Tuesday, July 31, 2012
Friday, July 27, 2012
means peace, welfare, completeness, hello and goodbye.
In his 1995 eulogy at Yitzak Rabin's funeral, Bill Clinton captured the
world when he uttered the simple Hebrew phrase, "Shalom Chaver" --
Farewell, my friend. This week I had the unfortunate duty of saying
goodbye to my friend.
In Beth Nielsen Chapman's song "Sand and Water," which is about the
premature death of her husband, she sings "All alone, I came into this
world. All alone, I will someday die." And so it was with my friend,
who died under a bridge, homeless and alone.
There is, however, a notion embedded in that song about the impact a
person can have in between those two points of being alone -- the
impact they can have on our lives. As Nielsen Chapman sings, "I will
see you in the light of a thousand suns. I will hear you in the sound
of the waves. I will know you when I come, as we all will come.
Through the doors beyond the grave." My friend would have appreciated
the metaphor -- he loved the beach and he died on the water near one.
He would appreciate that his life continues on through his kind words,
good ideas and other things that he has done.
People have said that I should feel no guilt at this passing. I
understand that I should not be ashamed. I understand that I did, in
each moment, what I thought was best. But I also believe what Judith
Viorst wrote in her book Necessary Losses, that losses "... are a part
of life-universal, unavailable, inexorable. And these losses are
necessary because we grow by losing and leaving and letting go." And
part of what I can learn to honor my friend's death are new tools to
help others in the future. And I will do this, in his honor. I can
also help others learn by sharing his story.
I wrote a note to a group of friends who had something in common with
my friend. We all suffer from either bipolar or depression. It was
meant to be a personal way to let them know of his passing and his
impact. I made the decision to share it here after getting a note from
one of those within that group who said that she hoped his story
reached a larger audience and also said, in part, that:
"In your piece, you've helped me appreciate what a fighter he was.
You've also done a masterful job of unmasking his unrelenting foe,
manic depression. Where's the parade for a solider who dies in a war
Wednesday, January 4, 2012
By Jayson Blair, Certified Life Coach
The importance of a good diagnosis has become even clearer as pharmaceutical companies have further refined their biological silver bullets for mental illness. Medicines like, for example, serotonin reuptake inhibitors can be targeted to treat depression, obsessive compulsive disorder and a variety of other illness. But they can have dramatically harmful effects on those with bipolar disorder. All things considered, its amazing that doctors are not more attentive to the symptoms faced by their clients. But increasing demands of the economy and insurance companies have made it harder, to potentially devastating consequences, for psychiatrists and psychologists to effectively diagnosis.
Increasingly it is fallen on clients to rapidly self-report symptoms in 15-minute to 30-minute initial evaluations and then the question of diagnosis never return. In the best practices of the profession, diagnosis is thoroughly evaluated and constantly re-evaluated. Clients, for better are worse, have become their now diagnosticians.
Gregory House, the fictional doctor on the show House MD, is in some ways a joke about the trend that doctors rarely have time for accurate diagnosis (his fictional Department of Diagnostic Medicine makes no money and runs up huge bills for the hospital). This article is designed to help clients identify and self-report their symptoms.
This article examines differential diagnosis of bipolar disorder and other illnesses. Subsequent articles will look at ADHD, anxiety disorders and personality disorders.
Bipolar Disorder and Depression
Bipolar disorder and depression are often the toughest differential diagnosis for the most seasoned mental health professional. Clients most often come in from the rain of depression to seek treatment and rarely seek a helping hand when they are manic or hypomanic. This means that those with bipolar, whose illness includes the symptoms of depression and mania, are often misdiagnosed with major depression.
This would hardly be a big deal if the front-line treatments for depression didn’t cause mania (often rapid cycling), which often includes high risk, life-changing behaviors that can be harmful and mentally painful to clients and their families.
Epidemiologists say that bipolar disorder effects 1% to 2% of the population and that about 10% of those with major depression will later develop mania. The first occurrence is often in childhood, teenage years or early adulthood. There is no gender difference when it comes to the prevalence of the illness.
The symptoms of mania, which can used to differentiate from depression, vary from person to person. They can include eutrophia, irritability, agitation, inflated self-esteem, poor judgment, rapid and pressured speech, aggressive behavior, increased goal-directed activity, risky behaviors, spending degrees, delusions an increased drive to perform and frequent work and social problems. A helpful Mayo Clinic article on mania can be found here.
