Chapter 1



The Psychiatric Treatment

of the Young Adult

at Ridgeview Institute

by

Steven R. Lee, MD

Program Director

Young Adult Psychiatric Outpatient Services

TABLE OF CONTENTS

Chapter Page

1 - Who is the Young Adult in the 21st Century 2

- The Brain of the Young Adult 3

- Stages of Development 4

- Parents of the Young Adult 5

2 - General Treatment Issues 6

- What to Expect from Treatment 8

- How Long Does it Take? 10

- Parents Role in Treatment 11

3 - Behaviors that Adversely Affect the Group 12

- The Use of Mood Altering Substances of Abuse

- What is Pairing? 14

4 - Specific Psychiatric Disorders 15

- Depressive Disorders 16

- What is the Potential for a Suicide Attempt? 18

- Anxiety Disorders 19

- Trauma and Stress-Related Disorders 21

- Attention Deficit Hyperactivity Disorder 22

- ADHD and Substance Abuse 25

- Personality Disorders 24

- The Parents Role in the Treatment of a Personality Disorder 27

- Autism Spectrum Disorders 27

- Asperger Syndrome

- Mood Disorders 28

- Bipolar Disorder (See Appendix A)

- Cyclothymic Disorder

- Mood Disorder secondary to:

- Medical Condition

- Medication, Alcohol, other drugs

- Psychotic Disorders 29

- Schizophrenia (See Appendix B)

- Schizoaffective Disorder

- Learning Disorders 30

- Somataform Disorders 31

- Bibliography 32

Appendix A Treatment of Bipolar Disorder:

A Guide for Patients and Families

Appendix B Expert Consensus Treatment Guidelines for Schizophrenia:

A Guide for Patients and Families

Forward

Welcome to the Young Adult Psychiatric Program. This booklet has been written to help the parents of a young adult who has psychiatric problems understand our treatment approach, the psychiatric problem that is affecting your child, and to understand a young adult. This program is designed to meet the special needs of young adults (ages 18 to 26 yo) who have a primary psychiatric problem (versus a primary addiction problem) and need a comprehensive approach to treatment. These young adults may also be abusing substances ( i.e. marijuana) but addiction is not their primary problem. 25 to 30% of young adults in our program have substance abuse issues and these issues will be thoroughly addressed along with the psychiatric issues.

Individuals with a primary addiction problem need to be in the Young Adult Addiction Program. Sometimes deciding which is the primary problem can be difficult. Also, since most psychiatric disorders do not begin until someone is in their 20's, it is hard to know if the addiction issue caused the psychiatric problem or if the psychiatric problem is a psychiatric disorder that would have developed even if the young adult did not have a substance abuse problem. A young adult is a work in progress and has not fully developed into the adult that they will be. The problems that caused the young adult to believe that they were a failure and a burden on their family can be resolved and they can see that what they thought was their personality was actually a treatable problem. When their self image changes, then the young adult can see their potential and will strive to reach it. When the young adult has hope that they can change, then their motivation returns and they will take responsibility for their life.

The average young adult in our program is ~20 years old, has been in college, is unemployed, lives at home, is not sure what they want to do in life, has a depression and /or anxiety problem, and has attempted some outpatient, individual therapy with medication and it did not work. He is a male, is not the most responsible person in society, feels entitled to be taken care of by his parents and does not understand the need to be grateful for what he has. He does not verbalize how he feels unless he is forced to do something that he does not want to do and then he seems to be able to explain this in no uncertain terms. The young adult is a paradox in that he is an adult and he is still dependent on his parents for financial support. In fact, if a 23 year old male is married, has one child, is the night supervisor at a Chick Fillet, spent two years in Iraq, and has his own insurance (not the parents insurance), then, this individual would not fit into our program.

In summary, the young adult is just about the worst candidate for traditional psychological therapies. Most therapists and Psychiatrists cringe when they realize that their new outpatient is a young adult. The anticipation of dealing with smartalick, angry responses; the patient coming late to appointments (if they remember to come at all); noncompliance with their medication; probable use of at least marijuana and alcohol; someone else paying for the sessions; and having to call the parents on every change in the treatment plan (which doubles the Psychiatrist’s time versus their other adult patients) is not what most doctors and therapists want to do.

The lack of positive results and the young adult's inability to connect with his emotions in a way that he can verbally process his problems becomes clear after the first couple of outpatient individual sessions. At this point, a parent and the young adult begin to feel hopeless that change can occur. This is when The Young Adult Psychiatric Program at Ridgeveiw Institute can be an oasis of relief to the hopelessness everyone feels when trying to treat the young adult through traditional outpatient, individual therapy and medication.

Young adults need structure. They need other young adults that can understand how they feel in order for the young adult to trust those around them enough to bring out their own feelings of inadequacy. They need therapists that understand that they are no longer an adolescent but not yet a mature adult and who want to work with all of their idiocycrasies. That is why they need the Young Adult Program at Ridgeview Institute.

As the father of two daughters who are now grown, I had to buckle my seat belt during their adolescent and young adult years. It was a wild ride. Just because I am a specialist in the field, I had the full range or reactions (good and bad) that a father could have. There were times when I did not know if my daughters were going to make it and there were times when my wife and I blamed each other for our children's problems.

A redeeming benefit from that period of my life is my first hand experience of the full range of issues that are addressed in this document. Hopefully, this information will be helpful as you navigate your way through the obstacle course of dealing with your young adult while they struggle with their emotional problems.

Steven R. Lee, MD

Program Director of the Young Adult Center of Excellence

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Who is the Young Adult in the 21st Century

The mental health issues of the young adult are not much different than those of adults older than 26 years old. The difference is the way each problem presents itself and how it must be treated and managed. Young adults are in many ways “professional adolescents”. At 18 years old a young adult is legally capable of making their own decisions but those decisions are based on their desires with little or no experience as to the range of possible outcomes that may occur because of those decisions. As parents, we remember the errors in judgment we made at this age and thank God that somehow we lived through those years. Now, consider what all of this may be like if the young adult is impaired with depression, anxiety and/or substance abuse.

Each young adult is an individual with their own unique set of assets and liabilities. Their ability to understand their problem areas and to make positive changes in these areas are affected by these assets and liabilities. Also, how quickly a young adult will trust a therapist is based on the young adults past experiences with other adults. A young adult can be categorized into one of the following categories which affects the approach taken by the therapist to develop a therapeutic alliance with the young adult.

1 – Responsible / Age Appropriate / Intact family

2 – Irresponsible/ Apathetic

3 – Angry / Oppositional–Defiant

4 – Immature (Socially / Emotionally)

5 – Antisocial / Breaking the Law

6 – Chronic Emotional Problems / Hopeless

7 – Drugs, Alcohol, or Eating Disorder

8 – Personality Disorders

9 - Autistic / Problems connecting with others (Asperger's)

10 - ADHD / Learning Disabilities / Problems processing new information

11 - No Consistent Parents (orphan, multiple foster homes) / Chronic child abuse

The young adult today is not the same young adult as 30 years ago. Today, one third of young adults move to a new residence every year and 40% move back home with their parents at least once. They go through an average of seven jobs and two-thirds spend at least some time living with a romantic partner without being married. The median age of marriage in the early 1970's was 21 for women and 23 for men. In 2009 the age climbed to 26 for women and 28 for men.

The young adult's self-confidence is a paradox both for society and the young adult. When asked if they are confident that they will get to where they want to be in life someday, 96 percent say emphatically, “Yes!". When asked if they feel like they are grown up and ready to be on their own, 60 percent say that they feel both grown up and "not-quite-grown up". Most young adults charge into life being told that they can do anything they want to do. They are taught through television, their parents, and at school to stand up for themselves and demand that they will only accept the best that life has to offer. Many young adults find out, through the "school of hard knocks", that having the best has to be earned through many years of hard work and experience. Having an attitude of gratitude for what you have versus an attitude of always wanting more is a lesson that many young adults do not understand before they come into treatment.

Many young adults, unfortunately, are disrespectful to their elders and are primarily focused on themselves. Most often this is the result of ignorance and not because they have a selfish personality. The prosperity of the baby-boomers gave parents of young adults the means to give to their children opportunities that they did not have. The young adult often takes these opportunities for granted because they did not have to earn them.

Lay-offs, unemployment and being relocated to other cities (when they finally get a job), was not the same environment of their parents ("baby boomers") when they were young adults. These facts create great fear, anxiety and frustration for the young adult which their baby boomer parents, in general, did not have. There is a constant feeling of uncertainty in this generation, yet they have been told all of their life that they could do

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anything since they have been given so many opportunities. Even the young adults who have worked hard and obtained a college degree many times have to move back home because they cannot find a job. A report by the U.S. Congress Joint Economic Committee published in May, 2010 states: "Although the economy has gained strength and overall labor market conditions have improved in recent months, younger workers have continued to struggle finding work. Employers added over half a million jobs in the last four months, yet the unemployment rate for young workers reached a record 19.6 percent in April 2010, the highest level for this age group since the Bureau of Labor Statistics began tracking unemployment in 1947".

The Brain of the Young Adult

The NIMH (National Institute of Mental Health) did a study that began in 1991. Neuroscientists once thought that the brain stopped growing shortly after puberty, but this study pointed out how the brain keeps maturing well into the 20's. 5,000 children from ages 3 to 16 were studied. They found that their brains did not fully mature until age 25. The most significant changes that took place were in the prefrontal cortex and the cerebellum. The prefrontal cortex of the brain is involved in emotional control and higher-order cognitive functioning (problem solving) (1).

NIMH scientists also found a time lag between the growth of the limbic system, where emotions originate, and the prefrontal cortex, which manages those emotions. The limbic system explodes during puberty, but the prefrontal cortex does not develop as fast as the limbic system. This area of the brain keeps maturing for another 10 – 15 years. This means that emotions and impulsive actions might outweigh good judgment for some young adults especially if they are intoxicated. The limbic system is our "flight or fight" center that takes over in an emergency to make us act even before we can have time to think through all of the possible choices. If a car is about to hit us and we can sense that this is imminent, in order to survive, we have to act before we think through what is happening.

The limbic system tells the body to act in order to deal with danger but it does not have memories of all of the consequences of that action. It does remember that a particular action gave relief to a particular stressor but it does not remember the details of all the complications that occurred because of the action taken. The cortex is supposed to remind the young adult of the dangerous consequences of any behavior before that individual does anything but the cortex is not fully developed until around 26 years old while the limbic system is fully developed at 18 years old. What this means is that the limbic system is in the drivers seat and any advice given to the driver by the cortex can be followed only if the limbic system believes it is in the best interest of the person. If the driver (the limbic system) of this car (the young adult) believes that the body needs to act immediately, it can override the immature cortex's concerns and proceed with the behavior.

If we continue to use the same analogy as above, the limbic system would be like an 20 yo driving a car. They have only limited experience as to the range of possible outcomes that may occur with every decision they make while driving that car. The cortex, which is about 10 years younger as compared to the limbic system, would be like the 20 year old's 10 year old brother sitting in the back seat of the same car. This 10 year old has seen a video in school of some consequences of driving dangerously. As the 10 yo realizes that the car is going greater than 100 miles per hour, he will begin to point out to his 20 yo brother the dangers of this excessive speed from what he learned in the video he saw in school including going to jail, serious injury to himself and others, etc. This 10 yo brother will tell the 20 yo to slow down and that he is frightened. The 20 yo may hear the concerns but, he believes he can manage the consequences of going this fast, plus he enjoys the wild ride which is more important to him. The point here is that the limbic system is in total control of driving the car.

