Friday, October 26, 2012

Tina Fey and Competitive Gymnastics

(1) Wish I could embed Tina Fey's very short rant about "legitimate" rape. You'll have to follow the link if you're interested.

The part about how merely repeating something that is "dumb" can essentially "dumb" a person down is something to think about.  It's why your momma tells you to watch what you say, and why your therapist will suggest that you think it don't say it, or write it don't send it.

As a reminder, this isn't a political blog, and linking to Tina Fey, not a political statement.
As if there is a way to communicate in the world and not be political.

(2). Should we talk about Halloween instead?  How it is the dentists are the ones to score, not the kids?
Making my mother an appointment, the receptionist says, "Oh!  Wednesday!  Halloween."

Bonus time, perhaps.

But here's a dilemma.  What if you leave the country, go far, far away, and all your grandkids ask from you is to bring back candy from a tiny middle eastern country?

Do you say no?

Candy is a universal language

Pressure.  I say it is the parents' job to teach them to brush, no?


Sunday, October 21, 2012

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD) is about emotional-behavioral management in children.  Reaching for more user-friendly semantics, FD refers to it as Calming Disorder, a seeming inability on the part of the child (hence the parent, too) to calm down.  DMDD is likely to be the latest flavor of the week, yet another label for children who are oppositional.  Willful.

We suppose that as these children age, as they grow into adults, they will be diagnosed as having Intermittent Explosive Disorder and treated with anger management.  Why we couldn't have used Intermittent Explosive Disorder with qualifiers: refer to children with a 1, adults with a 2, and a 1,2, or 3 to indicate the severity, is a mystery.  Perhaps the reason is that the temperament is chronic, not intermittent.

Here's the abstract.  I'll get to the article this week, but want to offer up a few thoughts regardless.  After all, they did ask me to be on the team to rewrite the DSM IV-TR.  Is it my fault that the page froze after checking "other" when asked for "type of license"?  I have two, and there was no way to communicate that. Calling in I was redirected, sent a new email.  But the link to the application didn't work a second time.

And life gets in the way.

Look for the article in PsychInfo if you have an academic affiliation. It might be on sale somewhere online if you don't.

Emotional dysregulation in disruptive behavior disorders.
Cole, Pamela M.; Zahn-Waxler, Carolyn
Cicchetti, Dante (Ed); Toth, Sheree L. (Ed), (1992). Developmental perspectives on depression.Rochester symposium on developmental psychopathology, Vol. 4., (pp. 173-209). Rochester, NY, US: University of Rochester Press, xix, 396 pp.

(The authors) present a view of disruptive behavior disorders as affective disorders and, from that perspective, discuss the emotional characteristics which are associated with the development of aggressive, antisocial behavior 
provide an overview of the disruptive behavior disorders, the history of the traditional segregation of behavior disorder from affective disorder, and the evidence and arguments for comorbidity of affective and disruptive disorders / consider possible developmental trajectories leading to these disorders / focus particularly on the role of emotion in early childhood and its implications for the development of deviant and aggressive behavior later in childhood and adolescence (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Seems to me we are looking for the prodromal, or warning signs of sociopathy, a disorder that defines what we have referred to as almost psychopathic in previous posts.

Parents are right to worry when their kids have symptoms of DMDD: uncontrollable tantrums, aggressiveness, an inability to manage emotion, an absence of empathy.  When they are cruel.  Dr. Cole has published on empathy in the past, and I think she is on the mark if she is thinking we have to teach children, all children, empathy.

We're talking about it right now because the DSM V is due out in 2013.  Teams of researchers, revisionists, are making all kinds of changes to what we commonly call disorders.  For example, Asperger's, childhood disorder in the current DSM IV-TR, has been known for decades to be characteristic of adults, too.   It is thought to be a spectrum disorder, on the spectrum of autism, and may lose its status as a disorder exclusive to autism.

