Shrinks In Sneakers

Category: Psychiatry

  • Introduction to Mindfulness

    Introduction to Mindfulness

    Mindfulness never struck me as something I could see myself doing on a regular basis. For many years, I viewed the practice as something for “enlightened people” with no practical application for the average person. As the years went on and the research continued to pile up in the literature, I decided to try it out. 

    There are two basic ideas to keep in mind during meditation practice. We are not aware of how our body is feeling, and we are not aware of the constant stream of thoughts occurring all day long. By bringing attention to these two things we can begin to take control of our bodies and our minds.

    The process is very simple and can be performed from most locations. Ideally you want a quiet place where you will be undisturbed for 10-15 minutes. I personally like the 10-minute mediation session, and it works well if you have a busy schedule. 

    To begin the process, find a chair, preferably one you can sit upright in with your feet on the floor and back straight. I like to rest my hands on my legs.

    I begin the process with my eyes open, and a few deep breaths in through the nose and out through the mouth. On the 5th breath I close my eyes. I return to my normal rate and rhythm of breathing in through the nose and back out through the nose. 

    Next I begin the process of performing a body scan. I like to start at the head and work my way down to the toes, noting any discomfort or tension. I will also take note of areas on the body the fell relaxed and tension free. This should take 1-2 minutes. 

    If at any point thoughts pop into your head, it’s fine let them come but most importantly let them go. Do not dwell on any one particular thought, just allow them pass. 

    The next step is a series of breathing exercise I learned several years ago. Start with 10 breaths in through the nose and out through the mouth, counting each one. Then perform 10 breaths in through the nose and out through the nose, again counting each one as you go. Finally, take a breath in through the nose, hold it for 5 seconds, and release it slowly through the mouth to a count of 4. This sequence of breathing exercises should be performed two times for a total of 60 breaths. This will take approximately 5-7 minutes. 

    For the final 1-2 minutes do not count or breath in any particular manner just allow the mind the space to think about anything it wants to. After a minute or two bring the focus back to the body, feel the feet on the floor, and arms on you lap. Open your eyes slowly, and sit for a minute to think about what you are grateful for before starting your day. It’s an excellent way to practice some gratitude. 

    The more you practice this technique the easier it will be for you. As the days go on you will experience more control over both your body and your mind. 

  • Millennial Doctors Financial Woes Continue

    Millennial Doctors Financial Woes Continue

    Introduction

    All millennial physicians had a lot to process over the last several weeks. The coronavirus rapidly spread across the United States leading to the worst financial crisis since 2008. No generation in history has had to deal with two major events that ravished the economy in a relatively short period of time. It started with the financial crisis of 2008, and now a coronavirus pandemic that once again threatens the financial future of many people. At this point no one knows the full impact this pandemic will have on the economy.

    The current crisis presents a number of concerns for young physicians. The primary concern of many recent graduates, or early career physicians is taking care of patients and remaining safe. A big part of what happens to the economy over the next several months depends on the work of public health officials, hospital systems, and healthcare providers.

    Understandably, financial well-being is not the primary concern for many. Most physicians make a big financial sacrifice early in life, forgoing the earnings of our early 20’s in favor of education. Once you navigate medical school successfully, you enter another period of low earnings in residency. There is no doubt that our career choice and the multiple financial crises altered the lives of young physicians permanently.   

    Financial Tips for a Recession  

    It wasn’t too long ago when I received the first paycheck I ever made as a physician. It was a big moment for me, I received $763.26 for doing the work that I loved. I even have the paycheck framed on my wall. After eight years of not making a single dollar and taking out a six-figure loan to fund my education, I finally felt like this was my time. There were many things I neglected over those eight years that I needed to address. Most of my friends and family who chose different career paths were buying houses, saving for retirement, and not driving an old car. My initial goal was simple, I just wanted to stop worrying about how to pay my monthly bills. Below are several strategies I used over the last three years to save money, pay debt, and improve my financial health. 