The one thing that insurance companies know is that the risk factors are much higher for unmarried, young adults 25 years old or younger, than for older, married adults. This is an actuarial (statistical) fact based on the number of accidents and traffic violations that are dramatically higher for teenagers and young adults. This, of course, means about 30 to 50% higher premiums for auto insurance for a young adult.

The limbic system is also where most drugs and alcohol do their work. When someone uses a substance or performs a certain behavior (i.e. video games, sex) and gets relief from stress or feels extra good, the

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limbicsystem records that memory. The limbic system then drives the young adult back to that substance and/or behavior again and again because this is the quickest way to get immediate relief. Unfortunately, without

having more comprehensive experiences in life, they do not have enough knowledge to appreciate the real dangers of such behaviors as driving a car too fast or of having unprotected, sexual activity.

Since the part of the brain that is responsible for mature judgment and self reflection (the Cortex) does not fully develop until around 26 yo, the process of recovery for a young adult takes longer than that of a 35 yo.

Also,if that young adult has experienced years of living in an abusive situation as a victim; has a personality disorder; has a learning disability; has been habitually smoking marijuana (and/or using other drugs); then, this young adult will need more time to deal with their depression or anxiety disorder than someone who does not have these other issues. Years of living an unhealthy life style during adolescence or the young adult period sets up lifestyle patterns of behavior that can be hard to change once this individual reaches their late

20's. The earlier in life that someone changes how they respond to stresses in life, the easier it is for them to change. The longer that we repeatedly deal with life a certain way, the more ingrained these life patterns become. But with all this said, these issues can be dealt with and can change if the young adult has the right treatment structure and has some desire to change.

A synapse is a microscopic area in the brain where one neuron connects to another neuron. This allows the eye neuron to tell the foot neuron where to step. This is also necessary for problem solving. As the brain matures, there is "pruning of synapses". It depends on how any one brain pathway is used. By cutting off unused pathways (pruning), the brain eventually settles into a structure that is most efficient for that person, creating well-worn grooves for the pathways that the person uses most. Synaptic pruning intensifies after the rapid brain-cell proliferation during childhood and again in the adolescent and young adult years.

The longer the young adult is active in a particular life style during this pruning, the harder it will be to change patterns of behavior. This includes life patterns while they have been depressed and anxious as well as any active addiction or abuse. These patterns of behavior become so reinforced over time that without a concrete therapeutic structure to confront negative behavior, they will fall back into their old ways of doing things and not change. New synaptic connections have to develop while they are living a new lifestyle of healthy patterns of behavior socially, interpersonally, and spiritually. This process takes time.

The above facts make it clear that self esteem, personality disorders, and general lifestyle patterns are much more easily corrected up to about 26 yo. Once the synaptic pruning occurs, change is more difficult though it can occur if the individual really wants to change. Every effort should be made to be sure that young adults have the most comprehensive treatement available while they are a still a work in progress developmentally.

Stages of Development

We all go through stages of social, emotional, and psychological development. As defined by Erik Erikson, they are as follows:

• At 4 to 6 years old we start the Stage of Industry. This is when children begin to understand the world around them. They will ask many questions and attempt to dismantle things to see how they work. They will also build things.

• The next stage of development runs from 12 years old to age 18. This is the stage of Separation and Individuation. Many adolescents have a hard time during this stage and will separate and individuate through anger and oppositional/defiant means. They feel that their parents do not understand their generation and, therefore, must take charge of things themselves. This is the stimulus that motivates the child to leave the nest but sometimes they are not ready to fly. The mature 18 year old understands this fact and does not try to do more than they know they are capable of doing.

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• The next stage is the Stage of Intimacy and runs from 18yo to almost 30. During this stage, the young adult begins to form relationships that will possibly produce children. The narcissism of a child matures into an adult who begins to take complete responsibility for their behavior and their life. Thisability to take responsibility broadens to recognizing that, in an intimate relationship, they also have certain responsibilities for other people and maybe for their own children.

Addiction, early loss of a parent, major medical illness or anything that disrupts normal interactions with society adversely arrests many aspects of the development of a child into an adult (inadequate ego development). These problems greatly impact their ability to become an independent person capable of existing on their own, separate from parents and institutions. If they have not developed this "Stage of Intimacy" then they will need to build that part of their ego (personality) structure that did not develop due to the addiction, trauma, medical illness or loss of the parent. All of this must occur to be able to live successfully, in order to be capable of working a full-time job, have a long-term, intimate relationship, and to raise children responsibly.

In a recent report of youth, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that 21% of young adults aged 18 to 25 needed treatment for alcohol or illicit drug use. In addition, 96% of those who needed treatment did not perceive the need to attend treatment. Since recovery can only occur if the person wants it, helping the young adult to pursue recovery can be a real challenge (2).

Parents of the Young Adult

It is impossible to work with a young adult as a single individual. The young adult is an adult plus their parents. Although they are separate from their parents with their own personality, most twenty first century young adults are not capable of independently supporting themselves in today's society. They usually require their parents to provide them the resources necessary to have an automobile, a place to live, groceries, insurance, attorneys, etc.

Parents of young adults are in a “no win” situation. They have the experience in life and serve, in fact, as the mature cortex that the young adult does not yet have. Unfortunately, the immature, young adult is still in a process of separation and individuation. This means that the young adult believes that their “elderly” parents do not understand the modern young adult, therefore, their parent’s advice is not valid so the young adult believes that they have to make their own decisions. In the majority of these cases, the only leverage that the parents have with the young adult is that they have the money. Remarkably, many parents do not play this card for fear that their child will become worse by depending on their unhealthy peers for a place to live.

Any treatment of a young adult has to be done along with the parents. The therapist has to work with the young adult in a way that the young adult can feel respected as a separate individual from his parents while giving the parents the respect that they deserve for spending their life raising this child. The range of personality types and the differences in parents are diverse. Each parent have their own set of issues that are happening now and that happened as a wounding to their ego development when they were young. These issues clearly affect how the parent interacts with their child who is now a young adult. In general, parents can be categorized into the following types:

1. Motivated; emotionally healthy; clear boundaries (i.e. who is the parent and who is the child)

2. Codependent; caretaking

3. Concrete; rigid (right is right and wrong is wrong with little gray)

4. Orthodox religion; atheist; racist; sexist

5. Homeopathic versus conventional medicine

6. Self centered; too busy; absent, single parent working full time

7. Step-parent or adopted parent not emotionally connected with child

8. Unstable addiction or psychiatric problems

9. Angry; blaming

10. Inadequate (Unable to set limits or give direction to child because of disability)

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General Treatment Issues

There is a range of treatment options. Group therapy is the primary mode of treatment. On the first day of being in the program, those who have never been involved in a group process, may feel comfortable with this mode of treatment. The newcomer to the group usually believes that the only way they can deal with their issues is through individual therapy. Since the issues that brought them into treatment may include feelings of inadequacy and increased anxiety around people, they cannot understand how they can deal with their most intimate struggles in front of 10 strangers.

Initially, they may minimize their issues or outright deny them. They may look angry which they unconsciously use as a defense mechanism because of fears of rejection by others in the group. As they witness others who are farther along in treatment being vulnerable as they tell their life stories, then the newcomer begins to be real with their own feelings and takes a risk to talk about their own fears. Without seeing others open up about the same feelings of inadequacy or about past or present abuse issues, the individual would never be able to realize that their issues are part of the human condition for some people. In individual therapy it is hard for someone to deal with their core issues because they are either not aware that they are there or because they are too ashamed to bring them up. Most people who come to our program have been involved in individual therapy and it did not do the job. It is time to try another approach through group therapy.

Group therapy is an insight oriented process. It is an opportunity for the patient to express and process feelings, experiences, and perceptions and to have them validated. At the same time, it is also an opportunity to have maladaptive patterns of thinking and behavior challenged and addressed. It is important to understand that, while each patient’s story and experience is unique to that patient, the underlying themes are the same. Patients can relate to each other around feeling lost, broken, hurt, abandoned, afraid, and numb. Most young adults can relate to impairment in daily functioning, a decrease in academic or work performance, turning to unhealthy behaviors as primary coping strategies, problems in relationships, and withdrawal from the world. It is at this level that patients can learn from one another in a group setting. They begin to see how they had minimized and denied their own problems as they identify with the others in the group. The group process allows them to observe their own behaviors, feelings, and maladaptive responses mirrored in others. They finally break through their own defense mechanism that they unconsciously used to deal with their painful emotions and fears, and can see that they have a problem. They can then work together to challenge each other to move towards healthier, more adaptive ways of thinking, behaving and coping with their illnesses and with the world.

We use a mixture of "process" and "experiential" groups along with informational lectures on stress management, the scope of mental illness and family dynamics (how families interact with each other). The changes that have to occur in order to recover from the dysfunction caused by a mental illness require that the young adult becomes mentally, physically, socially, and spiritually whole. (Spiritually is defined here as recognizing that there is a power greater than just yourself.)

Living a Healthy Lifestyle

Anyone who has a psychiatric illness will need to structure their life style. Ideally, the body and the brain chemically work together in a balance to produce the levels of neurotransmitters, hormones and endorphins necessary for wholeness. Sleep, exercise (and body image), diet, social interactions, sexual stimulation, tobacco (and anything with nicotine), alcohol, caffeine, and abuse of other substances are all involved in affecting the length of time it will take the young adult to become well psychologically.

The young adult needs to go to bed and get up at the same time every day, plus or minus an hour, in order for the body to calibrate it's "biological clock". This process takes two weeks. A calibrated biological clock will cause a heavy excretion of cortisol from the adrenal glands one hour before awakening which activates

metabolism and allows us to be mentally alert and ready to get going. One hour before going to bed, the cortisols turn off and you want to go to sleep. This cycling of cortisol (diurnal variation) is critical to be able to have a complete sleep pattern and to be alert during the day.

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Anyone with an untreated Major Depression or an Anxiety Disorder has a disturbed biological clock such that cortisol is slowly excreted with very little or no relationship as to whether you are awake or asleep. These individuals do not rest right when they sleep because they do not get into the deeper stages of sleep. They do not feel mentally alert during the day and have a hard time making decisions. They just do not feel good. This is caused by the chemical dysfunction that is happening in the hypothalamus which is the area of the brain that is the cause of the mental disorder. Information is not sent appropriately from the hypothalamus to the pituitary gland. The pituitary gland's function is to tell all of the organs in our body when to function such that they cycle in rhythm. If the pituitary does not send information appropriately such that these organs do not cycle in rhythm, the end result is sluggishness, difficulty thinking, low motivation, fear, anger, isolation and feelings of hopelessness.

Once the brain is adequately treated to be able to produce sufficient neurotransmitters, then the hypothalamus can communicate clearly with the pituitary. The pituitary can then coordinate the rest of the body's organs to cycle in rhythm. The individual is then able to sleep, can think clearly, have energy to do things and will look forward to the day. This process takes two weeks when it is not cycling correctly.