According to yesterday's Wall Street Journal (Shirley S. Wang), "Aspie's" are up in arms about being subsumed autistic.  Not everyone likes the thought of being autistic, even if it is high functioning.  Yet, most of the "Aspie's" I treat tell me that they are very much in their own world.  They see the point.  More likely however, Adult Asperger's Disorder will make it into the DSM V, at least that is my hope.  Just a guess.

But back to our new flavor.  When we first recognized Bipolar Disorder in children, it amounted to medication, usually too much.  Manic kids were oppositional, hard to control by definition, and they suffered swings, clear signs of childhood depression.  Thus meds saved the day, theoretically, although those of us who work with a family model are generally reluctant to make that referral.

Children with Disruptive Mood Dysregulation Disorder are likely going to be over-medicated, too.  It doesn't take much to over-medicate children.  They are growing and changing all of the time.  And they are mini-emotional time-bombs under normal circumstances.  Having a motor that tends to puff and smoke at the worst possible times, it is understandable that parents are looking for help, lots of help, from that god of psychiatry, Big Pharma.

Thus we can only hope that parents remain patient, able to calm themselves, and bring little Joey to therapy.  If you are such a parent, stay in the room and learn strategies from the doctor/therapist.  The tried and true holding technique, grabbing the little tyke and holding her tightly (without hurting her) until she calms down, works for some kids, but as one reader puts it so well, restraining the child is:

 a tried and true way to exert dominance, lose the child's trust, and create permanent emotional scars.

I think we had both lose the phrase, tried and true, unless we can qualify them well.

Make sure no one is hurt no matter what you do.  Corporal punishment won't work, will work against you.  And although we are capable of holding, able to restrain children, being three times their size, we have to be careful. Not every child responds well to that.  If they are older, best to work on communicating in words, or in art, or play if holding is violently rejected.

There are other ways to treat DMDD.  Engage other siblings, certainly a second parent if one is around, or grandparents, aunts and uncles.  Use friends.  Use your people.  If you have none, find a support group.  Call the National Alliance on Mental Illness, NAMI.

Lose the idea that this is something shameful.  Get more into the idea that it takes a village to raise a child, because it does.

Behavioral modification won't always work, but try it early, start very, very young.  Even a two-year old needs to know the power structure in the family, that he is not the boss of you.  As a parent, you are the boss.

All of this assuming that marital dynamics lend themselves to the therapy, that the child isn't learning aggression in the home, a very big assumption.  And that the dyad at the top, Mom and Dad, or Mom and Mom, or Dad and Dad, have to have something of a working relationship themselves, must communicate, agree on a treatment plan.

It is most likely that children who will be diagnosed with DMDD, unfortunately, are identified patients, that their families are the patient, really, and that only a fraction, a tiny fraction of the children diagnosed in nursery, kindergarten, or elementary school, whichever system has booted them out, have the disorder.  If you hear the news: This child needs a psychiatric evaluation--it may not mean Disruptive Mood Dysregulation Disorder, no matter who slaps on the label.

I'll put myself out there and suggest that as a first line of attack, families need to find a good family therapist, not a psychiatrist, and leave the primary care physician alone about medicating the child.

When it is obvious that a child is dangerous, on the other hand, a team approach is surely necessary, with a primary care doctor, a child psychiatrist (go find one, good luck), and a therapist.  Sometimes  even hospitalization might be necessary.  Or so they're saying in the news today.


Wednesday, October 10, 2012

One Last Snap: Insect Phobia Corrections

Jet lag isn't that bad, assuming you don't mind sleeping at inappropriate moments anywhere, anytime.  A therapist has to be prepared to take a power nap.  It is why we have a comfortable sofa.  And you though it was for you.

With jet lag, however, you doze off in the afternoon, and then, late at night, find that your brain is on Central Standard Time.  Still.  Meaning it is really late afternoon.

One night I'm reading myself to sleep, something that has always worked in the past, doubly so upon learning that the reticular formation in the back of the brain stem expects, no wants, desires, demands that we lie down, enable additional blood flow to accomplish this seemingly elusive state of being, sleep.  Lying supine, an easy thing to do, a familiar buzz in the ear sets off an alarm.  