    Living with Family to get a Jump Start  

    The first choice which helped me immensely was selecting a residency program close to home which allowed me to move back in with parents for the first year. A goal of mine was to practice in the community I grew up in, and when that opportunity presented itself, I could not pass it up. It also allowed me to live rent free for one year to help pay for transportation, build a small emergency fund, and pay off the one private loan I took out for residency applications and travel. I realize this is not possible for everyone and my situation is unique, but if an option like this is available to you, consider it.

    Secure Reliable Transportation 

    I started with selling my old Honda and looking for reliable transportation. I eventually settled on a Honda which I purchased used for $16,500. I know it seems pricy for a person with limited resources, but the investment felt worthwhile due to my expected commutes. I like Honda for their reliability, low cost maintenance, and fuel economy. The other car company that fits into this category is Toyota. 

    Have a Small emergency Fund

    Next, I opened a high interest savings account with the goal of having $1,000 in it for emergencies. I wanted a small amount of cash available to cover any unforeseen expenses.

    Develop Good Financial Habits and Protect Your Family

    I focused on developing good financial habits, learning to save, and started thinking about how to invest a portion of my earnings in the next few years. Financial education became a big part of my study plan because it’s not taught in any medical school. I also secured own occupation disability insurance, and term life insurance. It’s important to protect yourself and your family in the event you are unable to do your job or pass away unexpectedly. This is even more important with the COVID-19 pandemic.

    Housing Is a Major Expense 

    One of the keys to my success was low cost of living. I made the decision to move out of my parents house 2nd year. This required some significant out of pocket expenses including a security deposit, some furniture, and costs associated with setting up a new place. The biggest impact was related to the monthly rent payment. Although it was reasonable for the location it was still a significant portion of my monthly income. Finding ways to reduce your housing costs may be the single biggest benefit to your financial future.

    Investment Options:

    From all my research, it was clear that index fund investing was the best method and produced reliable returns over time with minimal management on the investors part. The real decision was between opening a personal retirement account like a ROTH IRA or opening an employer sponsored account such as a 401k or 403b. Most advice you will find recommends the ROTH over the employer account given the eventual higher earnings and tax bracket most doctors will be in after completing residency. I have since found that it really depends on your individual situation. If you have a high student debt burden and want to reduce your adjusted gross income, or your employer matches contributions you may want to opt for the 401k or 403b. I settled on the employer-based retirement plan. I was able to select several low-fee index funds and was happy with the options provided. The automatic deductions made the process simple, and helped me reduce my adjusted gross income and thus my student loan payments.

    COVID-19  Optimism

    This is a work in progress as the year is ongoing. I’ve been looking at the entire COVID-19 situation in terms of the potential benefits that may arise. If you are still in training or an early career physician, the most important financial asset you have is time. Over the span of a 30-year career the economy will fluctuate, with some bad years and some really great years. Things were bad in 2008, but if you made saving a priority, invested your money wisely, and paid off debt by 2018 you were doing really well. Unlike those who are looking to retire, or are retired we have an opportunity to invest heavily in a down market. I believe it’s a prime opportunity to lay the foundation for your financial future.

    We also have the added benefit of some student loan relief which was not an area of focus in 2008. It looks like the economic stimulus will allow for no interest and no payments on direct or federally held loans for the next 6 months. If you are on REPAYE, PAYE, or PSLF you don’t need to do anything to qualify for the payment and interest freeze. It’s refreshing to see the federal government acknowledge the need to provide student loan relief after failing to consider the long term impact it would have in 2008. 

    We need to prepare ourselves for the next several months and continue to take the necessary steps to secure our financial future. We must believe in our own resiliency and capacity to grow during hardship. We’ve been through a recession before, and this is not likely to be the last. 

