- The gut microbiome consists mostly of bacteria and that is largely the portion of the microbiome we are focusing on (fungi and viruses exist but their function is largely unknown)
- Communication pathways exist between the microbiota-gut-and brain.
- Multiple mechanisms exist that allow gut microbiota to signal to the brain and control physiological processes.
- These include release of gut peptides from enteroendocrine cells which activate receptors of the immune system and vagus terminals in the gut.
- Studies indicate that these bacteria can manufacture and secrete essential neurochemicals including serotonin, dopamine, NE, GABA, and acetylcholine
- Depression and anxiety have been linked to a less well diversified gut microbiome.
- What can help diversify the gut microbiome? Diet, processed food, sugar, saturated fats, and red meat. Medication can also alter the gut microbiome, a good example is oral antibiotics used to treat an acute infection, sleep, exercise. Sounds a lot like a healthy lifestyle will get you the microbiome you need for optimal mental health.
- However, if you want a treatment there have been several studies that looked at fecal transplant to treat psychiatric disorders. Fecal transplants are much easier these days and now there is a capsule version that you take orally. There is not enough data to recommend this as a practical treatment and if the patient goes back to eating a poor diet, sleeping poorly, not exercising then the gut microbiome will revert after the transplant.
- What are the practical things you can do? Stop eating processed food, sugar, and red meat. Increase your fiber intake and select a diet like the Mediterranean diet or a plant based whole food diet that will provide those prebiotics. You could supplement with a probiotic but most of what you need can be had from a good diet alone and I think it’s far better to change the diet then to try using supplements to treat a poor diet. Fermented products like kimchi, kombucha and sauerkraut are good sources of live bacteria.
- If you choose to take a probiotic make sure it’s a quality, 3rd party tested product.
- Increase aerobic activity, I think if you goal is overall general health and you have limitted time, I think aerobic activity is a better bang for your buck.
- The way I believe you get and keep a healthy gut microbiome is through lifestyle modification. Improving your diet, exercise, and sleep is a good place to start. If you want to supplement with food products like kimchi or kombucha, go for it. I do not believe there is enough evidence to support a probiotic supplement for psychiatric disorders at this point, but if you want to spend $30 or more per month on a product if it’s a quality one that’s fine. Remember you cannot supplement away a bad diet.
I trained in a location where white coats were never worn by psychiatrists. I only wore mine during the professional photos on the first day of residency. From that point forward it remained in my closet.
The choice to discard the white coat always made sense to me, because I believe one of the most healing aspects of psychiatry is the physician patient relationship. One way to enhance that relationship is to make my patients feel as comfortable as possible. There is a concept in primary care called “white coat hypertension” where some patients have increased blood pressure only when coming to see their doctor. In psychiatry you can imagine a similar scenario. Some patients experience severe anxiety prior to the initial encounter. Others have had previous bad experiences with psychiatrists making them more prone to this “white coat syndrome.”
My goal is to have a meaningful conversation with my patients, and some of the material we discuss is very sensitive. There is no reason to make that conversation any more intimidating than it already is. Everything from my style of interviewing, to dress is meant to be casual to help establish trust. Trust is an important foundation for any relationship and is critical for any physician patient relationship.
I detached myself long ago from white coats as a symbol of knowledge or prestige. I trust in my skills as a physician and allow those skills to speak for themselves.
Anxiety is something most of us have experienced. This five-step exercise can be helpful during periods of anxiety by helping to ground you in the present moment.
Start the exercise by drawing attention to your breathing. Slow, deep, breaths can help you induce a feeling of relaxation. Once you feel relaxed, go through the following steps to ground yourself:
One: Note ONE thing you can taste
Examples may include: gum, sugar free candy, coffee, sparkling water (anything you can taste in the moment).
Two: Note TWO things you can smell
Examples may include: fresh air, scented candle, flowers, food cooking (anything around you that you can smell)
Three: Note THREE things you can hear
Examples may Include: people talking, cars driving, wind blowing, rain falling (anything in the environment you can hear)
Four: Note FOUR things you can touch
Examples may Include: desk, chair, pen, phone (anything around you that you can touch)
Five: Note FIVE things you can see
Examples may include: door, computer screen, car, tree, house (anything you see around you)
Amidst the abundance of coverage of the 2020 presidential election mixed with an evolving pandemic, here is a news story you may have missed: it’s 2020 and guns are more popular than ever in the US. According to data from Small Arms Analytics to date, Americans have purchased nearly 17 million guns in 2020. This is more than any previous year on record. Handgun sales increased by 81% and long-gun sales increased by 51%. We saw a similar trend in 2016 when 16.6 million guns were sold. This was driven by increased rhetoric calling for strict gun control laws in the wake of several mass shootings.