ADHD and Bipolar
Steriods and stimulants can have the same effects, so it’s very careful for bipolar to be differentiated from bipolar and attention deficit hyperactivity disorder. Atypical antipsychotics that can be used to calm manic storms can exasperate inattention. A preteen or a teenager with mood swings may be going through a difficult but normal development stage. They could be suffering from actual bipolar disorder with periodic mood changes going from depression and mania.
In addition, symptoms of ADHD often mimic symptoms of bipolar disorder. With ADHD, an individual may have rapid or impulsive speech, physical restlessness, trouble focusing, irritability and, sometimes, defiant or oppositional behavior. There are some similarities.
While ADHD is characterized by inattention and most often some distractibility and hyperactivity, bipolar disorder is characterized by mood swings between high energy and activity and feelings of sadness. People with ADHD may feel sad or even depressed, but rarely with the persistence and cycling of bipolar. Another sign is that hyperactivity and inattention symptoms persist in people with ADHD while they don’t always in bipolar.
Borderline and Bipolar Disorder
Borderline personality disorder is a persistent and pervasive illness that causes emotional instability, leading to stress and other problems, including temper tantrums, self-mutalization, elevation and devaluation of people, fast and furious relationships that crash and burn, frequent feelings of inadequacy and fears of abandonment.
From a medical perspective, differentiating between bipolar and borderline personality disorders is not relevant for medical treatment. The two diseases are often treated with the same medications to stabilize a person’s mood. It is helpful because atypical antipsychotics can have added effect with bipolar disorder and anti-depressants can be more readily utilized with borderline personality. But the medical consequences of a misdiagnose are not enormously negative.
The differential is important, however, for therapeutic options. Bipolar disorder can be treated with a variety of psycho-therapeutic modalities, while borderline is most effectively treated with dialectic behavioral therapy and transference-focused therapies. These later treatments are some of my favorites; they focus on the relationship between the client and the therapist, helping clients understand emotions and the difficulties that develop in therapy. The relationship between the two often serve as a model for future relationships outside the safety of the therapeutic room.
It’s a jungle out there.
And one of the hardest forests to untangle your way through is the differences between stress and anxiety, and the differences between the many anxiety disorders. It’s enough to make you anxious. But no worries, we’ve put together a little guide.
Anxiety disorders have one of the longest differential diagnosis lists of all psychiatric disorders.
One of the biggest problems is that clients with anxiety disorders also have anxiety about their disorders, and anxiety about treatment, making self-reports and diagnosis a difficult thing to work your way through. No worries, though. It might take time, but a careful clinician can often differentiate for you, and help improve your quality of life.
The importance of these differences is a key to selecting the most effective therapeutic and medical treatments.
One of the most important issues is the difference between anxiety and plan old stress.
Stress vs. Anxiety
Wikipedia puts it this way: “Stress is a term that is commonly used today but has increasingly difficult to define.”
The Mayo Clinic puts it better than I ever could: “Its normal to feel anxious from time to time, especially if your life is stressful. However, severe, ongoing anxiety that interferes with day-today activities may be a sign of” anxiety disorders.
The key differences: severe, ongoing and inferring with living a healthy day to day life.
The same goes for fear. Gavin de Becker pines about the gift of fear in his excellent book by the same name. Fear and institution go hand and glove and as de Becker puts it, “Intuition is always right in at least two important ways: It is always in response to something. It always has your best interest at heart … Denial is a save now, pay later scheme.”
But when fear becomes irrational it can interfere with functioning and its safe bet you should be checked out for anxiety.
It’s true that many of the things that help with managing day-to-day stress – mindfulness, exercise, cognitive behavioral techniques, deep breathing, guided imagery and meditation – can be beneficial for some people who have anxiety disorders. But the reality is that therapy, coping skills and medications are key parts of addressing anxiety disorders that are not usually needed in managing stress.