I swat at it, a mosquito.

"We have mosquitoes," I inform FD.

"You didn't know?"

There was a rumor.

This relatively small insect lands on page 433, The Corrections, Jonathan Franzen.  Is it not insult enough that the rain in Israel occasionally carries red mud, and a light drizzle through a bedroom screen has initiated this book, one that I do not own, but could not leave in the States?  Once I begin a Franzen novel, there is no stopping until the last page has turned.  (For the uninitiated, be prepared for much unrestrained, very raw, literary pornography; an unapologetic obsession on the part of every primary in a Franzen novel, at least the two I have read, add Freedom, with s-e-x.)

I swat at the mosquito.  Miss.

"Excuse me," I tell FD, climbing over him.  "I must find him."  I stand up in bed, survey the room, and flash back to a distant memory, a child of five years old, myself,  in the same position, too many years ago to count.

The child cries for her mother, her father, anyone who will rescue her.  "There's a mosquito in here!"  A kind woman, a mother in a thin nightgown, offers advice.  She seems very tired.

"You won't sleep until it is dead," she says, the voice of experience.  "Let's turn on the light, kill him."

The child agrees.  The two search the walls for an insect.  The walls are white.  There are none, however, no mosquitoes with bent spidery legs clutching walls, regrouping, thinking.

"Do you want to try to sleep?  Or would you prefer to stay up and wait?  It is okay with me if you stay up and wait, kill the mosquito.  If you don't, that buzzing in your ear will keep you awake anyway."

The child agrees to do this, lie in wait, alone, for the pest.  The woman kisses her good night, leaves the room.  The light isn't bright; there is a dimmer on the switch, and the child is tired.  But suddenly she sees it, a mosquito on the wall.  She takes destiny into her little hands, and with one blow, ends the life of the enemy.  She goes to sleep.

"My G-d!"  I exclaim, waking FD again.  "This is why I've never had any insect phobias!  I learned at a young age how easy it is to kill them!  This is how it feels to play Master of the Universe!"

Unwilling to lose valuable page turning time, I slip back into bed and read for a few minutes, hoping my nemesis might return to pages 444, or perhaps page 445, when an unmistakable prick stings my forehead, just above the bridge of the nose.  With all too much enthusiasm, I adroitly slap at my head with the palm of my hand, a hard but quick slap, not a smashing slap.  The mosquito falls onto my pajama top, slips down toward my belly, curls into a tiny ball of thorax, the proboscis no longer an issue.  Marveling at this skill, confidence returns.  Nothing can harm me now.

I sleep like a five-year old.


Tuesday, October 09, 2012

Vacation Snapshots

1.  Get Out of Town:  Literally

I can count on one hand how many times I've shared pics of myself, or my family, or my home. Actually, there are none.  And we're not about to start now.

For years it's been really hard getting away for vacations, this year worse than ever.  All summer long patients talked to me about their trips, things that went wrong, what went right.  Rain forests.  Africa.  Mexico.  I'd listen and wonder, "How do they get to do it, get away like that, and I can't?"

The rule has been that when we do go, our vacations aren't vacations.  FD is on the phone with patients, other doctors, nurses, lab techs.  I'm checking messages, too.  We have micro-practices, and although there's coverage, letting it all go never seems possible.

Plus, the get-away is to see kids, grandkids, in-laws of kids, an exertion that simulates a vacation in many respects.  But isn't.
United to Israel

To air out more often, it seemed prudent to start a business with a psycho-educational mission.  Educate people in other cities about abuse and neglect, what a number it does on one's mental health.  Not exactly getting away from it all.

My nephew made it possible to get away, however, by not staying single. If you have a chance to go to a nephew's wedding, you don't blow it.

You try not to blow it.   To say that we almost blew it is no exaggeration.

But we got on that airplane above.  When you leave the country, travel very far away, even if it is to see relatives, you are on a real vacation.

If you're me, reunions make you just a little self-conscious.  Friends and family, people who haven't seen us for years, are probably shocked to see so many more creases in my skin, a little bit of a craggy look. Without "work" it can happen to anyone.  Whereas FD still has baby skin.