As psychiatrists and concerned citizens, this data is alarming. We know that the presence of a gun in the home alone increases the risk of suicide. Specifically, owning a handgun is associated with a dramatic increase in suicide risk. Men who owned handguns were eight times more likely to die by self-inflicted gunshot wound. Women who owned handguns were 35 times more likely to kill themselves with a gun. Access to guns in the home is such a concern for depressed patients that it’s a part of every psychiatric evaluation. Suicide is often an impulsive act, and many of those who survive a suicide attempt regret their actions. Guns permit people to be dangerously impulsive. Lethality of means determines whether a person will survive a suicide attempt. In the United States, where more civilians’ own firearms than any other country, our most lethal means are guns. Suicide attempt by firearm will most likely result in death: an irrevocable and permanent result of the combination of an impulsive decision and a gun.
So, what is this about? Is there an increased interest in hunting that some of us missed? The plain answer is no. Most guns purchased in the US are not intended for hunting; instead, people are purchasing guns for “protection.” The increase in gun sales comes at a point in history of great political and social unrest. Maybe it is unsurprising that people feel an urge to protect themselves and their families. Fear is at an all-time high.
You know what else is at an all-time high? Isolation, loneliness, anxiety and depression. The most well-adjusted people are struggling in 2020. Depressed moods can progress to clinical depression which may include suicidal thoughts as part of the diagnostic criteria. Now, we have a country full of depressed people buying guns. In the mental health field, we are scared. You should be too. The financial, political, and public health uncertainties of today’s world form a perfect substrate for depression, fear, and impulsivity. Adding a gun is not the way to fix it.
We know that gun access provides a substantial risk for suicide. It remains important that we educate our patients about the risk of gun ownership. This is especially important for patients who have a history of depression or other psychiatric disorders. All this could be a potentially dangerous combination of psychopathology, and access to lethal means.
Thinking Style in Anxious Patients
- There is a heightened level of attention to potential threats in the environment
- Example: A women with fear of airplanes has to fly across the country for work, she believes the plane is likely to crash despite the low risk of this actually occurring.
Predominant thinking patterns in Anxiety
- Fears of harm and danger
- Increased attention towards potential threats
- Overestimation of the risk of situations
- Automatic thoughts associated with danger, risk, uncontrollability, incapacity
- Underestimates of ability to cope with fearful situation
- Misinterpretation of bodily stimuli
- The emotional and physical response to the feared object or situation is so severe that the person will do anything to avoid it.
- Because the avoidance behavior is rewarded with emotional relief, the behavior is more likely to occur when the person is faced with similar circumstances.
- Example: A person with anxiety is invited to a party and decides to make up an excuse not to go and the anxiety is relieved. Each time the person is faced with a similar situation they are likely to act the same way.
CBT Model for Anxiety
- Unrealistic fear of objects or situations
- A pattern of avoidance reinforces the belief that I cannot deal with the feared object or situation
- The pattern of avoidance must be broken to overcome the anxiety.
- There are two general methods of behavior treatment for anxiety
- Reciprocal inhibition: A process of reducing emotional arousal by helping the person experience a positive or healthy emotion in place of the unhealthy one. (deep breathing, relaxation techniques)
- Exposure: expose yourself to the stressful situation, fear will occur but cannot be sustained indefinitely and the person will begin to adapt to the situation.
Assessment of symptoms, triggers, and coping strategies
- What is the event that triggers the anxiety?
- What are the underlying automatic thoughts, cognitive errors, and schema involved in the overreaction to the feared stimulus?
- What is the emotional and psychological response?
- Habitual behaviors such as avoidance?
- Cognitive errors have been found to occur more often in people with depression and anxiety.
- There are 6 main categories of cognitive errors
- Selective abstraction: A conclusion is drawn after looking at only a small amount of information. Other contradictory information is screened out to confirm the persons biased view of the situation.
- Arbitrary inference: A conclusion is reached in the face of contradictory evidence or lack of evidence
- Overgeneralization: a conclusion is made about one or more isolated incidents and then extended illogically to cover broad areas of functioning.
- Magnification or minimization: The significance of an attribute event or sensation is exaggerated or minimized.
- Personalization: external events are related to oneself when there is little or no evidence for doing so.
- Absolutistic thinking: judgments about oneself, others or personal experiences are placed into one of two categories: All good or All bad
- Relaxation training: reducing muscle tension induces a state of relaxation and often results in reduced anxiety
- Rate the level of anxiety and muscle tension on a scale of 0 to 100, with 0 being no tension and 100 being max tension
- Try making a fist and squeezing to a level of 100, then release it to a level of 0. Try doing so with the other hand. Notice that we have voluntary control over how much tension we feel.