When sleep is healthy, there are 5 stages of sleep; one through four and REM. Each stage of sleep is essential for the brain to produce certain neurotransmitters and other chemicals that are necessary to prevent the

depressive and anxiety disease states. Restorative Sleep is the term used when someone sleeps through all of the stages of sleep plus REM with a sufficient amount of time in each stage to allow the brain to produce these

chemicals. Erratic sleep patterns and sleep produced by alcohol and drugs of abuse adversely affect the brains ability to produce these substances.

In the same way, all of the other aspects of a life style can either enhance or deplete your ability to produce the normal levels of these neurotransmitters, hormones and other substances. Every adult must exercise by doing sustained movement (walk, run, swim, aerobic, other) for at least 30 minutes, four days per week. Eating at least three meals per day which include the right amount of protein and minimizing carbohydrates and sugar is critical to have the nutrition you need for physical energy and to allow the brain to function at its full capacity.

Learning how to communicate with others, appropriate sexual behavior, and not isolating through gaming, internet surfing, or other individual activities are critical to prevent depression. Something about having healthy interactions with others is also involved in the development and utilization of other chemicals in our body such as our endorphins. Endorphins are our body's natural "narcotic" which gives us a sense of well being. Isolating or having minimal contact with other people does not allow certain chemicals to be made appropriately or released.

Cigarettes (and other nicotine substances), excessive caffeine, and other mood altering substances like alcohol or marijuana greatly affect the balance of how chemicals are released in the body. Any stimulant will not only keep you awake and give you a temporary increase in your sense of wellbeing, but it will also stimulate

all other aspects of your body and mind. Anxiety disorders, rage reactions, and insomnia are adversely stimulated by these substances. You may feel better for a few hours after using these substances but after this stops, the stimulating effects will continue for about 6 to 8 hours.

Also, stimulating the release of endorphins through the use of alcohol, marijuana (and other drugs), cutting yourself, purging, or excessive sexual activity may give you a brief sense of wellbeing but depletes the storage of endorphins. The next day you may be irritable, overwhelmed, and have problems making decisions. It takes 24 to 36 hours for there to be enough endorphins to provide the sense of wellbeing necessary to feel right to be able to handle the normal stresses of the day. If you have a depression, the suicidal feelings will be stronger, and if you have an anger problem, you are more likely to react angrily because your frustration tolerance is too low.

Nicotine addiction is the worse addiction on the planet. It causes the most premature loss of life, the most premature break up of families because of early death of the smoker, the most loss of days at work because of medical illness, and is the hardest addiction to treat. Nicotine is responsible for lung, mouth, throat, esophageal,

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stomach, pancreatic, bladder, lung and liver cancer as well as emphasema and chronic bronchitis. It advances athrosclerosis in the blood vessels and weakens the heart. The broken down vascular system of a smoker can cause early heart attack and stroke. If someone has a heart attack, there is a multifold increase in the possibility

of heart ventricular fibrillation and other arythmias that cause death versus a non-smoker who will survive the heart attack because they will not have the arrythmia.

We strongly recommend that if someone is smoking less than 10 cigarettes per day, they should stop smoking when they come to the program. If they do not, eventually they will be smoking a pack per day or more as they develop tolerance to the effects of nicotine. If they are smoking a pack per day, then they may have to wait about 3 to 6 months to stop smoking because stopping smoking at this time may be too much along with getting over an acute depression or manic episode.

The above is not a comprehensive list of life style changes that have to occur in order for someone to be in a wellness state. Helping the young adult to be a responsible adult versus a professional adolescent is a labor of love. We need to educate them in creative ways that will get their attention so that they will understand that these healthy life style changes are in their best interest so they will feel better overall making these changes.

The program at Ridgeview does not "cure" the young adult's illness. The program builds the basics that are needed for the patient and their family to continue in outpatient treatment to maintain and sustain progress back to full functioning in society.

What to Expect from Treatment

A patient's treatment in the Young Adult Outpatient Psychiatric Program begins either as a transfer following inpatient stabilization or as a direct admission to the program. The admission occurs because the patient and their family has experienced some type of crisis. A young adult rarely "asks" to go into treatment. People are unsure of what to expect from treatment; what the varying levels of treatment represent; how long it will take; and what is hoped to be accomplish in treatment. The following hopefully will clarify these questions.

There are three basic levels of care.

• Partial Hospitalization Program with a residential component is often referred to as PHP/Half Way House. Patients participate from 9am till 3pm Monday through Friday and reside on campus in the Ridgeview Half-Way House.

• PHP/Home is when the patient participates Monday through Friday from 9am till 3pm and commutes from home. Patients at this level of care may also reside in a ¾ house (e.g. Hope Homes, Safety Net).

• Intensive Outpatient Program (IOP) is when the patient participates Monday through Friday but from 9am till 12pm. This level of care is a step down level providing the patient with the opportunity to begin to self-structure, to establish or reestablish outpatient relationships with providers, and to become reacclimatized to life outside of the treatment program. Those patients who are mature, are able to structure themselves, can arrive on time, and are self-directive could start their treatment in the IOP. (Most young adults who can do this are probably not a young adult or do not need our program.)

The treatment program provides several modalities of treatment addressing a broad spectrum of issues. Patients receive psychopharmacologic treatment with management and monitoring under the care of their attending physician and nursing staff; participate in group therapy facilitated by the patient’s case manager; participate in individualized family therapy with an assigned family therapist (not a part of IOP Program); and benefit from psycho-educational groups, lectures, and other adjunct specialty groups.

Group Therapy – In PHP there are eight group therapy sessions per week with the case manager. IOP patients have 5 groups per week. These groups provide an opportunity for the patient to:

• present and process treatment assignments

• to address past and present concerns and stressors

• to engage in reality testing, to practice new skills and behaviors

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• to process and address how others experience them and how they experience others

• to address, take responsibility for, and alter behaviors and patterns that may contribute to or exacerbate presenting concerns

• to hold peers accountable for their behavior and what they say and to be held accountable by the peers in the group

• to learn to communicate emotions and needs in an assertive, congruent, and healthy fashion

• to experience, process and express emotions in a healthy fashion

• to learn more productive and healthy ways of living

Family Therapy – The patient and the family have a variety ways of connecting with and participating in the treatment process.

• Multi-Family Group (every Tuesday from 7 to 8pm) – a group therapy process involving other patients and families in the treatment program.

• Family Workshop (second full week of each month) - family and patient participate in the day to day process of treatment including psycho-educational lectures focusing on the diagnosis and treatment of psychological and addictive illnesses, codependence, healthy communication, family dynamics, and other pertinent topics. During the Family Workshop family members have the opportunity to participate in groups with other family members and the opportunity to participate in group therapy with their child.

• Individualized Family Therapy - The participation of the family in the treatment process and the family participating in their process of self-care is an important and necessary component of the treatment process. (Family therapy is not a part of the IOP level of care.)

Psycho-educational Groups and Lectures

• Conflict management

• Interpersonal Relationships

• Spiritual Education

• Stress Management

• Wellness/Holistic Living

• Self-Esteem

• Healthy Coping

• Dialectical Behavioral Therapy (DBT)

• Relapse Prevention

Patients additionally have access to adjunct psycho-educational groups ranging in topics including:

• Men’s and Women’s Issues

• Trauma specific groups

• Expressive Therapy

• Life Skills

• Relapse Prevention

• Personal Growth

Patients with co-occurring substance related disorders (substance abuse or dependence) will also be directed to psycho-educational groups and lectures that address this component of their illness.

Goals and Outcomes of Treatment

The treatment goals for each patient are individualized, but in general, the focus of the treatment process is:

• To further stabilize the acute stage of the psychiatric illness;

• assist the patient in developing healthy insight and awareness into their illness;

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• to begin and maintain a healthy recovery process;

• to assist the patient in developing healthy coping skills that encourage self-responsibility in the management of their illness and for independent functioning.

After finishing the program, patients:

• continue treatment on an outpatient basis with an individual therapist;

• maintain medication compliance with the assistance and monitoring of a psychiatrist;

• continue to seek support through the participation in adjunct groups such as Emotions Anonymous (EA), Codependents Anonymous (CODA), The Depression and Bipolar Support Alliance (DBSA), the National Alliance for Mental Illness (NAMI), Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

• have the opportunity to remain connected to the RVI recovery milieu through a variety of options.

How Long Does it Take?

Once someone decides to come to our program, they have usually been seeing a therapist and a psychiatrist, and though everyone was doing what they could, the patient did not feel that much better or did not cooperate with the treatment such that either a crisis occurred or the young adult became more dysfunctional. We realize that when you come to Ridgeview, that this will not be a simple depression or anxiety problem that will be fixed by taking a medication and giving you a list of the secrets on how to cope with life.

First, the young adult will have to accept that they have a psychiatric problem. Obviously, this is not an easy thing to do. Having a psychiatric problem is nothing to be ashamed of though we understand that this is how many people feel. The problem is that this shame can be a major stumbling block in terms of recognizing and dealing with their problem. Young adults are very private people and do not easily open up about what they are thinking unless it is to other young adults.

Once they accept there is a psychiatric problem, then they have to connect emotionally with this problem in a way that they can feel it and work with it. This is a lot easier said than done because most young adults emotionally disconnect from their psychiatric illness to avoid the pain of the illness. They then act out these feelings in destructive or obnoxious ways. This avoidance and sometimes outright denial does not allow the

young adult to deal with it, so they can resolve it. Learning how to describe it and to verbally talk about it is even more difficult.

The doctor will work with the young adult to find the right medication to help the problem. The medication can help the young adult to not be so overwhelmed so that they can work with themselves to begin to stabilize their emotions. There is much more about medication in the "Specific Disorders" section. Medication, by itself, cannot fix the problem. The young adult will have to be honest with themselves and the group about their past and their fears of the future.

The process of starting in the program, accepting that there is a problem, starting medication, and emotionally connecting with the problem in a way that the young adult can see the source of the problem, usually takes at least 2 weeks. Now they can begin the process of understanding how they can get what they need to make whatever changes in themselves that are necessary to live a responsible, adult life.

Making some basic changes in how you take care of yourself, asking for what you need, and giving to others is not easy. Sometimes your own defense mechanisms that protect you from being hurt create a strong barrier to taking the risk necessary to get out with others or to ask appropriately for what you need. This barrier will need to be discussed in the group to help you to develop a plan to make changes in your life. You will have to

be emotionally connected with yourself in a way that you can understand what it is that needs to be changed. All of this takes at least another week or two.

If everything goes as planned, the first two parts of treatment take at least 3 or 4 weeks. After this time, if you are feeling better and understand the issues involved, then you can be discharged and follow up with a therapist and a psychiatrist. If you are still feeling bad and not connected with your emotions in a way that you can verbalize them, then your treatment may take longer. Many young adults will transfer to the IOP level of care for a week or two to transition from the program. This is the time that you cannot let the needs of your life,

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such as school, friends, and lovers pull you back into your old life style where you will soon relapse into your old ways.

Our goal is to help you to understand your psychiatric problem, to develop a plan as to what you will do to deal with this problem, and to help you to find those people in the community that can continue to work with you. You will not be "fixed" when you are discharged, but you will know what to do to continue to improve.

Learning how to work with a psychiatric problem and to communicate with others takes practice and

instruction, in the same way as learning how to play a musical instrument, learning a foreign language, or going to school to get a degree.

