have panicked. Footprints are like wet paint, she explains. They get smeared by other people walking over them, and contaminate the entire house. Bare feet, mean warts, mean disinfecting her floors with vinegar.

The coffee mug I use is not hers. She has her own that no one else touches.

I leave it on the living room floor and she has a hard time picking it up after I’m gone. There is coffee inside. And it’s lukewarm — prime breeding ground for bacteria.

She manages to pick it up. “I already felt contaminated,” she says. She had prepared herself to have a “dirty day” anyway. She doesn’t know me, or the state of my own house, and I am in her space.

She throws out the coffee and puts the cup in the dishwasher. She hasn’t touched it since.

“I won’t use it again until it feels right,” she says. Maybe in a couple of months.

She washes her hands. Since shaking my hand, she’s been careful not to touch her hands to her face. Then, awhile later, she showers with hot water.

She’s allowed one shower a day. She planned for my visit by having a shower the night before. She knew she couldn’t have one in the morning, because she’d need one after I left.

People often say things to her like: “Oh, I have OCD too. I love it when my house is clean.”

There is no comparison. None.

“You may like a clean house,” she says.

“I can’t get it out of my mind that my house isn’t clean.”


Ashley’s List of Fears:

• Only shower once a day (20 anxiety)

• Only wash body parts once while in the shower (20 anxiety)

• Only clean washroom once a week (20 anxiety)

• Not showering for a full day (30 anxiety)

• No showering for 30 minutes after going to the gym (40 anxiety)

• Walk with socks down the hallway at the hospital (50 anxiety)

• Walk down the same hallway without socks (60 anxiety)

• Be around someone who has been in contact with a wart (70 anxiety)

• Be around someone with a wart (80 anxiety)

• Touch a wart and wash hands (90 anxiety)

• Touch a wart without washing hands (100 anxiety)

• Swim in a public pool without swim shoes (100)

Ashley’s recovery began in 2008 when she started seeing a psychiatrist at the Anxiety Treatment and Research Centre, at St. Joseph’s Hospital in Hamilton.

Part of her healing involved facing her worst fears. In her words, “a calculated form of torture.” Planned exposures to events that make her live in fear until her anxiety drops by half.

She is writing a book about her experiences. It’s full of raw, honest anecdotes. Warts are her biggest fear. She’d rather have cancer than warts.

She writes about her first appointment with her psychiatrist, a woman she calls Dr. X.

She took me into her office and told me to take a seat. There were two chairs in her tiny office; it took me a minute to decide on which chair I would sit in, and which chair would occupy my ‘clean’ purse. I hated putting my purse on the ground, as the bottom would get contaminated and eventually end up in my room. The contamination would spread from my purse to my floor to my socks to my bed sheets to my raw skin. Purse on floor now meant panic attack later. So I often kept it above my waist. When I try and explain contamination fears to people I often tell them to think of it like never-ending wet paint. Watch it’ tracks and you’ll see what I see.

Therapy began by developing a list of her worst fears, rating them out of 100. Showering was the first to be tackled.

At this point in my life I was showering 2-4 times per day. I had shower rituals that would take up to 45 minutes each time. I cleaned the washroom every other day with a bucket of pure bleach, with a new clean pair of latex gloves every day. I would use a different towel every time I showered, and was careful not to touch my feet to the tiled floor when exiting. We had two rugs in the washroom that I allowed myself to step on with bare feet. I changed my socks 5 times a day, depending on if I was out in public it would be more. I kept an extra pair in my purse just in case of emergency. Most people keep money for an emergency, I choose socks.

She kept her showers to 10 minutes, once a day, with lukewarm water. She whittled them down to seven minutes.

She felt confident. Empowered. Enthused to tackle more fears.

Then came her third session. When Dr. X announced she had to be “completely honest,” Ashley’s thoughts exploded.

“Oh no, do you have a wart?” My heart was racing. If she had a wart that means that her whole office would be contaminated. I would have to burn my clothes, and all of the other clothes that I’ve worn here, I need to make a list and burn them all. I can buy new clothes, but I can’t come back here. I can’t believe she has a wart. How did I get stuck with a psychiatrist who happens to have a wart. Only 10% of people have a wart at this moment in time, how am I with someone who is in that percentile? She interrupted me with her confession.

Dr. X confessed that her daughter had a wart on her foot.

Ashely had a wart, once. It took her a year to get rid of it. A year that consumed 2-4 hours of her life every night. Exhaustive, self-imposed rituals involving multiple latex gloves and handwashing in red-hot water. If she didn’t execute it precisely, she’d start again.

“It’s not about the pain,” she says. “It’s about the ritual, the exhaustion.”