  • Chronic Inflammation And Depression

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    Introduction:

    Inflammation is the body’s natural response to infection or injury. It’s an important response in the acute setting but chronic inflammation can contribute to the development of diseases such as heart disease and even depression. Most psychiatrists now recognize that inflammation plays a role in depressive disorders, although it’s not an inflammatory disease. Much of the research on inflammation and depression is ongoing and will develop over time. 

    Risk Factors for Inflammation

    ·         Childhood trauma

    ·         High stress levels (work, school)

    ·         Depression that is resistant to treatment

    ·         Severe anxiety

    ·         Obesity BMI> 30

    ·         Medical illness

    ·         Recent injury or surgery

    What are some nonpharmacological things we can do to reduce inflammation and thus the risk of disease?

    Complementary and alternative therapies

    Lifestyle: Exercise, Healthy diet, Mindfulness practice, CBT all have anti-inflammatory effects.

    N-acetylcysteine studies with 2000 mg/day improved anxiety and depressive symptoms

    L-methyl folate: L-methyl folate 15 mg/day as augmentation to antidepressants

    Omega-3: 1000 mg/day of omega-3 fatty acids with DHA to EPA ratio > 60% improved depressive symptoms

  • When Should Hospitalization be Considered for Depression?

    Introduction 

    This post is significant to me because one area I really enjoy working is the inpatient psychiatric unit. This might seem strange, but it’s a place I just gravitate towards and fell like I’m having a meaningful impact. You can think of it as the equivalent to the medical intensive care unit (ICU). It’s a place to learn about the most severe psychiatric pathologies and medication management.

    In this post I will cover some of the signs and symptoms that may indicate inpatient hospitalization could help and possibly be lifesaving. 

    Signs and Symptoms

    Suicidal Ideation:

    If your depression has become so profound that you have thoughts about “killing yourself,” then it might be time for inpatient treatment. Many clinicians, especially those not working in mental health, feel uncomfortable asking direct questions about suicide. Contrary to a common belief, asking about suicide does not increase the risk of suicide. I like to use the term “kill yourself” when doing a suicide assesment. It’s very definitive and clear to the patient what I’m talking about. The concern increases if there is a plan in place for the person to kill themselves, the plan is logical, feasible, and the person intends to carry out the plan. All of these are warnings that the person is at high risk. If these thoughts are persistent that’s another indicator that the problem is more serious. 

    There is a significant difference between the above situation and the person who has “passive suicidal thoughts.” Passive suicidal thoughts are statements like “If I didn’t wake up tomorrow, I would be okay with it.” It’s not that the person is actively trying to prematurely end their life, rather they would not mind if something happened that hastened the path towards death. 

    Hopelessness:

    Another validated risk factor for suicide is severe, unremitting hopelessness. Hopelessness consists of feeling that nothing is getting better, nothing will ever get better, and there’s nothing I can do about it. This, independent of other risk factors, puts the person at high risk for suicide.

    Loss of Interest:

    Severe anhedonia (loss of interest) in previously pleasurable activities is part of the diagnostic criteria for depression, it’s also something that can increase suicide risk. If a person previously went to the gym five days a week or watched every new episode of The Bachelor and suddenly no longer cares about these things, it may be cause for concern.

    Poor Response to Outpatient Treatment:

    If you have been in traditional outpatient therapy and medication management for many years with minimal or no improvement, and you have never been hospitalized for psychiatric purposes before, then inpatient hospitalization may help. Sometimes the break from the daily life stressors for 3-5 days allows the mind and body to rest. If you tried everything else, then who knows? This could be the intervention that changes your life.

    Seeking inpatient psychiatric care is nothing to be ashamed of, and many mental health professionals are working hard to destigmatize psychiatric care. I like to think about inpatient psychiatric care as a mental wellness camp, and not as a punishment for mental illness.

    If this information is useful please like, share, and subscribe to the blog and other social media sites. Drop us a comment about what topics you are interested in, and we will try to cover them. 

    If you or someone you love is at risk for suicide, the following resources are available. 