Patient Expectations and Responsibilities

While in treatment patients are expected to:

• Attend the program daily from 9am to 3pm if in PHP, and from 9am to 12pm if in IOP. Patients are expected to leave a message with their Case Manager if running late, or if they have a medically excused absence.

• Any patient that has been absent for three days in a row will be discharged administratively because we do not know what is really happening with that patient. A patient that misses 2 days in a row, and has also missed 5 days throughout their stay in the program, also will be discharged for the same reason.

• Complete all assigned homework by Case Manager. The assignments generally consist of a self assessment, recovery plan, and a discharge plan. Assignments are also provided that focus on the individual needs of the patient.

• Attend all lectures and psychotherapy groups daily.

• Abstain from the use of any non-prescribed mood or mind altering substance (alcohol, cannabis, and other drugs) regardless of diagnosis. Patients are also expected to avoid high-risk people (i.e. active addicts), and places (any situation or environment you are likely to be exposed to alcohol or drugs).

• Attend at least two meetings per week (AA, NA, CA, EA, CODA, DBSA, SLAA, OA, GA, or the Tuesday night Multi-Family Group)

• Report thoughts of self-harming or hurting others to case manager, attending, or staff immediately. Address these urges and refrain from acting on them.

• We discourage patients from seeing their individual, outpatient therapist during the time that they are in the program, so that the patient may better develop an alliance with the group. This alliance is the energy that is necessary to get well. If the most critical, sensitive issues are only being dealt with through their outpatient therapist, then these issues may not be brought up at all in the group. That patient will not be able to benefit from the power of the group process. Of course, there are exceptions to this rule but this needs to be discussed with the treatment team at the time of admission so that we are all on the same page.

If patients are unable or unwilling to comply with these recommendations they may be asked to increase their level of care (e.g. transition from home to the Half-Way House, or from IOP to PHP), or they may be discharged with referrals to other programs. Patient needs must also be balanced with the needs and the

safety of the treatment environment.

Parent's Role in Treatment

Anyone reading this booklet hopefully will be aware that the parent's role in treatment is essential for all of the reasons explained. Not only are parents critical to provide the structure and the financial support for the

treatment but every parent has their own issues that usually come out with the right pressure. The human condion includes our fears, inadequacies, and dreams that have not come true.

Codependency is the behavior of taking care of others at the expense of taking care of yourself. When your major purpose in life is taking care of someone because that someone does not take care of themself, then you are considered "codependent". Even though this gives you purpose and worth, you can see that eventually you

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will become weak and depressed (and maybe angry) because you are not getting all of your own needs met. “Taking care” of that person gives them extra time so they can expand their unhealthy behaviors which is called "enabling”. Also, only voicing your anger without setting limits (i.e. taking away the car) does not help the young adult to change their behavior. If the family does not get their own therapy to understand and deal with these issues, then the family gets sick and the young adult does not change. The young adult will then expect everyone else in the world to do what the family is doing. The young adult is shocked when the rest of the world (employer, police, neighbors and partner) does not take care of them in the same way as their parents.

Parents have to clearly define the boundaries and limits that exist in the family unit. There are certain behaviors that cannot be tolerated if multiple adults are to live together. Mutual respect of each others’ space requires consideration of noise levels (i.e. music), maintainence of common areas (i.e.kitchen, den, bathrooms), and coming and going from the house after bedtime. No matter how intimidating the young adult may be when confronted about these issues, these basic rules of the house have to be maintained or the young adult cannot live there.

Guilt is one reason that a parent does things that they would never do if this were not his child. Chances are the parent loves their child and did the best they could to be sure that their child had the support and direction that they needed. However, no matter how objective we think that we are, we still feel guilty if our child has a problem. The fear that our child is in this situation because we possibly missed giving them something is a

normal feeling as a parent. More times than not we did not miss anything in the child's development and we did the best that any parent could.

The problem is that guilt (based on real neglect or perceived neglect) can cause a parent to enable their child by giving them too many breaks when the young adult needs to feel the full consequences of their wrong behavior. Guilt can cause you to be too angry and "hard-nosed" in an attempt to make up for all the times that you felt that you had been too lenient in the past. Guilt can cause you to be too harsh with your spouse because you irrationally believed that your spouse should have been stricter with your child. The examples go on and on with you looking for the causes of your child's problems. Until you obtain help to better objectify your responses to your child, all you are doing is making the situation worse. As part of the young adult's means of

distracting you from their problem, the young adult uses your behavior as an example of how you, not them, is the one out of control.

One of the hardest things that a parent may have to do is to tell the young adult that they have to leave home. There are good reasons why a mother bird pushes her young out of the nest that is two stories from the ground. Hopefully, the process of the child leaving home will occur with everyone in agreement but many times the young adult has to be told to leave even though they are not "ready". Your fear that they will go to their negative friends or will be hurt because of their impaired judgment are all valid concerns but allowing a ranting and raving young adult to hold the family hostage is also a recipe for disaster. If you believe that your child is actively suicidal then call Ridgview Institute at 770-434-7032 to have them admitted to the inpatient unit, otherwise, tell them they have to leave.

Behaviors that Adversely Affect the Group

There are four behaviors that clearly affect the ability of the group to be a safe place to bring up and process issues. These behaviors can cause great anxiety, fear, anger, and depression. Without the safety and mutual respect of all the group members, recovery cannot occur. These four behaviors so adversely affect the functioning of the group, that they will not be tolerated.

1 - Any direct or indirect threats of violence

(includes bullying and sexual abuse - verbally or physically)

2 - Using mood altering substances of abuse

3 - Pairing off

4 - Any Disrespect of Others

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Acting out is the conscious or unconscious expression of an internal emotional conflict through a behavior that represents this internal conflict. Some people are aware and connected with their emotions such that they

can verbally deal with them. Other people have a problem communicating their emotions verbally such that conflicts (in relationships, conflicts with their identity, spiritual conflicts) are not verbally processed. These individuals may "act out" these issues versus verbally discussing them.

If someone exhibits any of the above behaviors, we will work with that person to help them to understand their behavior. If the individual is unable to resolve their internal conflicts through verbal communication within the group then clinically they need a different level of care or a different program to treat their problem. If someone's acting out adversely affects the group's ability to function then that person cannot remain in the group. Everyone with a psychological problem is not able to deal with their internal conflicts through a group process. If we are not able to move that person to another program in the Ridgeview system then we will help that person to move to another program outside of the Ridgeview system that can better treat their problem.

The Use of Mood Altering Substances of Abuse

What most people do not appreciate is that the use of alcohol and marijuana in the evenings and on the weekends affects their ability to function psychologically in the group the next day. After the initial ingestion of alcohol, there is a sense of wellbeing for about 2 to 3 hours and most people think that is the end of it. In reality, the reason for the increase in the sense of well being is because "endorphens" are borrowed from tomorrow in order to feel better today. Other chemical reactions also take place but the "endorphens" give the most immediate response.

Endorphens are our natural narcotics and are one of the reasons we have a general sense of well being. They are slowly released all of the time. When we use alcohol, they are essentially squeezed out all at once. The problem with this is that it takes a day or longer for our body to replenish the supply. The next day we have a deficit of the amount of endorphens needed for that day.

There are 4 Stages of Sleep plus the REM (rapid eye movement) Stage. Each stage of sleep is the only time our brain can make certain essential substances. If you sleep in stages one and two but rarely get into three and four or in the REM stage, some substances are not made. Alcohol may help you go to sleep but this sleep is not "restorative sleep" in that you do not spend enough time in each stage of sleep to allow all of the essential substances to be produced. When this occurs, your ability to be 100% mentally and emotionally will not be there the next day. Clearly, any use of alcohol during a depression, an anxiety, or other mental health episode

will adversely compromise your ability to deal with that episode. Alcohol may give a couple of hours of feeling good but it decreases your frustration tolerance and makes your depression, anxiety, impulse control, and anger worse for the next 24 to 36 hours.

When dealing with their psychiatric disorders in treatment, patients will be asked to work through situations in their life that were too overwhelming to deal with before coming into treatment. Once these issues come to the surface, the use of alcohol or any other mood altering substance causes disinhibition of emotions. This means that the person may impulsively say what they feel before they think about what they are saying such as threatening someone. They may also act out what they feel when they would not do this otherwise. If the person

is suicidal or wants to hurt someone, they may actually follow through with these feelings and act them out when they are disinhibited because of the use of alcohol or other drugs of abuse.

If the use of alcohol or other mood altering substances has been that person's way of coping with the pain of the situation, they will have to abstain from these substances and learn better ways to cope. If they cannot abstain during the time that they are in our program, then they may need to be treated for a substance abuse problem first, then return to the psychiatric program to deal with the original issue that brought them to the program. Again, the use of mood altering substances during treatment can be dangerous and even life threatening if someone has suicidal ideations.

Marijuana acts in a similar way as alcohol in terms of the release of endorphens, but it clearly does other things in terms of how it heightens certain senses (appetite, sexual desire, etc) and dulls others. Marijuana may initially "chill you out" and relax you so that you can sleep and not be overwhelmed by certain emotions, but the

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same problem also occurs here as with alcohol. The next day, you have a deficit of endorphens and other substances that are necessary for you to deal with the day's challenges.

Unfortunately, marijuana also comes with a few other problems. Since marijuana stays active in your body for at least 3 to 5 days, it is affecting your thinking and judgment during that time. Though you only feel "high" for a few hours, the impulsivity, the loose associations (inability to stay focused on one subject), and the

disinhibition of emotions are problems for 3 to 5 days as a result of that one use of marijuana on Saturday night. When someone is in intensive psychiatric treatment, the use of marijuana, even once, may be the factor that tips that person over the edge or prevents them from resolving the conflicts that need emotional work.

If someone uses marijuana several times during the week to deal with stress or to be able to go to sleep, then, after the high wears off, the individual realizes that whatever was not dealt with emotionally before they smoked is still not resolved. They then realize they are even more behind (homework, chores, going to see their probation officer, etc) and feels that they have to smoke more marijuana to deal with that stress. The cycle continues resulting in more anxiety.

Marijuana also can give you a "do not care" attitude. It does not do this in the early stages of smoking but, over time, the occasional apathy becomes a daily attitude and affects being able to accomplish anything productive. This is called an amotivational syndrome. The problem is that the marijuana user does not realize this has happened because they are busy doing a number of things, all of which are not productive in terms of working a job, preparing for midterms, or taking care of chores in the house. In fact, they may believe that their ability to think and to produce is better. The problem is that they are thinking of esoteric issues and not what they need to be thinking of in order to take care of business. Many projects may be started but most are not finished.

Marijuana gives a high for about 3 to 4 hours. Marijuana stays in your body for at least a month. Studies have been done days after smoking a marijuana cigarette. Those who smoked were clear that they did not believe it affected their functioning but when tested concerning how they remembered a situation and how they performed on hand-eye coordination, their performance was worse than the control group not using marijuana. A person's ability to deal with emotional issues is clearly compromised even with just a small amount of marijuana smoked days before a therapy session.

Most non-addicted people also realize that the use of cocaine, amphetamines, opioid drugs and hallucinogens adversely affect your ability to deal with problems in life. Each substance has its own personality as to how it affects someone but they are also like alcohol and marijuana in that you feel better because they borrow from tomorrow the essential substances that are needed to deal with tomorrow. There is no free lunch.

What is Pairing?