Immediately after her doctor’s confession, Ashley was engulfed in a full-blown panic attack. She felt like she was going to die. Racing heart. Watery eyes. Red hot. Burning up inside. Short, gulps of breath. Drenched in sweat. The room was spinning.

No one can touch her. During an attack, a hug is abrasive and painful. She is not ashamed; she just needs time.

Dr. X helped her breathe and relax. Ashley felt like she’d run a marathon and was driven home, exhausted.

I was contaminated. I took an hour shower when I arrived home. Scalding hot, including all my rituals. Hair washed first, then face, scrubbed from shoulders to toes, repeat twice. When I got out of the shower, my body was red, burned, and hot to the touch. I was finally clean. A stage that would last for only seconds, but I cherished these tiny moments, as they were few and far between.

Over many weeks, Ashley completed exposure therapy. She walked in her socks, then in her bare feet, down the hospital hallway. She walked barefoot on the deck of an indoor pool. Swam without water shoes, bare feet touching the shiny, wet ladder on the way down.

The air was warm and humid, and it smelled blissfully like ‘clean’ chlorine. There were other swimmers, just two in the far right corner of the pool. I stood on one tile, feet together and belly breathing. I wasn’t sure if I was ready. The girl in the corner got out of the pool and was trying to dive back in. I noticed that she was handicapped, and her father was teaching her how to swim. Her illness was so clear to the world. Mine was hiding. I sometime wish that I could wear a bracelet or some sort of insignia that people knew I had a mental disorder. It would free me from all of the worrying about what people actually thought of me when I was freaking out in the middle of a panic attack. The girl dove in as her father caught her just in time. We were a lot alike, me and this girl. She also needed her father to help her as much as I needed my mother there to encourage me. I smiled as she came out of the pool to attempt another dive. If she could do that, I could certainly do this. I took another step onto another tile and waited for my anxiety to drop. There were metal steps leading into the pool that I was instructed from Dr. X to go down. Silver, shiny and wet, the three words that I could certainly do without.


People in Business for Sunday, Nov. 25

Union Bank promotes Nelson and Moritz

Union Bank Trust has promoted Chad Nelson to vice president-manager in greater Nebraska and Amanda Moritz to officer-branch manager in Grand Island.

Nelson has been with the bank for 10 years and began his career as branch manager of the Fairbury branch. He transferred to Grand Island as branch manager in 2009.

With his promotion, Nelson will oversee and lead the retail and lending aspects of Union Bank’s 12 locations across greater Nebraska. Nelson earned a bachelor of science in business administration from Doane College in Crete.

Moritz has been with the bank for 11 years and was a branch supervisor and consumer loan specialist in Lincoln before transferring to Grand Island as branch supervisor in 2009. With her promotion, Moritz will be responsible for staff management and fostering a culture of customer service, as well as business development, mortgage, consumer and commercial lending.

Moritz attended Nebraska Wesleyan University in Lincoln. She serves on the board for the Boys and Girls Club of Central Nebraska and is a member of the Grand Island Area Chamber of Commerce Young Professionals Group.

Grand Island law firm hires Malm, Hruza

Tim Malm has joined the Leininger, Smith, Johnson, Baack, Placzek Allen law firm in Grand Island.

He received a bachelor of arts from the University of Nebraska at Omaha in 2009, double majoring in history and political science. He graduated cum laude from the University of Illinois with his juris doctorate in 2012.

Malm is admitted to practice in Nebraska and U.S. District Court, District of Nebraska. He is a member of the Nebraska Bar Association. He sits on the board of the Central Plains Chapter of the American Red Cross. A Plattsmouth native, Malm and his wife, Kasey, moved to Grand Island in June.

Tim Hruza has joined the Leininger, Smith, Johnson, Baack, Placzek Allen law firm as an associate attorney.

He graduated from the University of Nebraska at Kearney in 2009, receiving a dual degree in political science and economics cum laude. Hruza was involved in both the honors program and student government at UNK, serving as the student body president and student regent during his senior year.

Hruza received his law degree from the University of Nebraska-Lincoln in May, graduating with distinction. He also received a certificate of concentrated study in the area of agricultural law, focusing heavily on water law issues and farm program compliance. While in law school, Hruza was a member of the Nebraska Moot Court Board and won awards for his performance in oral advocacy competition.

He grew up in Ord and is married to his wife, Rachel.

Bachman announced as managing broker

Woods Bros. Realty has named Max Bachman as the managing broker for the Grand Island office at 819 Diers Ave.

Bachman has a bachelor of arts in business administration from the University of Nebraska-Lincoln. He received his real estate sales license in 1992 and his broker’s license in 2005. Bachman has been associated with Woods Bros. Realty since 2000.