    National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org

    National Suicide Prevention Hotline: 1-800-273-8255

    SAMHSA: https://www.samhsa.gov/grants/grant-announcements/sm-20-011

  • How to Tell if You Have Depression

    Images that show what it feels like to suffer from mental illness. Bringing the inside to the outside.

    Depression is not always easy to spot, and in a world filled with social media it always seems like everyone is living their best life. 

    In the most severe states people can have suicidal thoughts and profound hopelessness. The symptoms can be mild, moderate, or severe. Depression can affect anyone. 

    Depression is an illness like any other disease (diabetes, hypertension, heart disease) that affects thoughts, feelings, physical health, and behaviors. 

    People with major depressive disorder have several of these symptoms every day or nearly every day for 2 weeks or more. 

    Here are some signs that you may have depression 

    At least one of the following, loss of interest in things you previously enjoyed or depressed mood  

    At least 3 of the following 

    • Feeling slow or restless 
    • Feeling guilty or worthless
    • Increased or decreased appetite
    • Suicidal thoughts 
    • Problems concentrating, making choices, or remembering things 
    • Difficulty sleeping or sleeping too much 
    • Having low energy 

    Potential physical signs of depression include 

    • Headaches
    • Muscle tension 
    • Digestive symptoms 
    • Sexual problems 
    • Feeling “keyed up”

    This can be summed up in the mnemonic SIGECAPS taught to medical students everywhere. The mnemonic comes from the prescription a doctor might write for a depressed patient

     SIG:  1 energy capsules per day 

    Please like, comment, and share the post if it was helpful. Let us know what else you would like to see. 

  • Addiction 101: Making the Diagnosis

    Addiction 101: Making the Diagnosis

    Chances are high that you know someone with an addictive disorder. This article provides information on how we diagnose addictive disorders and the symptoms included in substance use disorder diagnoses.

    Diagnosing addictive disorders is based on the Diagnostic and Statistical Manual of Mental Disorders aka DSM, which is currently on version 5. The DSM is considered the Bible of psychiatry (be on the look-out for a forthcoming article on the storied history of the DSM, it’s more dramatic than you might think). First, let’s address which substance use disorders are currently included in the DSM.

    1. Alcohol

    Self-explanatory. Beer, wine, liquor, hand sanitizer (yup, I’ve seen it).

    2. Caffeine

    That’s right, caffeine use disorder is a psychiatric diagnosis. It’s a substance that produces psychological and physiological effects in the body and is frequently overlooked. This includes coffee, tea, diet coke, monster energy drinks, and the list continues. Some over the counter supplements contain caffeine such as popular pre-workout drinks. It’s a sneaky chemical and found in many foods and beverages.

    3. Cannabis aka marijuana

    Consumed in various ways. Comes from the various parts of the cannabis sativa or cannabis Indica plant. There is a frequent misconception that “marijuana isn’t addictive.” While marijuana doesn’t typically have a withdrawal syndrome, it most certainly is included in the list of substances that may result in substance use disorders.

     4. Hallucinogens

    Hallucinogens are divided into classic and dissociative hallucinogens. The classic category includes drugs like LSD, psilocybin (magic mushrooms), peyote, and DMT (ayahuasca.) Examples of dissociative hallucinogens include PCP, ketamine, dextromethorphan (found in cough syrup), and salvia. They can be used in a variety of ways and generally alter awareness and perception.

    5. Inhalants

    Okay so this is a really random category because it may include so many things. Basically, anything that can be inhaled and shouldn’t be. Spray paint, gasoline, whipped cream bottles, cleaning spray, lighters. If it is a substance that gets inhaled, it falls in this category.

    6. Opioids

    Makes the news all the time due to the high risk of overdose death. Includes drugs like Percocet, OxyContin, heroin, and fentanyl. May be taken by mouth, snorted, or injected. The respiratory arrest caused by these drugs is reversed by a drug called Narcan or naloxone, which is administered via injection or nasal spray.  