People are forgiving, in any case, don't mention things like this.  I've always said that by not looking good, other people think they look good.  What better gift than that?

2. Will He Make It 30 Years?

Even far away, news travels.  Jerry Sandusky!  Going to jail for the duration!  30 -60 years.  He'll die in jail!  And still, he tells us, he's innocent of abusing young boys.

Jerry Sandusky, throw away the key

We can only hope that those institutions with "everything to lose" (seriously?) under the pall of a scandal like his, think twice before covering one up.

3. Stripped of Sir

Jimmy Savile, not a Sir
Speaking of falls from grace.  It is nice to know that another sexual predator, "Sir" Jimmy Savile, has been outed as one, although he's quite dead.  The Brits can't strip Jimmy of his title for his crimes, but as they lowered him below the earth, he automatically lost it.

Technically we don't call people who sexually abuse adolescents pedophiles.  A pedophile is an adult who is sexually interested in children under the age of twelve.

Jimmy Savile was an ephebophile, an adult who is sexually obsessed with and sexually assaults young people between the ages of 13-17 (18).

Consider that your psycho-education for the day.

Savile, a British television star, is guilty of at least 30 counts of sexual assault, and more appear to come to light daily.  First women came forward, now men, too, are saying that he raped them as young adolescents.  The story is too gruesome to repeat on a clean blog like this.

If I stayed away from television, from stories like these, it would be okay.  But seeing Law and Order and CNN with foreign language subtitles is a nice way to reinforce a second language.

4.  Losing Ground

Why not just a little more about me.

Before leaving, no question, the nerves were frayed.  No day a good day.  The feeling?  Like I'm slipping.  A descent, a loss of grounded-ness,  Being grounded is everything to a therapist, it is the essence of Yoda.  When problems build up, as they do in middle age, sandwiched, as they say, we tend to sense it dissipating, as if the ground is literally crumbling beneath our feet.

We become less like Yoda at the end of the day.  And everyone depends upon us to do an imitation, certainly, during the day.  Being grounded is why they come.  Why bother with a therapist who isn't?

Don't ask questions when yours tells you she needs to get away, even if it sounds like an extended absence.
Throw her a party.

And don't envy the money she will spend to go.  She's supporting the world's economy and the economy of the United States, each and every day, with her taxes.  Nobody in this profession ever gets out of the middle class.  The first candidate to fix this gets my vote.  .

5.  The Western Wall in Jerusalem

Ah, there is nothing better than walking toward, approaching, coming close to this.   Perhaps you understand, have an idea.
The Western Wall-HaKotel
This is the holiest place in the world. Thousands come here to pray.  They put names of sick friends on little pieces of paper, squeeze them into ancient cracks and crevices of the Wall, hope their prayers are received, then answered.  It is a local call in Jerusalem.

Only a few hundred yards away, people eat and drink, buy and sell religious objects. Things probably went down differently well over two thousand years ago when millions made holiday pilgrimages.   Kings, queens.  Everyone had to see what was happening here.

The Judean Hills at dawn

6.  The Land

Those are the Judean hills on your left. Pretty obvious why cultures clash over this land.

 There used to be a commercial for cigarettes that referenced Marlboro Country. And a beer commercial about God's Country, maybe Wisconsin, probably.

They got that one wrong.

Electric Car

7.  Going Green

The pic on the right is what you see on the dash when you charge up your electric car.

Why isn't Israel polluted?

People actually buy electric cars, not just hybrids. Of course, the tax exemptions help.  It is like driving a real car, without the exhaust or the noise.

But don't get stuck in traffic.  That's all I'm going to say.
A Kosher McDonald's

8.  Don't Super-size Me

If you live in this country you have to join the army after high school. There you learn to stay in shape, and to eat right, generally, which is why everyone, young and old, seems thin and can eat at McDonald's.

McDonald's in case it is lost on you, is not kosher anywhere else in the world. I don't think.