Bachman, a lifelong Grand Island resident, has been married to his wife, Melanie, for 30 years. They have two children.

Bachman can be reached at 380-1983 or Max.Bachman@WoodsBros.com.

Grand Island downtown announces new director

The Grand Island Downtown Business Association has named Tami Brunk as its new director, effective Nov. 1.

Brunk has more than 22 years of property management experience working for Costello Property Management in government housing as its Nebraska regional manager. She received Manager of the Year from U.S. Department of Agriculture Rural Development in 1999.

She is also a general notary public.

Brunk and her husband, Dr. Douglas Brunk, own Equine Veterinary Associates in Grand Island.

She can be reached at 404 W. Third St. from 8 a.m. to 2 p.m. Mondays through Fridays, 398-7022 or director@downtowngi.com.

New case manager joins Hope Harbor

Beth Rhodes has been hired at Hope Harbor as self-sufficiency case manager.

The new self-sufficiency program will fill gaps for those who successfully leave Hope Harbor by continuing to offer support in their quest for self-sufficiency.

Rhodes will assist with building and maintaining community support, help locate safe and affordable housing and provide in-home case management and financial education. She recently moved to Grand Island from California.

AseraCare Hospice adds Gunderson to staff

AseraCare Hospice in Grand Island has hired Phyllis Gunderson as an advanced practice registered nurse.

She will be responsible for face-to-face assessments to certify hospice eligibility.

Gunderson attended the University of Nebraska Medical Center through the University of Nebraska at Kearney to become a registered nurse, earn her bachelor of skilled nursing and become an advanced practice registered nurse.

She has also worked with Department of Veterans Affairs and is a member of the Nebraska Nurses Association.

New stylist seeing clients at Fringe salon

Molly Clark has joined the stylist team at Fringe in Grand Island.

She has been a stylist at Great Expectations in Omaha, J.C. Penney Salon in Kearney, DeAnna’s in Kansas City and E.J. Bain in Kansas City. She graduated from Bahner College of Hairstyling in 2000.

Clark is an advocate for Freedom Stylist, a branch for the nonprofit organization Rapha House, which educates and trains at-risk young women in communities where they are in danger of being sold into slavery or exploited. A portion of each salon service is donated to Rapha House through the Freedom Stylist program.

Originally from Doniphan, she and her husband have three sons and one daughter.

Fringe is at 3406 W. Capital Ave. Suite 2. For appointments, call (308) 258-3758.

McElroy wins Health Care Social Work Leader of Year

St. Francis Medical Center Social Work Director Cris McElroy was recognized as the Health Care Social Work Leader of the Year on Oct. 18 in Lincoln at the Nebraska Hospital Association convention.

Established in 2000, the award recognizes an exceptional chapter member of the Nebraska Society for Social Work Leadership in Health Care.

The award recognizes a social work leader from any of the health care settings in which social work is influential and honors a social work leader in health care who develops and implements creative and innovative ways to improve the delivery of social work services.

Schwan attends training on EEG neurofeedback

Joan Schwan, a licensed mental health practitioner and owner of Joan Schwan Counseling Services in Grand Island, attended a two-day intensive mentoring program with neuroscientist Dr. Mike Cohen on Nov. 10 and 11 in Jupiter, Fla.

The training focused on new brain research affecting mental health protocols for treatment, as well as skills to enhance reading electroencephalography (EEG) brain waves, brain mapping and EEG neurofeedback.

EEG neurofeedback can be used to treat attention deficit hyperactivity disorder, anxiety, depression, obsessive compulsive disorder, autistic spectrum, sleep disorders and other issues. It can also be used to enhance peak performance training.

Research conducted by the psychiatry department at the University of Western Ontario has shown neurofeedback as a “safe, inexpensive and accessible tool for modulating brain function in health and disease.”

Schwan can be reached for questions or appointments at 381-7010.

Hutchinson receives national NAIFA Quality Award

Michael C. Hutchinson, an agent for New York Life Insurance Co. and financial adviser with Eagle Strategies, a registered investment adviser in Grand Island, has received the NAIFA Quality Award from the National Association of Insurance and Financial Advisers for 2012.

The award recognizes professionalism through education and earned designations, production, adherence to the NAIFA code of ethics and service to the association.

Hutchinson serves individuals, families and businesses in Grand Island, Kearney and the surrounding communities. His office is at 1213 Allen Drive in Grand Island, and he can be reached at 382-0619.

Seven nominated for March of Dimes award

Seven nurses from St. Francis Medical Center were nominated for the March of Dimes Excellence in Nursing Award.