Some good questions to ask yourself before you right off your anxiety as a not needing intervention are: do you feel tense and wound up for a significant amount of time? Do you feel numbness or tingling? Do you feel hot when stressed? Are you unable to relax? Do you feel a sense of dread? Dizziness? Is your heart racing? Do you have to do routines that interfere with your function or drive those around you batty? Do you feel losing control or death when the possibility does not seem realistic? Do you feel ridicule, rejection or abandonment when there is not real evidence that its coming? If you answer yes to an of those, I would suggest you see a therapist, a coach, a psychiatrist or your primary care physician and ask them to administer the Beck Anxiety Inventory (treatment providers should try to rule out the impacts of drug abuse, other mental health conditions, migraines, folic acid deficiency, seizures, caffeine-related disorders, CND-based sleep disorders, pregnancy and diabetes mellitus, among other potential disorders) .
The scores on the inventory not only guide clinicians on the question of whether you have anxiety but also what’s the best treatment. Being unable to relax suggests cognitive issues while feeling hot suggests autonomic symptoms. Feeling dizzy or lightheaded suggests nueromotor issues, while feeling like you are choking suggests a panic attack. These facts help clinicians design the most effective treatment for you.
Generalized Anxiety vs. OCD
Obsessive-compulsive disorder is an illness that is defined by intrusive thoughts that produce uneasiness, apprehension, fear or worry, that are most commonly demonstrated through repetitive behaviors aimed at reducing the driving wave of anxiety.
It often works. But it often, also, screws up the lives of people who suffer from the disease. As one client puts it, “It’s a monkey on my back, one that I can’t survive with and I cannot survive without.”
One of the common misconceptions about OCD is that those who suffer from it are ridiculously clean. In fact, may people who OCD are hoarders – the behaviors are repetitive and are designed to help them manage their fears and anxiety. Others have trouble doing things like walking on cracks in the sidewalks or other strange behaviors that sooth them but can infer with their lives (think, Mr. Monk). Often, like Mr. Monk, the symptoms come on or come on stronger after a severe emotional or financial crisis. It can boarded on paranoid and even psychotic in its presentation, if not its true symptomology.
Despite people with OCD being out of the norm, it’s not as rare as it might seem. It is the fourth most common mental disorder, diagnosed nearly as often as asthma and diabetes.
Luckily, there are some excellent medical treatments for OCD.
OCD vs. OCPD and Autism Spectrum Disorders
Not everyone who presents with the symptoms of OCD have the illness. Many actually have autism spectrum disorders or the perhaps even more tortuous illness of obsessive compulsive personality disorder or, frankly, no pervasive or persistent disorder at all.
Autism spectrums disorders are illnesses of executive functioning. The resulting social skills problem, difficulties with nonverbal cues, time management problems, organization problems and prioritizing problems often lead to a lot of anxiety. People with autism spectrum disorder also often have restricted and repetitive symptoms.
OCPD is, frankly, the same nightmare as OCD with the added twist built on top. As one National Institutes of Mental Health publication puts it, “OCPD has some of the same symptoms as [OCD]. However, people with OCD have have unwanted thoughts, while people with OCPD believe that their thoughts are correct.”
The belief complaints relationships, often leads to significantly outbursts and a series disinterest in seeking help. These often leads to painful battles with friends and family, who walk on eggshells with people who have OCPD. People with OCPD are more likely than people with OCD to have an obsessive need for cleanliness and over-attention to details. Thing to get black-and-white really fast and there is often little room for other opinions.
Several other disorders, including bipolar and avoidant personality disorder and dependent personality disorder, have significant symptoms of anxiety, but in bipolar it tends to be affective – mood related – and avoidant anxiety tends to play out in, well, obviously, avoidance, and dependence tends to be focused on fears of being abandoned.
It’s worth checking out other anxiety disorders, such phobic disorders (specific fears of spiders, water, wholes, or anything else), panic disorders (focused on full-blown panic attacks), agoraphobia (fear of panic attacks that are so great that people avoid people, places and things). Personality disorders should also be examined, such as paranoid personality disorder (delusional anxiety) and borderline personality disorder (fears of abandonment).
If there is a point here, if you are feeling that stress if impacting your functioning, it’s a jungle out there it is worth it to find an expert to guide you through the vines and the trees.
Jayson Blair is a certified life coach and can be reached here.