Pairing is when two or more members of a therapeutic group have a more "personal" than a therapeutic relationship with each other outside of the group . These individuals begin to discuss their more intimate feelings and issues with each other rather than discussing them in the group. Pairing can be a special friendship because of similar personalities or it can develop around a feeling such as anger, sex, or love. This relationship can develop into a collusion that will be unconsciously used to avoid the painful effort which is required to look deep into their own past events and present fears.

The closeness that occurs in treatment because the young adult has found a kindred spirit, can create an intimacy that the young adult has not ever experienced. This intimacy does not mean that this relationship is based on the best match in terms of developing a long term, intimate relationship. This feeling of closeness, because everyone in the group knows each other's most taboo secrets, is deceiving. The newcomer to the group still has many internal and external battles to fight, and at this point in his recovery, getting into a sexual or emotional bond with someone stops the process of recovery. It is easier to bond around this superficial intimacy than to deal with the self with all of its feelings of guilt, shame and inadequacy. The joy and the excitement of life that results from the initial part of this pairing feels like a welcomed relief but this is just another pattern of behavior used to avoid dealing with the problem. Any quick fix that makes a young adult

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feel good for the moment does not allow them to work through their problems which is what they have to do to mature into a responsible adult.

Interactions between group members should only occur during the program time. Phone calls, getting together for lunch or dinner and meeting as a subgroup at someone's house is a set up to start a personal relationship versus the therapeutic relationship that occurs in the program. When these occur outside of the program time, sensitive issues can be discussed without the support and direction of the case manager. Since this time in treatment is a vulnerable time, information may come up in the pairing that they did not predict. This information may be a critical factor in their treatment and can be either disturbing or kept in secret with only those in the pairing and never dealt with appropriately.

Remembering the past and making changes in life is hard work. The newcomer to treatment is quick to find many ways to avoid the pain of self-reflection and dealing with past emotional, physical and/or sexual trauma. Learning how to be honest about who they are as a product of what happened in their life and what they have done is not easy. They need the direction of the case manager and the safety of the group to be able to deal with these issues. Historically, as they begin to get closer to those issues in their past that have caused them emotional pain and emptiness, finding someone that makes them feel wanted and not alone, can become a substitute for dealing with the past.

Pairing, in the worst case, ends up in sexual activity, either as an attempt at an intimate relationship or to just feel good. Because of their age, young adults yearn for an intimate relationship so the behavior is understood, but pairing-off of two young adults in the young adult program is like the blind leading the blind. The ego (personality development) of the average young adult in the program has parts that are either broken or have not developed. When a young adult, who is not in full recovery, forms an intimate relationship with another young adult who is not in full recovery, then that relationship will crumble with the first conflict in the relationship. Both young adults involved will add this failure to the list of the other failures in their life and interpret the result as another example of how they are inadequate or even worthless..

Pairing, in terms of special friendships, weakens the group. First, the group can feel that there are secrets in the group. When the group has secrets, then there is a breach in trust, and the group members will not feel comfortable bringing up sensitive issues. Only in an atmosphere of complete honesty will the group members not feel vulnerable to critisim and humiliation if they disclose how they truly feel or what they have done in the past that they regret.

When two group members have paired-off, they will not be objective with each other for fear of being rejected by the other person in the pairing. One of the two in the pairing may support the other person's statements or behaviors when that person is clearly wrong. One of the two in the pairing may be angry with the other person if one member of the paired couple feels rejected by the other one. Objective thinking becomes very subjective and is confusing for the other group members.

We recognize that the young adult is in the developmental stage of intimacy and it will be very hard for two individuals who are attracted to each other to resist pairing-off. Because of this biological fact, it will take much effort from family and friends not to collude with the young adult over this issue. This may seem like a Victorian idea but if one patient pairs-off with someone in the group, then they will not be able to stay focused on their own treatment and the integrity of the group will be greatly affected.

Specific Psychiatric Disorders

The most common psychiatric disorders are the Depressive Disorders and the Anxiety Disorders. These disorders are medical problems, not a weakness of character nor a means to get attention. Acting out to get attention is a manipulation which is different. A psychiatric or psychological disorder is defined as an emotion or a behavior that repeatedly causes dysfunction in a person’s life. In the medical disorders of psychiatry this emotion or behavior is not "caused by" an event or a problem in a relationship. An event or a problem in a relationship may trigger an episode of the disorder though an episode of a disorder can start without any specific trigger. People who do not have a depressive or an anxiety disorder would work through this event or problem in a relationship and move on but this is not the case for those with the depressive or an anxiety disorder.

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A “disorder” is to be distinguished from the normal feelings of depression, anger and anxiety. In fact, someone may have a Depressive Disorder but not feel depressed. The presenting feeling may actually be anger. It is only after the anger is stabilized that the person has the feeling of depression. Someone can have a feeling of depression or anxiety and not have a depressive disorder nor an anxiety disorder which are medical problems.

Many young adults do not recognize they have a problem. Others who do realize they have a problem will not seek help because of pride, shame, fears of losing their independence as an adult, and the expense of treatment. Many lack awareness that this is a medical problem that can be treated.

Some young adults may still be in the developmental stage of separation and individuation of adolescence. The new found separateness from their parents sometimes is more important to the young adult than anything else in their life. This independence versus dependence issue many times will override objectivity in terms of recognizing their dysfunction caused by a psychiatric illness. This issue is a major stumbling block to the young adult in terms of them seeking treatment and staying in treatment because they believe they have to be in total control of their life.

The following list of Psychiatric Disorders will be discussed in more detail (4):

1 - Depressive Disorders

2 - Anxiety Disorders

3 - Obsessive-Compulsive Disorders

4 – Trauma and Stress-Related Disorders

5 – Dissociative Disorders

6 - Attention Deficit Hyperactivity Disorder (ADHD)

7 - Personality Disorders

8 – Autism Spectrum Disorders (i.e. Aspergers)

9 - Mood Disorders (i.e. Bipolar)

10 - Psychotic Disorders (i.e. Schizophrenia)

11 – Learning Disorders _______________________________________________________________________________________

1 - Depressive Disorders

- Dysthymic Disorder

- Major Depression

There are two Depressive Disorders. A Dysthymic Disorder is when someone has been unhappy with his life for at least two years. People with this disorder usually have depressive symptoms starting after puberty. They are able to function in relationships, go to school or have a job, but they do not really enjoy anything that they do. This is to be differentiated from the appearance of apathy when the young adult is required to do chores or to be with the family during family functions yet they have a great time when they are with their peers. Medication does not help this disorder. Psychotherapy, when the young adult wants to examine who they are and how they react to others, is the only treatment.

A Major Depression is a medical illness characterized by a number of specific symptoms including problems with sleep, appetite, and energy. Suicidal thinking and lack of motivation to do basic hygiene or to go to work or school can be a problem. If the young adult has these symptoms for at least two weeks, this is considered a Major Depression. A Major Depressive Episode can be situational and not caused by genetics or it can be part of a Major Depressive Disorder which is genetic.

Sexual abuse, chronic pain from a traumatic injury, death of a spouse or parent, or any major series of losses are a few examples of causes of Major Depressive Episode. In these situations, the Major Depressive Episode is not a genetic disorder but a biological reaction to a situation. Someone with a Dysthymic Disorder is more likely to have a Major Depressive Episode after multiple losses in their life than the general population.

Once someone has had several Major Depressive Episodes then this is more probably a Major Depressive Disorder especially if a sibling, parent, or grandparent also have depression. This disorder can be caused by a genetic predisposition just like the medical illnesses diabetes and hypertension. Those who have these medical

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problems will have high blood sugar in diabetes and high blood pressure in hypertension which are going to eventually occur without any initiating event. They are “genetically prewired” to have these medical illnesses.

The treatment of a Major Depression requires both psychotherapy and antidepressant medication. Without the medication, psychotherapy by itself has no chance of working because the core issue here is a problem with a chemical imbalance in the brain involving the amount of certain "neurotransmitters" that are too low. The

medication does not actually supply the brain the neurotransmitters that are lacking. It helps the brain to increase those neurotransmitters so that the brain brings itself back into a holistic state. Even though medication may bring the brain chemistry back into a holistic state, we know that any major stressor or unresolved conflict in the person's life makes the chemical imbalance worse. Psychotherapy is essential to deal with any repeated maladaptive patterns of behavior and unresolved conflicts.

A juvenile diabetic has a problem with the pancreas not producing enough insulin. This person has to take insulin in order for the cells of the body to metabolize glucose. If that person gains 25 pounds; eats all the wrong foods; does not exercise or sleep well, then the amount of insulin they take will not be enough to treat their diabetes. All juvenile diabetics need ongoing instruction by an assortment of people concerning their life style which includes how they eat, exercise and sleep. This instruction for a diabetic is like psychotherapy for someone with a Major Depression.

Antidepressant medication is not addictive, does not make you "high", and is not a substitute for psychotherapy. Any side effects have to be managed and may be an objective reason to stop that particular medication. A flattening of emotions (affective blunting) is an uncommon side effect, but when it occurs, is not acceptable. This may be a side effect of that particular antidepressant medication and not the way another antidepressant will work for that patient.

Antidepressants can have a "paradoxical reaction" which occurs in 2% of the population. People with this paradoxical reaction will actually become more depressed as they continue to take the medication. This becomes clear within the first month of its use. If this happens, that antidepressant must be stopped. Most medications can have a paradoxical reaction such as the commonly used allergy medication Benadryl. Benadryl is that part of Tylenol PM and Excedrine PM that helps you go to sleep if you have insomnia. However, a small percentage of the population have a paradoxical reaction to Benadryl in that it keeps them awake. Several different antidepressants may need to be tried to find the one that gives the most efficacy with the least amount of side effects. Everyone has a different chemical makeup that requires different antidepressants. Though part of the decision for a specific antidepressant is trial and error, many factors are used to pick the right one for each patient. Specific depressive symptoms ( i.e. sleep, appetite, energy, motivation), the likelihood that they will take the medication regularly, their ability to pay for the medication, and other factors are all considered.

These medications are usually taken once per day and have to build up for at least a week before they start working. It takes a month for a specific dose of the antidepressant to reach its maximum benefit. If the person forgets to take this medication, even one day, the therapeutic blood level is not maintained, and they will have mood swings and a progressive decline in benefit with every missed day. They will also have a discontinuation syndrome which includes nausea and a feeling that the room is moving or spinning (very much like having motion sickness). Within 2 hours of taking their dose of medication, these sensations will stop.

If the individual only has a Major Depressive Episode, 6 months after stabilization, they can stop their antidepressant. This is tricky because if they have a Major Depressive Disorder and stop their medication, then eventually they will have another Major Depressive Episode which can be devastating. Once a decision is made that this is a Disorder, the patient should continue to take the antidepressant for the rest of their life, just as in Hypertension and Diabetes.

Psychotherapy is essential to help the person to not only deal with their past and how they are dealing with the present, but to prepare for the future. The following are only a few of the issues that medication alone cannot resolve:

- distorted self image made worse by the depression

- learning how to cope with stress

- learning how to get emotional needs met

- old emotional woundings that occurred in relationships

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- understand and change unhealthy life styles

- an endless assortment of other issues including communication skills and how to set boundaries with other

What is the Potential for a Suicide Attempt?