They included Amy Djernes, Pam Glaser, Mary Micek (retired from St. Francis), Alice Quick, Linda Ulmer, Maxine Vieth and Sue Whitman. Quick and Vieth were among 25 recipients of an award given for clinical excellence.

St. Francis Vice President of Patient Care Servicers/CNO Francine Sparby congratulated the seven nurses on their accomplishment.

Bullied, Institutionalized for Tourettes

From the age of 7, Frank Bonifas has endured the most severe form of Tourette syndrome, and it started long before the medical community even had a name for the neurological disorder.

Doctors convinced his parents that he could control his tics and outbursts, which had him grunting, jerking and swearing with impunity. They blamed his mother for coddling him and, in 1968, as a young teen, they sent him to a psychiatric hospital for 18 months.

Bonifas, now 58 and living in Coldwater, Ohio, experienced assaults by school bullies and was forced to take high-dose medications that made him so listless one year, he lost two months of school.

Even in hospital wards, he was tortured by staff members who thought his outbursts were deliberate. He even had to fight with Social Security to get disability payments because Tourette syndrome was not listed in the medical journals.

“I resented all psychiatrists, psychologists and social workers,” he said. “They had no idea what was wrong with me and blamed me, my mom, dad and sister for my problems.”

Now, in a self-published memoir, “Fu-Fu-Fu Frank,” he writes about his wrenching childhood and the determination he had to overcome the odds of living with a misunderstood disorder.

Bonifas prefaced his Thanksgiving day telephone interview with ABCNews.com in anticipation of his uncontrollable use of the “F word,” punctuated with grunts and screams.

“I am not a violent person,” he said. “I am a loving person who just has Tourette’s.”

Despite severe physical handicaps, Bonifas was able to write the book because of Marilyn Kanney, a former nurse and friend of his late mother who has loved and supported him since he was in high school. He calls her “a second mother.”

“She took my thoughts and put them into sentences and wrote them into paragraphs and chapters,” he said. “They were all my words, but she allowed me to make it a reality … It took us 15 years to finish it.”

Bonifas decided to go public with his story after friends encouraged him to write. His first goal was to educate others about Tourette syndrome. But the second was to be financially independent and get off disability assistance and Medicaid.

The turning point in his life was in 1973, when a husband-wife psychiatric team, Drs. Arthur and Elaine Shapiro of New York Hospital, gave his condition a name.

At 18, Bonifas was one of the first people in the United States to be diagnosed with Tourette syndrome.

“I taught my doctor everything he knows about Tourette,” said Bonifas. “Dr. Shapiro said to me at the time, ‘Frank, to your credit, you haven’t blown your brains out by now.

“I put my trust in doctors and nurses for the first time in my life,” he said.

According to the Tourette Syndrome Foundation, the disorder is defined by multiple motor and vocal tics lasting for more than one year. The verbal tics can include grunting, throat clearing, shouting and barking.

It was named for a French neuropsychiatrist, Gilles de la Tourette, who assessed the disorder in the late 1800s. But it wasn’t until the 1970s that it was widely recognized in the U.S., where it was thought to be exceptionally rare.

In 1980, the condition was broadened to include milder cases of tics. Fewer than 10 percent of all patients swear or use socially inappropriate words, which makes Bonifas’s condition so socially isolating.

The first symptoms, usually before the age of 18, are involuntary movements of the face, arms, limbs or trunk, such as kicking or stomping. They are frequent, repetitive and rapid. The patient cannot control these movements and they can involve the whole body.

ADD and OCD Can Accompany Tourette Syndrome

According to Dr. Jonathan Mink, chief of pediatric neurology at Rochester University, who sits on the board of the Tourette association, the disorder is still poorly understood and likely has a genetic link.

Many patients, like Bonifas, also have symptoms associated with attention deficit hyperactivity disorder and obsessive compulsive disorder.

“The majority of kids, even those bad enough to seek treatment, are likely to have their tics diminish or go away,” said Mink.

Habit reversal therapy — teaching a person with Tourette to hold his or her breath, for example, instead of saying the repeated word, can sometimes help. Antidepressants are used to treat associated anxiety.

Today, several medications have helped Bonifas manage his symptoms, but his early years were spent in torment, in and out of mental institutions, hospitals and experimental programs.

In the introduction to his memoir, doctors attest to the “exorcisms” that Bonifas underwent to rid him of his “demons.” He claims he was exploited and abused, even sexually, by many who were entrusted to care for him.

A devote Catholic and former altar boy, Bonifas once considered entering the seminary. Strangely, his first outburst of profanity occurred in the seventh grade when looking at a church spire.

The thought — “The Blessed Virgin Is a F***er” — just burst into his mind. He was convinced he would burn in hell.