Monday, August 8, 2011
There are many signs that the Washington economy has experienced a resurgence. Unemployent is below the national average. Housing prices are better than they have been in recent years. Foreclosures here are happening at much lower rates than places like Baltimore, Las Vegas, South Florida and Phoenix. It’s a wonder with all the good economic news that we do such brisk business in career coaching in Northern Virginia.
Some of our clients include high school, college students and college graduates trying to find where their aptitudes and interests align with their purpose and passion. Some of our clients include those returning to the workforce, like the stay-at-home dad re-entered as a budget analyst at a large government agency. Others are doing financially well but don’t have passion for their work, like the high-paid government contractor who was a rising star at his company who left to work as an entrepreneur in a gym business.
But we have recently been seeing two new types of clients: the recently unemployed and those who fear they will soon be unemployed.
One example was a government contractor who recently came in and asked to see a career coach because he feared that his company’s contract with the Marine Corps would not be renewed, and if it was, it would be at such a low level that drastic cuts would be inevitable. He feared that he did not have the skills to stay on or easily find other work.
Another example is a client of the practice who was laid off in January as a personnel security official at major government contractor. In her job, she was responsible for managing the clearance process for people obtaining Secret and Top Secret clearances in the Defense Department, the Intelligence Community and other agencies. She says her company anticipates a 30 percent reduction in government contracting over the next three years – and that especially with her high salary compared to those entering the workforce, she was no longer needed.
“It’s all I’ve ever known,” she said recently about the world of facility and personnel security. “I don’t know what I am going to do.”
There is little likelihood that the federal government's dominance in the area will go away or that there will not be jobs in the future. But what Washington could be experiencing soon is a bit akin to the well-known picture of a Star Wars storm trooper on a New York City subway with the caption that reads, "Unemployment. Sucks when your job gets blown up."
Despite all the signs that the Washington economy is strong, our career transition business has been brisk. Some of it could be psychological – individual fears and companies concerned about the federal economy. But some of reality is challenging the notion that the Washington, D.C. area economy is recession proof. After all, as the rest of the nation faced the early recession, Washington, D.C. area unemployment grew with the creation of the Department of Homeland Security and the nearly doubling of the budgets of the Central Intelligence Agency, the National Security Agency, the National Geospatial Agency and other agencies.
A couple of things have happened to change that. Among them, the exodus of federal jobs to other metropolitan areas, such as Denver. A second fact is that the Defense Department has made clear that it will do its part to help reduce the national deficit, announcing $7.8 billion in cuts in January and a plan to eliminate 10 percent of its contractors over the next three years (translate that to at least 8,000 jobs). I can't imagine that some of those won't come from the increases in Langley, Fort Meade, Reston, Springfield and Chantilly. In addition, there are concerns on Wall Street that the problems with the federal economy will have a negative rating on the local governments supported by it.
A recent article in the Leesburg Today highlighted the Moody’s Investor Service rating agency’s quick turnabout on the outlook for the Loudoun County economy (the ratings will affect the costs of boring for the county, which could lead to layoffs as the county pays off interest at higher rates).
“The ratings of these local governments, particular those with high economic dependence on federal government activity, would be vulnerable to a downgrade of the U.S. government,” Matt Jones, senior vice president for U.S. Public Finance at Moody’s, said in a statement printed in the paper.
Higher borrowing costs means more money going to interest payments and less for public works, government contracts and employees. Then you’d have to throw less tax revenue, from fewer federal and government contracting jobs, and the picture starts to get uglier for teachers, police officers, firefighters, social workers and others.
While employment austerity leads those with the most versatile (the utility infielders of corporate or government work) or recession-proof skills (accountants and psychiatrists will always have a broad base of clients), to move down a peg in terms of their income, it forces many others into unemployment at a bad time – when federal unemployment extension benefits are about to disappear.
It all provides a case for career change and re-training programs, both for those who are looking for their passion and purpose and those who are trying to retool to the new Washington, D.C. economy that appears to be not-to-far in front of our collective windshield.
Jayson Blair is a certified life coach at Goose Creek Consulting.
Sunday, July 24, 2011
Initial news reports describe the official cause of death as "unexplained;" the unconfirmed leaks suggest that alcohol, drug use and emphysema may have contributed. Winehouse's struggle with drugs and alcohol had been widely chronicled in the British and American press and the singer's hit song "Rehab" seems, if nothing else, to be autobiographical. Less widely reported, but no less salient, was Winehouse's struggle with bipolar disorder, also known as manic depression.