- Starting with the legs tense and release each muscle group working your way up to the head. (I prefer to do this laying down)
- Try to keep positive mental images in your mind while doing this. Example: picture your tension and worries melting away like ice when left out in the sun.
- Try doing this daily for 1 week and record how you feel before and after a session.
2. Thought stopping: Stop negative thoughts and replace them with positive adaptive thoughts.
- Recognize: that a dysfunctional thought pattern is active
- Give self-instructions to interrupt the thought pattern: Shift attention away from the anxiety provoking thought. (STOP! Or Don’t go there!)
- Consider guided images: try to imagine doing something enjoyable, playing a game, watching a sport, going on vacation. This can be combined with muscle relaxation
3. Distraction: Develop several positive scenes that you can go to when anxious. Examples include walking in a nice park, going to your favorite restaurant, and spending time with friends/family
4. Decatastrophizing: examine the evidenceto see that the likelihood of adverse outcomes is much less than we estimate
- Estimate the likelihood: of the event occurring. Rate it on a scale of 0 to 100%
- Evaluate the evidence: for and against the event occurring
- Review the evidence list: now re-estimate the risk of the event occurring after going through the evidence
- Create an action plan: brainstorm strategies to reduce the likelihood of catastrophic occurring. Write down actions that you could take to prevent the feared outcome.
- Develop a plan for coping: if the event should occur.
- Reassess: compare the original rating to the new rating
- Debrief: What was good about working through a catastrophic event in this manner?
5. Deep Breathing:
- Aim for 30-60 breaths, 1-2 cycles
- Start in the sitting position, hands on la or knees
- Take 10 breathes in through the nose and out through the mouth
- Take 10 breaths in through the nose and out through the nose
- Take 10 breaths in through the nose and hold for 5-10 seconds, then release out through the mouth
6. Exposure: systematically or all at once (flooding) exposing yourself to the feared object or situation. This is the most important part of CBT for anxiety. Systematic desensitization: graded exposure, starting with less anxiety provoking situations
- Be specific: details matter, “stop being afraid to go to parties” is not specific “go to my neighbor’s house party for 20 minutes and talk to one person”
- Rate each step on a scale of 0 to 100 depending on how much anxiety you expect to occur
- Develop at least 8-12 scenarios that go from lowest to highest anxiety
- Work with the therapist to select to order of steps for graded exposure therapy
- Two types: imaginal and real-world exposure, depending on the case both may be used (good for OCD and PTSD)
Anxiety is a part of life; we all experience it. The amount of anxiety a person experiences is to some degree related to how important a particular outcome is to that person. It seems like everything these days is high stakes and anxiety provoking. There is a global pandemic that continues to create chaos around the world, economic uncertainty, gender and racial inequality, and now a presidential election.
People are more anxious than ever about this presidential election. According to a recent article by the American Psychological Association 68% of U.S. adults say the 2020 U.S. presidential election is a significant source of stress. This is compared to the 2016 election where 52% of U.S. adults found the election stressful. It might just be a symptom of the times, but it remains a significant concern. If you are having election anxiety here are some simple ways to reduce stress and anxiety during this election cycle.
- Make sure you are getting enough sleep. Set a regular sleep time and wake time. Make sure the room you sleep in is as conducive to sleep as possible (e.g. dark room with no ambient light). Limit the bed to sleep and sex only, do not play games on your phone or read in bed. If you can’t sleep get out of the bed and do a mildly strenuous activity. A good example is a crossword puzzle, then come back to bed when you feel tired. If you are not sleeping well it can cause problems in other areas of life such as mood and cognitive function.
- Get outside or stay inside whichever you prefer, but make sure to move. Exercise is a great way to cope with stress and anxiety. There are countless free guided exercise routines on sites like YouTube that require little or no equipment to perform. If you do not like that option, take a walk in your favorite park, take a bike ride, or go for a hike on your favorite trail.
- Limit your consumption of news throughout the day. Set aside one or two times per day to check the news and see what is going on with the election. Resist the urge to continually check in and get play by play updates. This simple, but difficult to follow advice will save you a lot of stress and anxiety.
- Avoid talking to people in your life about the election who are unable to keep their emotions under control while discussing the topic. You should have a good idea of who these people are in your life. This will save you a lot of stress and anxiety by simply choosing to talk about other topics with those individuals.
- The last thing I recommend for people who want an activity they can perform to reduce stress is a thought journal . This can be as simple as a piece of paper that you record the thoughts on. There are printable versions of this online. I will provide a link to one such example here. This is a common technique used in cognitive behavioral therapy (CBT) all the time.