But Bonifas had no control over that or other obsessive-compulsive habits, such as dressing, washing and brushing his teeth in a particular sequence.

His behavior in school was problematic, too. Teachers saw his outbursts as an attention-seeking device. He was “barking, snorting, sniffing, hissing and more.”

By high school, he was badly bullied. Seniors pulled down his pants, taunting: “Now we’ll see if he is a dog or a human being.”

Another time, he was pushed into a large garbage can and rolled down the steps to the first floor.

After being sent to a local hospital ward for treatment, he got “special care” more than a half dozen times. Orderlies confined Bonifas to a locked steel cell with a pillow and a pad. After that, he developed lifelong claustrophobia.

In exercise classes in a swimming pool, he claimed the leader seemed to enjoy dunking his head underwater until his lungs “nearly burst.”

But eventually, Bonifas found New York Hospital, where modern treatments and an educated and understanding medical team, gave him hope. He was the 35th patient Dr. Shapiro had ever treated.

His roommate was Dr. Orrin Palmer, a Maryland doctor who overcame Tourette and now practices psychiatry.

“Frank and I went through hell on these protocols,” Palmer wrote in one of the forwards in the book.

Doctors experimented with an array of high-dose medicines that caused side effects, such as insomnia, motor restlessness, mood swings and even Parkinson’s symptoms.

“I had to sign papers that I was a guinea pig,” said Bonifas. “If the medicine made me incompetent or I lost my mind or was comatose or died, they were not responsible.”

His response to his doctor’s orders was, “Just tell my small town that I am not the devil, not doing this on purpose and that I have a mind.”

After five months, his mother brought him home and things started to get better. Were it not for her, “they would have institutionalized me for life,” he said.

Today, Bonifas works as a part-time mail clerk at a local bank. He said life is still “incredibly difficult.”

But since the publishing his book, he said, “Many people have a better understanding of what I go through on a daily basis, and I have been treated much better.”

He takes a low dose of haldol, ativan, cogentin and many natural vitamins. Bonifas also has taken up yoga with a trainer.

Bonifas cares for his 88-year-old father who lives upstairs. His beloved mother died of Alzheimer’s disease in 2004.

“I just wish she were alive to read it, but my faith tells me that she is in Heaven and is proud of everything I’m trying to accomplish,” he said.

More recently, cultural attitudes toward those with Tourette syndrome have begun to change, according to Bonifas.

“Most people who have become familiar with it are more understanding,” he said. “However, many are not aware of how serious the disease is, still feel that anyone afflicted with it should be able to control all of its symptoms.”

Much still needs to be done, according to Bonifas.

“Parents and teachers can be more supportive and understanding of people who are different,” he said. “Children learn at a very early age how to treat others, and there are too many bullies today as a result of the prejudices of all who teach them.”

Bonifas volunteers in schools and organizations to help change attitudes.

With all the hurdles he has overcome, the dark shadow of growing up in a world ignorant of his needs still haunts Bonifas.

“I have tried to put my past behind me, but every day is challenging and difficult,” he said. “I’m working on it.”

“I think that all people should accept those who are different or handicapped,” he said. “They should have to spend one day in their shoes, and see how it feels.

His faith and the encouragement he has received from readers of his memoir keep him going.

“It just comes down to this: There is you and God,” he said. “I have a lot of faith and a lot of determination.”

Also Read

OCD Brain Has Higher Activity When Dealing With A Moral Dilemma

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Main Category: Psychology / Psychiatry
Also Included In: Anxiety / Stress
Article Date: 11 Nov 2012 – 0:00 PST

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Morality problems cause much more worry for people with OCD (obsessive-compulsive disorder), compared to the general population, researchers from the Hospital de Mar, Barcelona, Spain, and the University of Melbourne reported in Archives of General Psychiatry.

The authors added that their findings prove that patients with OCD are much more morally sensitive than people without the disorder.

Obsessive-compulsive disorder is a chronic (long-term) condition in which the patient has persistent and repetitive thoughts and compulsive behaviors.

Co-lead authors, Carles Soriano, said:

“Faced with a problem of this type, people suffering from this type of anxiety disorder show that they worry considerably more.”

The scientists studied how the participants’ neurofunctional activity rose when faced with moral dilemmas with the use of fMRI (functional magnetic resonance imaging). They recruited 146 volunteers, 73 with OCD and 73 “healthy” individuals. They measured each person’s brain activity when faced with different moral questions – choices had to be made between two alternatives, neither of which led to positive consequences.