"Amy had battled drink and drugs problems throughout her career," according to the British newspaper, The Sun. "Her hit song, 'Rehab,' which included the lyrics: 'They tried to make me go to rehab; I said no, no, no,' echoed her refusal to seek help."
"She acknowledged," the newspaper continued "struggling with eating disorders and told a newspaper that she had been diagnosed as manic depressive but refused to take medication."
Within hours, Twitter was ablaze with posts about the 27-year-old musician that were variations of the question "Why do so many musicians die at 27?"
It seemed fitting that I was listening to “Mercedes Benz,” the last song that Joplin recorded before her heroin induced death at age 27.
After hearing the news about Winehouse, I sent a text message to a friend in New York, ”What’s up with the age 27? Hendrix, Joplin, Morrison, Kurt Cobain – and now Winehouse.” As I reread my message, another thing struck me – how many of the people I had listed were believed to have suffered from chronic bipolar disorder or depression, and who now would have been viewed as self-medicating their illnesses with substances.
Joplin completed her recording of “Mercedes Benz” on October 1, 1970 and died later that night or the next morning of an overdose of heroin after a night of drinking. Joplin’s death at 27 shocked a music world that was just coming to grips with the death sixteen days earlier of Jimi Hendrix, who was also 27. Hendrix’s use of LSD, amphetamines, marijuana and alcohol were widely noted. His autopsy said that he asphyxiated on his own vomit, with red wine filling his airways. Less than a year later, Jim Morrison, the lead singer of the Doors, was found dead in a bathtub in Paris. An autopsy was not performed, but associates later said that Morrison had taken heroin after a night of drinking. On April 5, 1994, Kurt Cobain, the lead singer in the band Nirvana, died of a self-inflicted gunshot wound, according to authorities. Cobain’s history of drug use and past suicide attempts was well-documented.
The 27 Club, also known as the Forever 27 Club or Club 27, is a name for a group of influential musicians who died at the age of 27. “The 27s: The Greatest Myth of Rock & Roll,” by Eric Segalstad and published in 2008, examines the lives of 34 musicians who died at the age 27. Some of the most prominent members of the 27 Club suffered from drug and alcohol abuse, but many of them also had another connection: confirmed or suspected mood-related mental illnesses.
The connection between creativity and mood disorders has been documented thoroughly, most pervasively in Kay Redfield Jamison’s book “Touched with Fire: Manic Depressive Illness and the Artistic Temperament.” The connection between mood disorders and madness is self-evident. The connection between mood disorders and self-medication with drugs and alcohol is, perhaps, both unappreciated and one of the most important elements to helping prevent many tragedies, among rock stars and many average people you and I have never heard of.
Modern researchers believe that Morrison suffered from bipolar disorder or depression. Joplin has been said to have been afflicted with either bipolar disorder or depression. Cobain’s cousin, a nurse, claimed that Cobain was diagnosed with attention-deficit hyperactivity disorder as a child and bipolar disorder as an adult, and noted that two of her uncles had committed suicide with guns. There is no solid evidence that Hendrix suffered from bipolar disorder, but after his manager at the time told him that he sounded like a manic depressive, Hendrix wrote the song “Manic Depression.” The diagnosis of each of these musicians are less than clear, but what is clear is that each suffered from serious mood swings and, mostly, mood disorders that contributed to their abuse of drugs and alcohol.
Much focus has been placed on the loss of talented musical artists to substance abuse, but it seems obvious that the underlying mood swings and disorders that are being self-medicated by drugs and alcohol are the primary culprits.
Winehouse was self-aware of the connection, even if that connection did not lead her to seek treatment. “I do drink a lot,” Winehouse once said in an interview on the British television show, “The Album Chart Show,” according to an ABC News report. “I’m manic depressive, I’m not an alcoholic, which sounds like an alcoholic in denial.”
One factor that probably contributes to the ambiguity of many of these musicians is the fact that bipolar disorder and several other mood disorders tend to emerge in early adulthood.