And no, I didn't eat there.  Are you kidding me?

9.  Coming Home

Sure, sure.  I'll come home.  Just not yet.  You wouldn't want your therapist insufficiently, not totally, grounded. 


Wednesday, October 03, 2012

How to Be You

This was going to be a Snapshots post, but I couldn't find a snapshot of identity.  This one goes around the world to get to where I want us to be.  And for the record, only applies if and when it applies.  In other words, as with every other intervention, it may not work for you and isn't intended to work for everyone.

I'm finally beginning to see why the "ultra-Orthodox" (Yids/Jewish observant), tend to shy away from therapy.  It isn't the stigma so much as a certain confidence, a can-do spirit, belief that the power of change resides in the individual.  Not all that different, philosophically, than any school of individual therapy.

Without examining history, religious codes (no disrespect here, some of the best scientists are/were quite obsessive about code) do not always account for extenuating circumstances. Ask your local rabbi/clergy-person if yours apply.

Let's move on.

We just finished rounds one and two of the Jewish High Holiday season, and are in the middle of the relief holiday, Succot.  What this means is that is that if your therapist is Jewish, she didn't return your calls religiously and left apologetic voice mail about getting back to you in a couple of days.

You know the drill.  "If this is an emergency, dial 911 or go to the nearest emergency room."

Most think that this means we're partying, having huge dinners and drinking lots of wine and shots of whiskey (Canadian whiskey, we're Jews, with although some do prefer Scotch; vodka, if Russian).  But in fact, the New Year implies judgement of the world, according to this tradition, judgement of the universe, of you and of me. New Years kicks off the holiday season with pause.

In this system of belief, any losses, any gains, for that matter, that any one of us will incur from now until the next Jewish New Year's Day, are determined on Rosh HaShana, New Year's Day.  That's what we think, anyway, and it is a good system, because it gives us a fresh start.  Each Rosh HaShana (a two-day affair, considered one long day), observant Jews go over their errors and ask forgiveness from friends and family. It is assumed that we hurt them in some way over the past year.  And we ask forgiveness from the Old Mighty, too, for being scofflaws, ignoring the rules that don't seem to make much sense sometimes, even those that do.

The serious self-examination begins toward the end of the summer, a personal inventory familiar to addicts and alcoholics who work 12-Step programs.  Jews stay up very late and pray at midnight, or get up really early in the morning.  It's that time of year  She* is listening.  Might as well talk it out.

This tends to wear people out, and you might notice, if you know about these things, that your Orthodox friends and physicians are a little cranky and tired this time of year. All the prayer and self-criticism wear a person down. Then, at the end of that long New Year's day, it all shakes out, whether or not we get to live another year, even whether or not there will be a 9-11, something catastrophic.  Perhaps who will become the next President.  The decree is written in pencil.

Ten days later, on another holiday all is engraved in pen, hopefully for the better.  On Yom Kippur, the Day of Judgement, there's a huge push to confess our wrong-doing while fasting, to apologize for the many arrogant, selfish, callous, careless, base, deliberate or accidental, no matter, unbecoming things we did or inspired others to do over the previous year.  It is the date people dread, not unlike an on-the-job performance evaluation, the one that goes in the permanent record.  We know the standards are high, but bank on the character traits of our Supervisor to see us through, primarily mercy.  Those who have been working their program are not afraid, even feel excited, joyous.  Those who haven't are scared.

I imagine all of the religions have something quite similar, some seasonal way of changing life around,  and use ritual to accomplish the job.

Our ritual is a little harsh, the whole staying up late, getting up early thing.  On Yom Kippur, to be more like that divinity, there is a 25 hour fast, no food, no drink.  Jews wear white, shy away from leather, which is nice, actually.  The truly pious are on their feet most of the day.  You wouldn't sit in the presence of a flesh and blood king.  This time of year you can practically touch an ephemeral king. Heck, we're practically kissing.  Talk about mixed emotions.

In this process, if a person has managed to figure out what to change, how to be a better person, it is a happy day.  An entry in the Good Book is assumed after the fast, a fast that atones for everything, it is hoped, although it helps to repent, pray, and give charity.