For example, they were presented with a classic in philosophy classes – The Crying Baby. The participants had to imagine they were in a war and enemy soldiers were lying in wait to attack. The whole village is hiding in a cellar. A baby starts crying. Unless the crying is stopped immediately, the solders will find the villagers. Smothering the baby’s crying would save the villagers, but would also risk suffocating the baby – would it be right to stop the crying in this way?

Soriano pointed out:

“The brain activations displayed by participants in the face of such a moral question were compared to those displayed for trivial choices, like choosing between going to the countryside or the beach for the weekend.

The authors found that during moments of moral dilemma, those with OCD had significantly more activity in the orbitofrontal cortex, especially in the medial part, which is associated with decision making processes and the development of moral sentiment.

The researchers wrote “The data allows us for the first time to objectify the existence of cerebral dysfunctions related to alterations in complex cognitions, such as experiencing morality. This allows us to expand further on the characterization of altered cerebral mechanisms in OCD.”

OCD and Anxiety compulsion

Obsessive-compulsive disorder is characterized by persistent thoughts (obsessions) that trigger worry and fear, as well as repetitive behaviors (compulsion) which are performed in an attempt to reduce associated anxiety. Approximately 2% of people are affected by OCD.

OCD patients are generally categorized into different types. “The majority are characterized by being obsessed with dirt and compulsive cleaning or by doubting that they have carried out important actions properly, like turning off the gas. Such behavior makes then repeatedly check whether they have performed such actions.”

Other obsessions and compulsions may include the need to be surrounded by perfectly symmetrical objects – patients may hoard them.

In some cases, patients may suffer from unwanted sexual or religious thoughts in which they are not sure whether they have committed an unacceptable sexual act, and wonder (worry) whether they have blasphemed. “This last group of patients is identified for precisely having a higher level of moral hypersensitivity.”

Written by Christian Nordqvist

Copyright: Medical News Today

Not to be reproduced without permission of Medical News Today

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Disability insurance urged for dental hygienists

Identify Depression Among ‘Perfect’ Colleagues


The dental hygiene job market is saturated in some areas and soon to be saturated in more areas. There are fewer full-time positions, and the part-time positions usually have no health insurance benefits. For many, this means paying for their own health insurance, and what is affordable has a high deductible and probably little or no prescription coverage.

Dental hygienists who are not practicing are working odd jobs in unrelated fields or are simply unemployed. Some have given up on the profession entirely, and are becoming educated in other professions. The financial strain and frustration can lead to anxiety and situational depression, even in those people who have never before experienced depression.

This article is dedicated to a dental hygienist who practiced for over 25 years, and due to the recent scarcity of jobs, could find only a part-time position. She had no benefits and only catastrophic medical insurance because that’s all she could afford. She suffered from depression, and the only treatment that seemed to help was a “specialty drug” (medical insurance term for brand name top tier) she could not afford, and her insurance would not pay for it. She described her severe anxiety and emotional pain as “unbearable.” Sadly, she took her own life.

In order to protect her identity, details about her are not included in this article. The personality trait that was a contributing factor to her severe anxiety and depression was called elevated perfectionism. Another factor that contributed to her depression was stress.

The objectives of this article are to promote an awareness of these factors and their association with general anxiety disorder (GAD) and major depressive disorder (MDD); discuss how the combination of anxiety and depression increases the chances of suicidal ideation; and to promote awareness and suicide prevention.


Striving for excellence is a healthy goal, but when people have unrealistic expectations of themselves and others, they create unhappiness in themselves and their relationships. Continuously functioning in this self-deprecating manner often leads to severe anxiety and depression. With perfectionism of this magnitude, there is often procrastination due to fear of failure, or even difficulty with decision making, as the choice may result in failure.1

Adjustment to life changes that do not align with lofty pursuits can result in extreme anxiety and profound sadness. For the elevated perfectionist, coping with day-to-day life is a challenge, but when a traumatic event occurs, coping can become nonexistent.1

Research has shown that elevated perfectionism not only makes certain individuals vulnerable to depression; it also makes them vulnerable to a variety of anxiety disorders, eating disorders, and obsessive-compulsive disorders. Many psychotherapists now use assessment scales to diagnose and treat perfectionism to reduce anxiety, depression, and associated disorders.3

Here is a link to the free electronic Multidimensional Perfectionism Scale: http://www.bbc.co.uk/science/humanbody/mind/surveys/perfectionism/


The accuracy and attention to detail required of dental hygienists make perfectionists ideal candidates for the profession.4 Ask any dental hygiene instructor about their daily dealings with students, and they’ll tell you that many insist on getting an “A” in every class or on every clinical exam. Perhaps we’ve recruited many perfectionists into the profession. You may remember being in dental hygiene school and hearing your instructors say, “Dental hygiene is not an exact science. Therefore, we call it ‘practice’ because we never get it perfect!”