“Stories of young people suffering through their 20s are not new,” Jennifer L. Tanner, psychologist, writes in an essay. “In the 1970s, Jimi Hendrix, Janis Joplin and Jim Morrison all died at age 27 as a result of mood disorders and addiction. These incidents four decades ago suggest that mental health problems have been a consistent threat to emerging adults.”
“Since the 1930s, Tanner continues, “psychiatric opinion has been that emerging adulthood is the ‘the age for neuroses.’”
The story of Britney Spears, who has acknowledged having bipolar disorder, is a more recent example. The story of John Nash, the Nobel Prize winning mathematician, in the book and movie “A Beautiful Mind” provides another salient explanation of how talented young people struggle to realize the development of their mental illnesses.
Tanner writes that “we have far to go in learning how we can best help emerging adults access the help that they need.” It is clear to me that one of the key priorities should be educating young adults and those outside of the mental health community on the symptoms of mood disorders and other mental conditions, and the times of life they are most likely to emerge.
My own experience provides my cautionary tale in this regard. I began to suffer the symptoms of bipolar disorder most noticeably, in retrospect, during early adulthood, with it leading to self-medication with drugs and alcohol, and, after much turmoil, a diagnosis eight years ago – at age 27.
Monday, October 25, 2010
The decision was made Monday morning to fly to Bangor, Maine last Thursday to see a client who needed a check-in. The check-in was as much for me and his parents as it was for him, and it seems, as best as I can tell, that he is doing as good as possible given the coming darkness of winter. As I boarded a U.S. Airways jet to LaGuardia Airport, the layover on the way to Bangor, I thought of the passage in Isaiah that explained why I would cancel my plans and leave my home in the morning for the 640-mile commute:
And I heard the voice of the Lord say, "Who shall I send
and who will go for us? " and I answered,
"Here I am, send me"
The verse has been used many times to describe the warrior ethic, the notion of being willing to serve anywhere and everywhere, wherever, whenever.
It was fanciful and not too subtly narcissistic of me, but I do see my work as a bit of a calling. The trip turned out to serve its purpose. I was able to collect the ground truth to help my client and capture Maine at a breathtaking time of year, as the leaves turn red, orange and golden over the landscape and the town of Bangor gets ready for what must be its most important holiday, Halloween, given its most famous resident is Stephen King. In addition to my work, there was enough time to visit King's house, a beautifully restored home on a hill on West Broadway. On my way out, there was time to visit parks along the majestic Kenduskeag Stream.
In one of my interviews to gather information for my client, I asked about what was the most curious thing I had seen: hundreds of uniformed military from the Army's 10th Mountain Division sleeping on the floor, smoking outside, pacing around and eating in the diners at Bangor International Airport.
My host explained that Bangor was the last stop for many American soldiers before they headed off to war in Afghanistan, for some, she explained, the last step they would take on American soil before returning in caskets at Dover Air Force Base in Delaware.
"I always look at them and wonder," my host said, "which ones of them are not coming home."
Bangor International Airport lies on the former grounds of Dow Air Force Base, and, for thousands of soldiers, sailors and airmen each month it is their last stop in the United States before they head to war and their first stop on American soil on their way home.
"You can always tell whether they are coming or going because they are so excited when they are coming home," she says, "And when they are leaving, you can see their anxiety."
The wars in Iraq and Afghanistan have barely been in my face since leaving The New York Times as a reporter in 2003. Sometimes it's easy to forget about the real people behind the operations and body counts thousands of miles away in Southeast Asia and the Middle East. Not so in Bangor, whose citizens have established a program where local residents greet the contract flights that bring the military personnel in and take them away.
"They are there," my host said, "no matter what time they arrive, no matter what day of the week."
The troop greeters have been celebrated in a film documentary called, “The Way We Get By”. The film also touches on the personal lives of a few of the greeters. A man in his 80s who is fighting cancer and is a veteran of World War II. A woman of the same age whose daughter was a Blackhawk helicopter pilot who had been deployed to Iraq. For all of Bangor's aesthetic beauty, what happens at the airport captures a feature of compassion and kindness almost more noteworthy.
My thoughts of my own dedication and inconvenience fade away when I think of the lines of soldiers, in formation, marching down the terminal hall in Bangor, and the tears in the eyes of the strangers they left behind, both being called upon to go, both taking on a service that goes beyond duty.
The thought makes the things that I am called to do each day come much easier.