    7. Sedatives/Hypnotics/Anxiolytics

    This category encompasses CNS depressants including the ever-popular benzodiazepines (such as Xanax and Valium). Also includes sleeping medications such as Ambien as well as some old school medications like phenobarbital. (Fun fact: butalbital, a barbiturate related to phenobarbital, is one of the ingredients in a prescription headache medicine Fioricet, in combination with Tylenol and our friend caffeine.)

    8. Stimulants

    Most famous drug of abuse stimulant first: cocaine. My favorite song about cocaine is White Lines by Grandmaster Flash and the Furious Five. Give it a listen. White Lines on YouTube. Methamphetamine (crystal meth) is probably the second most well-known stimulant, sensationalized by the popular show Breaking Bad. Other drugs of abuse in this category include medications for ADHD such as Adderall.

    9. Tobacco

    Cigarettes, dip, vaping. Perhaps the deadliest of the drugs of abuse. According to the American Academy of Addiction Psychiatry, tobacco use disorder is the most common substance use disorder and affects 60-80% of smokers. (Reference) This drug has been directly linked to a number of cancers, stroke, blood clots, heart disease, and lung disease and causes a tremendous burden to public health.

    10. Other

    Catch-all for any other drugs that meet criteria for a substance use disorder. Continually evolving.

    Bonus: Gambling

    Gambling is the only behavioral addiction currently included in the DSM although internet gaming and hypersexual disorders are under investigation. 

    Diagnosing

    Next – how are these disorders diagnosed? Contrary to what you may think, quantity of drug consumed and frequency of use aren’t included in the diagnostic criteria. The mandatory component to diagnosing a substance use disorder is that the drug use leads to significant impairment or distress. If there is no impairment in life functioning or distress, there is no substance use disorder, regardless of whether the behavior upsets others.

    In addition to functional impairment, there are eleven criteria that comprise the diasnosis of substance use disorder. Two are needed to make a diagnosis. The criteria are divided into four categories: (i) impaired control, (ii) social impairment, (iii) risky use, and (iv) pharmacological criteria. The diagnoses are further classified into mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6-11 symptoms). The symptoms must have occurred during a twelve month period. Below you’ll find examples of each criteria for alcohol use disorder.

    1. Using more substance than intended or using over a longer period of time than intended.

    Example: Planning to have a glass of wine and then drinking the whole bottle.

    2. Using substances in hazardous situations.

    Example: drunk driving

    3. Continued use despite interpersonal problems.

    Example: arguing with spouse while drunk, arguing about drinking too much

    4. Tolerance

    Example: Needing six drinks to feel buzzed when it used to take three.

    5. Withdrawal

    Example: Getting tremors, or “the shakes” when abstaining from alcohol.

    6. Continued use despite problems at work, school, or home.

    Example: getting suspended from school for showing up drunk

    7. Unsuccessful efforts to cut down on substance use 

    Example: Decided not to drink this weekend, but by Friday night, purchased a case of beer

    8. Lots of time spent obtaining, using, or recovering from the substance.

    Example: Teenager spends the entire day on a Friday finding someone to buy alcohol for the weekend and then all day Monday in bed with a hangover.

    9. Important activities given up due to substance use.

    Example: Stopped going to the gym because of either being drunk or hungover most of the time.

    10. Continued use despite physiological or psychological problems caused or worsened by the substance.

    Example: Drinking despite having elevated liver function tests indicating liver damage.

    11. Craving.

    Example: The strong desire for a drink. If you haven’t had a craving before, it’s difficult to explain. It can occupy your entire brain and thoughts.

    This has been a fairly dense post, but hopefully it clarifies how substance use disorders are diagnosed. In the future, this foundational knowledge will provide a framework for current event topics related to addictive disorders.

    Addictive disorders are of particular interest to Shrinks in Sneakers! If there are any specific topics you would like to hear about, please reach out and we will work on something.