Unfortunately, that expression falls on deaf ears of people with elevated perfectionism. She or he is the one who becomes anxious at patient checkout for fear the dentist will discover some minor omission in the dental hygiene patient exam. Then one day that hygienist may find something the dentist missed in his or her patient exam, and hopefully the hygienist will learn that “Perfection is unattainable.”


Fear of failure, or just plain trying to survive, when there is insufficient income for living expenses is a daunting situation. The uncertainty of survival and lack of adequate medical care can keep someone in fight or flight mode. This is anxiety on a continuous level, the type that causes insomnia and physical symptoms common to general anxiety disorder (GAD).

Anxiety disorders include:

  • Panic attacks — occur due to a sense of doom and lack of control.
  • Obsessive compulsive disorders — obsessive thoughts or repeated behaviors of checking, counting, or hoarding, often paired with eating disorders, over-exercising, and a variety of routines that relieve anxiety.
  • Posttraumatic stress disorder — anxiety and depression that occur within three months of a traumatic incident. Flashbacks replay the trauma as if it were occurring again.5

The following link includes a free anxiety assessment scale: Taylor Manifest Anxiety Scale (http://personality-testing.info/tests/TMA.php).

Major Depressive Disorder (MDD)

Major depressive disorder includes a variety of depressions that may or may not include all of the symptoms in the syndrome of generalized depression:

  • Inability to function
  • Inability to concentrate
  • Fatigue
  • Lack of energy
  • Feeling immobilized
  • Sleeping too much
  • Insomnia or sleep disturbance
  • Loss of interest in daily activities
  • Loss of interest in sex
  • Overeating or lack of appetite
  • Nervousness and agitation
  • Persistent sadness, crying
  • Anxiety and hopelessness
  • Guilt and worthlessness
  • Thoughts of death or suicide

Physical symptoms such as headaches, pain, and gastrointestinal disturbances that become chronic and resist treatment are often associated with major depression.6

Comorbid Anxiety and Depression

Current reviews of the literature show evidence of high risk of suicide in people with a combination of anxiety and depression.7 The largest percentage of people presenting with this combination are middle-aged women.8 There is an overlap in the symptoms of the two disorders, making it difficult to discern whether the anxiety is a symptom of the depression, or a separate disease entity that will not be relieved by antidepressants.

Comorbid anxiety and depression often require a combination of antidepressants such as selective serotonin reuptake inhibitors (SSRIs), or selective serotonin-norepinephrine inhibitors (SNRIs) and antianxiety drugs such as benzodiazepines. Examples of common antidepressants are fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), and desvenlafaxine (Pristiq). Common antianxiety drugs are alprazolam (Xanax), diazepam (Valium), and clonazepam (Klonopin). If the patient’s condition still resists treatment, antidepressant augmentation with aripiprazole (Abilify) has shown complete remission in some patients with comorbid anxiety and depression, and pramipexole (Mirapex, Mirapexin, Sifrol) has shown complete remission in some patients with depression not combined with anxiety.9,10,11,12

Patients may not be diagnosed with comorbid anxiety and depression, but may be treated on symptoms. Most antidepressants do not relieve every symptom on the MDD list.13 The physician may treat various symptoms with additional drugs, e.g., benzodiazepines for anxiety, sedative-hypnotics for insomnia, and proton pump inhibitors for acid reflux. A patient may be on an array of medications for various symptoms and still not be in complete remission from depression. Could the profile of comorbid anxiety and depression be masked by the regimen? Does failure to diagnose comorbid anxiety and depression present a greater risk for suicide ideation? More research is needed to answer these questions.

Comorbid anxiety and depression require a multimodal therapy carefully planned by the physician who has conducted a comprehensive evaluation of the patient using all assessment scales and diagnostic methods to arrive at the accurate diagnosis. Psychotherapy as well as pharmacotherapy must be included in the treatment plan.13

Suicide Awareness

Not everyone exhibits classic signs of depression or suicidal ideation. If they did, more lives would be spared. But if someone you know is depressed, it’s a good idea to ask that person if he or she is having thoughts of suicide. Suicide websites and training kits contain information stating that asking does not provoke someone who is not suicidal into becoming suicidal, and asking may be the key to getting someone to accept help.

NOW, you the reader — Do you have thoughts of suicide? If you answered yes, call the National Suicide Prevention Lifeline 800-273-TALK (8255).

For a complete guide to suicide awareness, go to www.suicide.org/index.html.

Local hotlines are also helpful for those with suicide ideation. Here is the National Suicide Prevention hotline link for finding a center categorized by country or state — http://www.suicide.org/suicide-hotlines.html.