Any patient with a Major Depression has to be assessed for the potential to attempt suicide. There are two parts to the assessment:

• First, what are the risk factors that increase the potential for an actual suicide attempt?

• Second, when someone has suicidal ideations, how do you decide if there is an imminent risk that they may attempt suicide ?

If you realize that someone has gone into a Major Depressive Episode, you must ask directly for the presence and the nature of suicidal thoughts (SI – suicidal ideation). Suicidal thoughts are characterized as passive ("I would be better off dead") or active ("I am planning to shoot myself!"). In either case, if someone is suicidal, they have to be assessed by a mental health professional as soon as possible. In the meantime there are some questions that you can ask to determine if this is an imminent risk.

The mental health professional will determine the frequency of the suicidal thoughts and the circumstances around the thoughts. They will determine if there is a current intent or a plan. They will ask for plan details, including rehearsals. Surprisingly, most people who are suicidal will tell you this information if you just ask. Even the most depressed person usually does not want to die and is looking for someone who cares enough to help them to find some shred of hope for a change in their situation.

Asking someone if they are having suicidal thoughts, does not "plant the seed" and cause them to think about suicide. Asking about suicide may be what opens a discussion that may prevent them from attempting suicide.

More details have to be obtained including:

1 - A history of thoughts, wishes, impulses or attempts

2 - Availability and lethality of means to commit suicide have to be determined such as access to a gun.

3 - Attitudes, beliefs and values about suicide greatly affect someone's potential to act on their suicidal feelings.

4 - An individual's culture and religious persuasion are all factors to be assessed.

5 - Is there a shared suicidal ideation with any individual or with a group (common in teenagers)?

6 - Has anything changed this time that will raise or lower the risk?

7 - Is there any support person who might be helpful in reducing the risk?

The risk for someone acting on suicidal feelings is greater if they:

1 - have had psychiatric hospitalization within the past year.

2 - are actively psychotic (see section on psychotic disorders for definition).

3 - have depression and/or a substance abuse disorder.

4 - have had a recent or impending loss.

5 - have committed violence in the past year.

6 - have access to guns.

7 - have suicidal behavior or have previously attempted suicide.

8 - have a family history of suicide.

9 - are socially isolated.

10- have a chronic, terminal or painful medical disorder.

11- are of advanced age.

12- are newly diagnosed with serious medical problems.

13- are male age 65 or older.

14- have lost a child either to suicide or in early childhood.

15- have a history of physical or sexual abuse in childhood.

16- have one of these psychiatric diagnoses:

- Depression (especially with psychotic anxiety), agitation and/or significant insomnia

- Bipolar Disorder

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- Alcohol and substance use disorders

- Schizophrenia

- Borderline Personality Disorder

17 - have a history of impulsive or self-destructive behavior

Self-mutilation is usually cutting or burning but is not suicidal behavior. Usually this is done to give anxiety relief because the cutting releases the body's natural pain reliever - endorphins. This behavior is strongly discouraged because it causes permanent scars which constantly reminds the individual of past emotional trauma that they could not resolve. Also, painful feelings are not dealt with in a way that there can be a resolution of the problem that caused the feelings.

After reading this, you may feel either overwhelmed or frightened because you are realizing that by yourself, you are not able to deal with all of this. You should not deal with this alone, so until you can get your young adult to a mental health professional, please discuss this with your spouse or a friend in order to get the support and help you need to think this through. Two heads are usually better than one.

The big question is "When do I need to actually act to stop a potential suicide versus just talking to the person and encouraging them to call their therapist on Monday?" The bottom line is that if you believe that the person's risk is severe and imminent, then a medical emergency exists which requires immediate containment and intensive medical treatment in a psychiatric hospital. Call that person's psychiatrist immediately. You will need to take the suicidal young adult to the hospital.

If, after you have decided that they need to go to the hospital and they refuse to go, or if you believe they will try to get away from you in route, then you will have to call 911. This option creates tremendous conflict in everyone since many times the agency that will respond to your call will be the police. Involving the police, because your loved one is depressed and dysfunctional, may imply to you that they are being punished as if they were a criminal. The problem here is that since they are an adult, you cannot just grab them up and throw them in the car and take them to the hospital. Waiting and hoping that they will not actually attempt suicide cannot be an option. The only alternative is to call 911.

When someone's suicide risk has become severe and imminent, their judgment is impaired. Their depression has chemically reached the state that suicide seems to the young adult the only option and they feel that they have to proceed with committing suicide as soon as they can. Typically, the span of time that someone is in this

state ranges from one to 8 hours. Usually, as long as you are talking to that person, they are not proceeding with committing suicide. If you do not believe that talking to the person has changed their mind then they have to be "contained" (hospitalized) to prevent them from killing themselves.

Most of us cannot see ourselves having to do all that is discussed above. First of all, if you have never experienced a Major Depression, it is hard to even understand why someone would want to kill themself. Second, we do not even want to think about that possibility. This is exactly why you need to understand suicide now and how to react if your loved one is a suicide risk. Making all of these decisions during a crisis, when we cannot think straight, results in a poor outcome. How we respond to the potential that our loved one may attempt suicide may make the difference in whether or not they will succeed in the attempt.

2 - Anxiety Disorders

- Generalized Anxiety Disorder

- Social Phobia

- Specific Phobia

- Specific Symptoms

- Panic Attack

- Agoraphobia

Generalized Anxiety Disorder is a medical illness consisting of almost constant anxiety in most aspects of a person's life. Sleep disturbances, appetite changes with weight gain or weight loss, isolation, avoidance of

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any location that can cause an increase in anxiety, and a possible panic attack are some of the symptoms that make up this illness.

The treatment is psychotherapy, which helps the person to understand the reality of the triggers of the anxiety, plus an "antidepressant medication". An antidepressant medication should actually be called an Antidepressant/Antianxiety medication since it is the standard of care to treat the anxiety disorders. When this type of medication is used to treat an anxiety disorder, it usually requires 3 to 4 weeks at the therapeutic dose to start obtaining relief of symptoms versus 7 to 10 days to begin to get relief from a Major Depression.

One person may get relief on 20 mg of Prozac and another person may need 60 mg before the medication covers all of the anxiety symptoms. It takes 4 to 6 weeks at a dose (e.g. 20 mg Prozac) to reach its maximum benefit so if anxiety symptoms continue at a lower dose, the medication should not be increased any sooner than every 3 to 4 weeks in order to find the lowest dose that will give the most relief. The higher the dose, the

higher the potential for side effects, so you must find the lowest dose that gives the most remission of anxiety symptoms with the least amount of side effects.

Sedatives is the name now used to describe the class of drugs that historically were called the "antianxiety medications". This is because these medications were developed before antidepressants existed. If we were to redevelop the nomenclature we would call the antidepressants, the"antidepressant/antianxiety disorder medications" but this is too long and cumbersome. This nomenclature causes confusion when a physician tells a patient that the treatment for their anxiety disorder is an antidepressant. The young adult may refuse the medication and be indignant because they do not feel "depressed". They cannot understand why the physician will not give them an adequate dose of either the Xanax or Klonopin which was given to them by their buddy and gave immediate relief.

The sedatives include Xanax, Klonopin, Ativan, Valium, Tranxene, Librium and Serax. In reality, these mediations do not adequately treat anxiety disorders for the following reasons:

1 - They do not cover the anxiety symptoms 24 hours a day. Xanax covers symptoms for about 4 to 6

hours which requires a dose of medication at least 4 times in 24 hours. Anxiety symptoms return before

the next dose starts to work resulting in mood swings.

2 - They may have the potential for abuse or addiction of the medication.

3 - Tolerance (less symptom relief with time) usually develops requiring increasing the dose to get the same

benefit as the initial response. Continuing to increase the dose can eventually create blood levels that will

impair judgment, disinhibit emotions (say and do things that are thought but are inappropriate to say or do)

and even cause a black out of time (a span of time not remembered).

Sedatives do well when they are used for short term anxiety episodes (phobia of flying in a plane, preparation for surgery, or dealing with the death of a loved one). Sedatives can also be used to cover the anxiety symptoms until the antidepressant begins to work . Sometimes these medications will be used for a

longer span of time, in addition to the antidepressant, to better cover the symptoms of the anxiety disorder but if the patient "leans on" this class of drugs as the core medication to treat the disorder, then, the above problems can occur.

Buspar and Vistaril are two other antianxiety medications. Buspar is an antianxiety medication which is effective for 50% of people with anxiety disorders. Each person has a specific dose that gives anxiety relief. Once someone is taking their therapeutic dose, then it takes about 2 weeks before the medication starts relieving the anxiety. It is not an antidepressant and is not addicting. It can be sedating with some people and must be taken 2 to 3x per day, however, most people can find a dose that does not have any side effects. Since compliance of taking a medication even once per day is generally difficult for a young adult, this can be an issue unless that young adult is responsible and reliable. Increase appetite is an uncommon side effect.

Vistaril is another antianxiety medication. It takes one to two hours to start working and gives anxiety relief for 4 to 6 hours. It does not have to build up in the body to start working. Vistaril is usually not as effective as the other medications discussed above but can give some people the relief they need. It is not addictive and potential side effects include sedation, dry mouth and constipation though most do not have any side effects.

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Social Phobia is a medical disease that is characterized by anxiety that occurs when someone is in a group of people or anticipates going into a group of people. This is not just about being shy but a true biological reaction that causes fear that either something horrible is about to happen or that they will have a panic attack and embarrass themselves by losing control. The treatment is the same as for Generalized Anxiety Disorder.

A Specific Phobia is characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior. Fears of heights, snakes, and enclosed spaces are examples. When these phobias cause significant dysfunction in a person's life, then it becomes a diagnosis and requires an antidepressant and sometimes psychotherapy.

There are two terms that define a specific grouping of symptoms that can be added to any of the above diagnoses. A Panic Attack is a discrete period in which there is the sudden onset of intense fear and frequently a feeling of impending doom. Symptoms usually involve shortness of breath, chest pain or discomfort in the chest, smothering sensations, heart racing and sometimes intense nausea and vomiting. Agoraphobia is anxiety about, or avoidance of, places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of a panic attack. Examples are a football stadium or a crowded shopping mall.

3 – Obsessive-Compulsive Disorders

In Obsessive-Compulsive Disorder, anxiety occurs through irrational repetitive obsessions or through irrational compulsions to repetitively do a behavior. These behaviors can be related to a specific event. This event may be insignificant and have no specific relationship to the patient. Extreme anxiety and sometimes a panic attack can occur if a series of obsessions or compulsions are not ritually performed after this event occurs. Actual examples of an event could be walking through a door frame, touching a door knob, someone touching your car or driving past a grocery store.

Counting to 43 is an example of an obsession and washing hands 13 times with Lysol is an example of a compulsion. Each person has their own ritual. Both people know that the compulsion to wash their hands and the obsession to count are irrational but they also know that if the ritual is not done, they will become more and more anxious and something horrible will happen.

Treatment is the same as with the other anxiety disorders but the amount of time an antidepressant takes to start working is usually twice as long as when used to treat a Generalized Anxiety Disorder. Also, Luvox

is a medication whose only indication is for the symptoms of Obsessive-Compulsive Disorder. Psychotherapy is recommended because the changes that have occurred in that person's life in order to perform these rituals have usually been going on for years before they seek help because they see this as an embarrassing, irrational behavior that they should be able to manage. Also, at times, the events that create the worst anxiety may have some significance in that person's past. Only through psychotherapy can this lost memory of some childhood traumatic event be understood and worked through.