Bear with me.  What has this to do with therapy?

Because in fact, to truly keep a promise for change is nearly impossible, which is probably why we repeat the process year after year.  The hope is that we'll work on ourselves over time, over the years.  Two steps forward, one step back.

Now.  The therapeutic intervention, one that compares, is inspired by religious fanaticism.  If it is good enough for the rabbi, it is good enough for us.  Can't hurt to at least read about it.  Nobody needs to fast in this intervention to develop more self-esteem, more self-respect. And none of us have to be like the rabbi in the story below, although it couldn't hurt.

We will need a bit of self-discipline, however.


A great Rabbi scrupulously examined his ways before every meal.  He didn't eat breakfast without reviewing the hours between breakfast and last night's dinner, how he had messed up, forgot to do something good, unintentionally did something bad.  Then he didn't eat lunch without reviewing the hours between breakfast and lunch in the same fashion.  He didn't eat dinner without first reviewing the hours between lunch and dinner.

You would say, Well, he had a great job!  He had so much time on his hands!  Discretionary time!  He had lunch!  And he's paid to do things like this, perfect himself.

I would answer that this is true, but we make our time, much of it.  Certainly the few minutes before every bite aren't clocked.  Most of us have a day off, too, some kind of weekend, and many of us work from home.  We don't want to do this, is the better answer.  It isn't something any one of us wants to do, waste time really examining our behavior.

And it is denial, let's call it as it is, that gets us into the most trouble.


A variation on our rabbi's method gives the nod to meditation and mindfulness which improve clarity, and also require discipline.

We'll take a look at one problem area, low self-esteem, which isn't a behavior but can change with alternative behaviors.

Low self-esteem leads to anxiety which leads to avoidance or indecisiveness, which reinforce low self-esteem.  Simply doing things is hard when you have low self-esteem.


Those who suffer this problem have trouble making a move without looking to other people for cues, seeing what they're doing.  When friends are wearing yellow, they will go with yellow.  If they know they are going to see a particular movie, they ask their friends what is good and will see it, even if they hate the genre.

Once called other directed-ness, now Looking Glass Theory, whatever you want to call it, the thrust is that when a person is this anxious over decisions, a fluid identity is at the core of the problem. Fluidity doesn't work when it comes to self and decisions.  A cohesive identity is a building block for self-esteem.

Needing instruction (the old Onion's joke about Oprah readers waiting for instruction), implies less self-esteem, less self-confidence.  Less self.  Not always true, obviously, but that joke works on the kernal of truth, as all do.

Developing a more stable identity, the obvious goal, requires some work.  Our intervention, therefore, does, too.  Yet it is fairly easy to remember.

1. You write down everything about yourself: values, habits, who you think you are, how you appear to others, especially.

2.  On a second page, examine the list and determine if what you wrote about yourself resembles the real you at all.  The real you, you see, is the person that you want to be.

3.  On a third page, write down those ideals, the values, habits, and personality traits that you want.  It is much harder, of course, to work on not being depressed, or not being angry.  Here emotions have to be defined in behavioral terms.  A therapist might need to be called in.

If you do this daily, refer to each list, concentrate on the person that you want to be, at least once a day, it has an impact.  It saves time in therapy.  Just knowing where we want to go is half the battle.  Therapy can help with the rest of the war.

Why It Won't Always Work, and Why It Isn't For Everyone

It is universal, even with narcissists, to think we are just not good enough as is.  It is how we are made.

And victims of child abuse and neglect are going to have more trouble accepting, loving themselves.  They can be obsessed, like the rabbi, with self-improvement, when they are often the most wonderful people in the world.

Their change is to see themselves as they are, as is, as good people, and loving themselves

Not so simple, usually requires a different morning, lunchtime and evening ritual.  Affirmations help here.  Calendars, little books.  You find them in the store.  Maybe not The Onion, so much.


(If you prefer Him, go for it, we merely assume on this blog that being made second, females are an improved lot).