Our fallen colleague was an elevated perfectionist, but out of the darkness of her quest for perfection, there was a crack of bright light filled with her love for friends and animals. She was an excellent caregiver to others. One could say she truly served the greater good, except she lacked self-love. She was perfect in many of her accomplishments, but not in her pursuit of happiness.

She is greatly missed and loved by many.

From the lyrics of the song “Anthem” by Leonard Cohen:

Ring the bells that still can ring
Forget your perfect offering
There is a crack in everything
That’s how the light gets in

Top 10 Signs Your a Perfectionist

  1. You cannot stop thinking about a mistake you made.
  2. You are intensely competitive and can’t stand doing worse than others.
  3. You either want to do something “just right” or not at all.
  4. You demand perfection from others.
  5. You will not ask for help if asking can be perceived as a flaw or weakness.
  6. You will persist at a task long after other people have quit.
  7. You are a fault-finder who must correct other people when they are wrong.
  8. You are highly aware of other people’s demands and expectations.
  9. You are very self-conscious about making mistakes in front of other people.
  10. You noticed the error in the title of this list3

Source: Gordon Flett, PhD


1. Flett GL, Stainton M, Hewitt PL, Sherry SB, Lay C. (in press) Procrastination automatic thoughts as a personality construct: An analysis of the Procrastinatory Cognitions Inventory. Journal of Rational-Emotive and Cognitive-Behavior Therapy.
2. Flett G. “York researcher finds that perfectionism can lead to imperfect health” York’s Daily Bulletin, York University, Toronto, Canada, June 2004.
3. Egan SJ, Wade TD, Shafran R. “Perfectionism as a transdiagnostic process: a clinical review. Clin Psychol Rev. 2011 Mar; 31(2):203-12. Epub 2010 May 5. Source: School of Psychology and Speech Pathology Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia. s.egan@curtin.edu.au.
4. Henning K, Ey S, Shaw D. “Perfectionism, the impostor phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students” Medical Education article first published online 4 Jan 2002 DOI: 10.1046/j.1365-2923.1998.00234.x.
5. Stein MB. Attending to anxiety disorders in primary care. J Clin Psychiatry 2003;64 (suppl 15):35-39.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR) Washington DC, American Psychiatric Publishing, Inc. 2000.
7. Cyranowski JM, Schott LL, Kravitz HM, et al. Depress Anxiety. 2012 Aug 28. doi: 10.1002/da.21990. Psychosocial features associated with lifetime comorbidity of major depression and anxiety disorders among a community sample of midlife women: The Swan Mental Health Study. Source: Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
8. Joffe H, Chang Y, Dhaliwal S, et al. Arch Gen Psychiatry. 2012 May;69(5):484-92. Lifetime history of depression and anxiety disorders as a predictor of quality of life in midlife women in the absence of current illness episodes. Source: Department of Psychiatry, Center for Women’s Mental Health, Massachusetts General Hospital, Harvard Medical School, Simches Research Bldg, 185 Cambridge St, Ste 2000, Boston, MA 02114, USA.
9. Hori H, Kunugi H. The efficacy of pramipexole, a dopamine receptor agonist, as an adjunctive treatment in treatment-resistant depression: an open-label trial. ScientificWorldJournal. 2012;2012:372474. Epub 2012 Aug 1.
10. Dold M, Aigner M, Lanzenberger R, Kasper S. Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a meta-analysis of double-blind, randomized, placebo-controlled trials. Int J Neuropsychopharmacol. 2012 Aug 29:1-18.
11. Yoshimura R, Kishi T, Hori H, Ikenouchi-Sugita A, Katsuki A, Umene-Nakano W, Iwata N, Nakamura J. Comparison of the efficacy between paroxetine and sertraline augmented with aripiprazole in patients with refractory major depressive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2012 Jul 17.
12. Maher AR, Theodore G. Summary of the comparative effectiveness review on off-label use of atypical antipsychotics. J Manag Care Pharm. 2012 Jun;18(5 Suppl B):1-20.
13. Dunlop BW, Davis PG. Combination treatment with benzodiazepines and SSRIs for comorbid anxiety and depression: a review. Prim Care Companion J Clin Psychiatry. 2008;10(3):222-8.
14. Pychyl TA. Words of Healing for Perfectionists: Forget Your Perfect Offering. Psychology Today 2010 Nov 19.

CYNTHIA BIRON LEISECA is president of DH Methods of Education, Inc., Home of Boot Camp for Dental Hygiene Educators. She is also the producer of two DVDs, “Precision in Periodontal Instrumentation,” and “A Focus on Fulcrums.” Cynthia is the distributor of “The Sharpening Horse Kit,” www.DHmethEd.com.

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