Tricotillomania (compulsively pulling out hair one hair at a time) and Hoarding Disorder are two less common disorders that are specific types of Obsessive-Compulsive Disorder. Ob-Comp Disorder is an uncommon disorder as compared to the Anxiety Disorders. There are many people with Ob-Comp personality traits but they do not have Obsessive-Compulsive Disorder.

4 – Trauma and Stress-Related Disorders

Post Traumatic Stress Disorder (PTSD) is an disorder which occurs when someone has a traumatic experience that is beyond what most people ever experience. Being sexually abused by a family member or witnessing the violent death of a friend or a parent are examples of such experiences. About 7% of the population is genetically prewired that when they experience trauma of this magnitude, a chemical reaction occurs in the brain that creates one or all four of the following symptoms:

1 - excessive emotional reactions (arousal) or

2 - blunted emotions to events that usually cause strong emotional reactions (avoidance)

3 - flashbacks of the traumatic event (reexperiencing)

4 – Persistent negative alterations in cognition and mood

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The stimulus (trigger) that starts a flashback in motion can be a smell or a noise that occurred at the time of the original trauma. Being in the same physical area of the original trauma or being with someone who looks like the perpetrator can trigger a flashback.

93% of the population can experience the same traumatic event that created the PTSD in the other 7%, and may feel overwhelmed for a month or two, but will be able to move on with their life. The traumatic event will be a painful memory but not something that causes dysfunction. This is not so for those with PTSD.

The treatment of PTSD is a specialized psychotherapy. Medication is used only to treat specific symptoms that occur because of PTSD related symptoms such as panic attacks or depression. There is no specific mediation to treat PTSD.

5 - The Dissociative Disorders

The Dissociative Disorders are characterized by a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. When a person experiences a traumatic event that is totally unexpected, and it feels intolerable to them, they may "dissociate" from themselves and may be in a "blackout". A blackout is a period of time that they do not remember and it can last a few minutes to most of the day. When this person is triggered by something that reminds them of the trauma, they dissociate. Dissociation can be a blackout of time or a variety of other symptoms. Dissociative symptoms can be one of the outcomes of a PTSD.

Rarely, these dissociations are the result of a Dissociative Identity Disorder which was formerly called the Multiple Personality Disorder. This is a real disorder and not just something developed by Hollywood. Dissociation in this context is a defense mechanism used involuntarily by someone to mentally escape during a traumatic event while it is happening. An example of this is a ten year old girl being sexually abused by her father and dissociating. Treatment of this disorder is better done by therapists that understand this illness.

6 – Attention Deficit/Hyperactivity Disorder

Attention Deficit / Hyperactivity Disorder (ADHD) affects 5% to 10% of school aged children with 60 % of the cases experiencing symptoms persisting into adulthood (~5% of all adults). This is a medical illness that at times can be crippling because of problems with attention, concentration, and impulse control. Unfortunately, other psychiatric problems also cause similar problems so the diagnosis is many times not clear.

The three types of ADHD are Inattentive, Hyperactive-Impulsive, and Combined. They all have problems organizing and finishing a task, paying attention to details, and following instruction and conversations. They are easily distracted and forget details of daily routines. The Hyperactive-Impulsive Type talks constantly and cannot sit still. Smaller children may even run, jump or climb constantly. They feel restless and have trouble with impulsivity. The vast majority of the Hyperactive Type stop the hyperactivity after puberty so that nearly all young adults do not have this type.

Parents frequently ask me to "test" their child for ADHD. There are specific tests but the diagnosis is a clinical one, requiring information from multiple sources, including school, parents, and observing the patient. A medical evaluation also should be completed to rule out any medical problems that may be affecting the individual's ability to concentrate and focus such as thyroid disease, low potassium or sodium, and other metabolic disturbances. The major problem with making the diagnosis is that depression, anxiety, Bipolar Disorder and addiction can all have symptoms that are identical to ADHD. If they are suspected, these disorders need to be treated first. If problems with attention and focus continue to be there, then the individual may have ADHD.

80% of those who come to me saying that they know they have ADHD, actually have another problem that exhibit symptoms identical to that of ADHD. The danger here is that an amphetamine (such as Adderall) can temporarily help the low energy and lack of motivation from a depression but in the long run can cause the depression to be much worse. Also, prescribing an amphetamine for a young adult who is suspected of Bipolar Illness can turbocharge that person into their first manic episode.

To make the differential diagnosis even more complicated, two thirds of children with ADHD have at least one of the following coexisting conditions: disruptive behavior, mood abnormality, anxiety disorders, tics,

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Tourette Syndrome and learning disabilities. Studies in 2003 done by Molina and Pelham identify that children with ADHD have an increase risk for early nicotine use followed by alcohol and drug abuse. The good news is that current research demonstrates the rate of cocaine and stimulant abuse is not higher among individuals with ADHD who were previously treated with ADHD medication as a child.

Adult ADHD is treated with medication along with behavior modification, organization strategies, and at times, individual psychotherapy. As a child matures into an adult and into his late 20's, he is more able to organize himself so that he can stay focused longer and, therefore, stay on task such that he may not need the medication that he needed as a child.

The medications used to treat ADHD are amphetamines, guanfacine (Intuniv), Atomoxeitine (Strattera) and clonidine. The most effective are the amphetamines. Unfortunately, this class of drugs are contraindicated with young adults who also have an addiction. Vyvanse, which is a long acting Adderall, is the most prescribed amphetamine at this time because it has a gradual onset of action and stays with the patient for 10 to 12 hours, then slowly stops working so the patient can go to sleep.

Many parents are concerned because of the addiction potential of amphetamines. Other parents are concerned that this medication may cause their child to be artificially happy or that it may cause their emotions to be flat. Some parents are puzzled as to why a doctor would prescribe a stimulant to someone that is hyperactive; it just does not make sense. All of these concerns are just a few of the reasons why parents are reluctant to giving their child an amphetamine.

The facts are that when someone with ADHD takes an amphetamine, they have a paradoxical reaction to the amphetamine as compared to people who do not have ADHD. They become calmer and more focused. When

the person has this response, it is clear that child has ADHD. If they take an amphetamine and they get more work done in school but are hyperactive and/or mentally racing (and possibly agitated) then this is a "stimulating" reaction, and the person does not have ADHD. This child may have a depression or an anxiety issue or even a learning disability.

Being emotionally flat, which is also called affective blunting, can be a side effect of amphetamines. Usually this happens because the dose is too high though some children can have this side effect on any dose. Any medication that has side effects that are intolerable even when the dose is adjusted, cannot be used with that child no matter how beneficial the medication is to the child. The child has to feel natural and "not medicated". If there are problems with one amphetamine, then attempts need to be made on several different types of amphetamines such as Focalin, Concerta.

The other two potential side effects from amphetamines that have to be monitored are loss of appetite with weight loss and a "tic". Unfortunately, adolescent girls will want to be on amphetamines because they know that there is a potential for appetite loss so they can lose weight. This is a real problem and can lead to an eating disorder. Also, if a child develops a "tic", the medication will have to be stopped or the tic may become permanent if the tic persists for several months while taking the medication. A tic is an involuntary movement of a muscle group usually around the eye though it can occur anywhere in the body. This is relatively rare but if it occurs, should be dealt with by stopping the amphetamine.

ADHD and Substance Abuse

In my experience, a young adult with an addiction should not be on an amphetamine because this class of drugs can potentially trigger the addiction. Any one with an addiction has the potential of developing an addiction with another substance or have a behavioral addiction such as sex, gambling, video games, or even become a workaholic (that may seem impossible). Amphetamines can trigger an addict to develop an addiction to the amphetamines or to another drug if they are genetically prewired to be an addict. If the young adult does not have this genetic predisposition, then the use of an amphetamine will not "cause" an addiction.

The issue concerning the potential for addiction/abuse with patients who have ADHD is even more complicated. Patients who do not have an addictive disease but who have ADHD and are not treated appropriately may start using drugs and/or alcohol to manage the symptoms of the ADHD. This can be confusing when attempting to differentiate the diagnosis of an addictive disease versus an abuse of

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substances in the service of dealing with the ADHD symptoms. Do not try to figure this out by yourself. It is complicated even for professionals with years of experience.

In 2003, Biederman did a study concerning substance abuse in adolescents age 15 and older diagnosed with ADHD which supports the above statement. 75 % of the adolescents not taking medication for their ADHD reported using illegal substances compared to 25 % of the adolescents on medication and 20 % from the control group.

In my experience, someone with ADHD who is taking an amphetamine, in general, does not abuse their amphetamine. A child with "true" ADHD does not get stimulated with this medication and, in fact, has a paradoxical reaction as compared to the rest of the population in that they get calm and focused. Abusing a medication that has this affect is not what that child wants to do. The issue for a young adult who has an addiction to another substance is that the amphetamine works in the limbic system and releases dopamine in the same way as the addicted substance (i.e. alcohol, opioids, marijuana) and this causes the young adult to start thinking about using their addicted drug.

If that child is abusing the amphetamine, then, it suggest that they do not have ADHD. In all probability this child is stimulated on the medication and this is why they are able to get more work done. Unfortunately, with all amphetamines that stimulate, the child will develop a tolerance to this effect and will need and want larger and larger doses of the medication. This is one reason that they may abuse the medication as they are trying to deal with the tolerance by increasing the dose to get the same benefits that they got when they first started the medication. Children with "true" ADHD do not develop a tolerance to an amphetamine.

Also, any child who is "genetically prewired" to eventually be an addict has the potential to abuse any medication particularly if it makes him feel good. Amphetamines also have a "street value" in that other

children will pay good money for these drugs. If your child does not like his medication, he may sell it to his friends. It is important for parents to monitor their child's medication as a rising problem with teen ADHD stimulant medication abuse. A study in the American Academy of Pediatrics showed ADHD medication abuse increased by 76 percent from 1998 to 2005. Keep the medication locked up. Also, though your child may not be abusing the medication, his friend that sleeps over may be.

7 - Personality Disorders

A personality disorder is an enduring pattern of inner experience and behavior that is distorted reality and deviates markedly from the expectations of the individual's culture. It is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Treatment is ongoing psychotherapy which provides a means of understanding how their personality traits distort their perception of the world and cause them to react the way they do. Psychotherapy does not make the personality disorder go away. The distress and impairment that result from their own responses to others and to their environment can be devastating, leaving the patient feeling abandoned, abused, humiliated, or afraid of others. The individual has to first realize that they have a problem, and second, want to change how they perceive and react to others. The obstacle here is that they may not see themselves as having a problem. They may go to a therapist to help deal with their depression, anxiety, or anger because of how "everyone else" treats them. Medication does not treat a personality disorder.

In general, most people with a personality disorder, already have the criteria for that personality disorder by their late teens. A young adult's personality is still a work in progress from 18 to 26 years old because the cortex of the brain is still growing. If the young adult will get into treatment, it is easier for them to understand how they react to others and to their environment than if they start treatment after 26 years old. Being able to see that they are the source of their problems helps to prevent them from developing ingrained feelings of inadequacy and anger because of perceived rejection by others who do not understand why the young adult is so angry at them.

Another factor that can affect the psychological age of the young adult is how their maturity can be stunted by drug use, medical problems, neglect, abuse, and many other issues. The psychological age of the young adult may be 2 to 5 years younger than their chronological age. With the appropriate structure and treatment, young adults can improve their self esteem, communication skills, self-centeredness and motivation. This can

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allow young adults to mature to their chronological age. Also, what may initially seem to be a Personality Disorder may actually be the results of a long term Depression, Anxiety or Attention Deficit Disorder.

The specific disorders include: Paranoid, Schizoid, Schizotypal, Antisocial, Borderline, Histrionic, Narcissistic, Avoidant, Dependent, Obsessive-Compulsive and Personality Disorder Not Otherwise Specified. The following is a brief description of most of the Personality Disorders.

Paranoid Personality Disorder

An individual with a Paranoid Personality Disorder has a pattern of distrust and suspiciousness and believes that the actions and motives of others are potentially harmful or malevolent. The fear may be of personal, physical injury or humiliation. When something goes wrong, it is because someone else did something purposely in order to hurt him. The paranoia is pervasive in every aspect of his life and not just focused on a specific individual. The Paranoid Personality Disorder is distinguished from the paranoia of Schizophrenia by the fact that the person does not have the negative symptoms of Schizophrenia (see Appendix B). It is distinguished from the paranoia of Bipolar Illness by the fact that the person has never had a manic episode. It is distinguished from a Major Depression with Paranoia by the fact that when the person is not depressed the paranoia is still there. It is distinguished from the paranoia of just being a young adult by the fact that as long as the young adult is getting what they want, they are not paranoid.

Avoidant, Schizoid, Schizotypal Personality Disorders

These three Personality Disorders have some similarities but each disorder has its own distinguishing characteristics. In each disorder, the person avoids relationships and isolates but for different reasons. The Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation. (They want to be with people but feels inadequate and cannot deal with any criticism.) The Schizoid Personality Disorder is a pattern of detachment from social relationships, but they enjoy being alone (the classic hermit). There is a restricted range of emotional expression. The Schizotypal Personality Disorder is a pattern of acute discomfort in close relationships with cognitive or perceptual distortions and eccentricities of behavior. They are bizarre, misinterpret other's intentions, and feel anxiety in groups.

Borderline, Histrionic, Narcissistic Personality Disorders

Another grouping of Personality Disorders are those who have a Borderline, Histrionic or Narcissistic Personality Disorder. The Borderline Personality Disorder is a pattern of instability in affect (emotion),

interpersonal relationships, and self-image with marked impulsivity. 95% of people with a Borderline Personality Disorder are females. There are two major issues in this disorder. First, this person cannot tolerate being alone. Second, she does not have an ego (personality) that is complete. Pieces of her ego did not develop such that she feels that she is not a whole individual capable of standing alone. All of this causes her to search for someone whom she feels will give her those parts of her ego (personality) that she does not have. Once she

finds this person then she feels whole. When this other person leaves her (i.e. to go on a trip or to visit his family in another state), the borderline individual feels abandoned and rejected. She also feels that part of herself was taken away when that person left. The borderline individual will either be angry because the other person abandoned her, or she will be depressed because he feels empty, alone, inadequate, and vulnerable.

A Histrionic Personality Disorder is a pattern of excessive emotionality and attention seeking. Though the person with a Borderline Personality Disorder may seem to be unpredictably emotional and have some of the characteristics of the person with a Histrionic Personality Disorder, the Histrionic person does not have the issue of the intolerance of being alone or the fear of abandonment; they want attention. What makes all of this more complicated is that there can be a Mixed personality disorder where the individual has both a Histrionic Personality Disorder and a Borderline Personality Disorder.

A Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy. 95% of individuals with this disorder are men. Unfortunately, individuals with this disorder are attracted to individuals who have a Histrionic Personality Disorder and to individuals with a Borderline Personality Disorder. People who have a Histrionic or a Borderline Personality Disorder are attracted to someone who

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seems to know all the answers because they feel inadequate and question their judgment. Those individuals who have a Narcissistic Personality Disorder are attracted to someone who will admire him. He is also attracted to their excess emotion because he has difficulty in feeling much emotion or showing empathy. When, in the course of the development of the relationship, each one realizes that neither person is going to get what they expected, then the relationship becomes toxic and destructive.

Dependent Personality Disorder

A Dependent Personality Disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of. This disorder may have some of the characteristics of the Borderline Personality Disorder, but a Dependent Personality Disorder individual is not dependent on others because of the issue of loneliness. They do not believe they are capable of living independently because of an assortment of other reasons. They may feel that someone else has to take care of them even if this means that they lose everything else in their life. They may consciously or unconsciously not take care of certain things ( i.e. bills, maintenance, legal matters) so that someone else has to take over these activities. They may allow themselves to get sick (e.g. diabetics not taking their insulin), or to be evicted from their home because they do not pay the rent, even if they have the money, as long as someone else takes care of them.

Many of these people are also passive-aggressive. This means that they express their anger towards their care taker by not doing certain things in order to harm their care taker even at the expense that this will also harm themselves. An example of this would be to continue to drive the family car until the engine is destroyed. They knew that there was a radiator leak, and the temperature gauge showed that the engine was too hot, but they felt justified in continuing to drive the car because it was not their responsibility to take care of the car. As a result of their passivity, not only does the family not have a car, but the passive-aggressive individual does not have transportation. The passive-aggressive individual feels that, at least, the caretaker was punished for whatever prior "transgression" the caretaker did to him.

Obsessive-Compulsive Personality Disorder

The Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control. These individuals can be very productive and achieve success in a job but they may be extremely difficult to live and work with. Their concrete approach to order in their environment becomes worse when problems arise in their life. Their rigid thinking can also get in the way of allowing for the imperfections of other people. They have little to no tolerance for mistakes or for someone not following a routine and they can be verbally abusive around this.

The Obssesive-Compulstive Personality Disorder is distinguished from Obsessive-Compulsive Disorder by the fact that a person with Obsessive-Compulsive Disorder knows that their obsessions and/or compulsions are irrational but they persist with them in order to not have a panic attack. Obsessive-Compulsive Disorder is more like an anxiety disorder and Major Depression is frequently a part of the disorder. Medication is required to treat this disorder as well as psychotherapy.

Medication will not treat the Obsessive-Compulsive Personality Disorder. These individuals do not see their obsessive-compulsive behaviors as irrational. In the event that they do realize that this part of their personality causes them dysfunction in their life, they may seek psychotherapy which can help as long as this individual wants to change.

Antisocial Personality Disorder

Do not assume that the name of this personality disorder defines the disorder. An Antisocial Personality Disorder does not mean that the person does not want to be social. An Antisocial Personality Disorder person can be the friendliest person you have ever met just before they steal your wallet.

The Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others. These individuals are born without the ability to feel guilt. They quickly learn what society will tolerate and not tolerate. They will do their activities in secret so that they are not caught and sent to jail.

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The psychopath is the most dangerous. Before the age of five they have performed atrocities such as killing small animals or setting fires in the house. Antisocial Personality Disorder is not treatable.

Lieing, stealing, destroying other people's property for fun are antisocial behaviors, but this does not mean that this individual has an Antisocial Personality Disorder. When they resolve their anger towards someone or when they deal with their depression, which caused them to not care, they can feel tremendous guilt for what they have done. If that guilt is not resolved then the person may fall back into the depression.

The Parents Role in the Treatment of a Personality Disorder

Fundamental in dealing with a loved one who has a personality disorder is communicating clear and consistent boundaries of that which is specifically the young adult's responsibility. This defining of responsibilities is not something that happens because you say the word "no" once or twice. It is a process of defining clear boundaries in every area of the family dynamics with definite and enforced consequences when the young adult's responsibilities are not carried out.

Someone with a personality disorder will not seek help for this problem as long as others are giving him what he wants. As you begin to understand these dysfunctional family dynamics, you may realize that you are getting a need met from this problem and that is why it will not stop. An example of this is a mother who is dealing with a loss of purpose in her life by unconsciously keeping a young adult in a child role through taking care of all of his problems. If the young adult can struggle with his own problems and see that he can find a solution, he can learn how to take care of himself. The young adult may be the one depressed but without family therapy to deal with the unconscious behaviors of the family, the young adult's behavior will continue to be passive-aggressive and passive-dependent. Please see the section entitled Parents Role in Treatment on page 11 for other issues that affect treatment. The parent's role is critical in the overall treatment and has to be incorporated into any treatment plan for a young adult.

8 – Autism Spectrum Disorders (Pervasive Developmental Disorders)

Historically known as Autism, these disorders are characterized by severe and pervasive impairment in several areas of development: 1 - Reciprocal social interaction skills,

2 - Communication skills

3 - Presence of stereotyped behavior, interests and activities.

Asperger Sydrome (Asperger’s) is a specific type of Pervasive Developmental Disorder and is characterized by severe and sustained impairment in social interaction and the development of restricted, repetitive patterns of behavior, interests and activities. There are no delays in language. Motor milestones may be delayed, although not necessarily, but motor clumsiness is often observed. The disturbance causes significant impairments in social, occupational and other areas of functioning. There are usually problems with empathy and the IQ is normal.

Problems socially occur because the young adult either does not acknowledge other people's attempts to connect with them such that the other person making the attempt feels rejected. Since the young adult with Asperger’s does not use any social filter when they respond to others, their comments are inappropriate or

are too direct such that the recipient is insulted or feels disgraced. An example of this would be the statement, "Why are you buying that candy bar when you are so fat?"

An example of repetitive behaviors may include either making annoying sounds or repetitive motor mannerisms. Examples are finger flapping or twisting, persistent preoccupation with parts of objects and/or a preoccupation with one or more patterns of interests that are abnormal either in intensity or focus (stereotyped). An example would be a preoccupation with train schedules.

The treatment of Asperger’s requires special techniques that can only be done by professionals who are specifically trained. The number of specialized therapists are limited even in metropolitan areas. The treatment takes a long time and improvement is slow. The realistic goal of treatment is not to eradicate the disorder (which is impossible), but to allow the individual to be able to function in society. The maturity of the patient

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and their recognition that they have a problem and needs help is necessary for the treatment to work. Since most people will not be able to work with a therapist specifically trained to work with these individuals, either

because such therapists are not available or because of financial reasons, working with a good, general psychotherapist can do a lot to help the patient better live in society and to deal with any depression, anxiety, or addiction if present.

The family needs treatment as well. Constantly correcting this child and feeling trapped in the home is exhausting. The caretaker many times cannot get their own personal needs met resulting in depression and anger. Conflict arises in the marriage as the caretaker feels that their spouse is not contributing an equal share of time in the caretaking role. Understanding the disorder and having realistic expectations of what kind of change is possible, allows the family to better cope with the problem. The family must deal with their own feelings of loss, anger and guilt. If the family does not understand their own feelings, then these feelings will be acted out with the patient which only causes more turmoil and disappointment.

Medication is only used with someone with this disorder to help with certain symptoms such as loss of sleep, anger, anxiety and depression. There is no pill to treat an Autism Disorder.

Autism Spectrum Disorders range from severe autism to a mild dysfunction in society. Learning disabilities, below average IQ, Personality Disorders and any of the psychiatric disorders, discussed in previous sections, can greatly affect how someone with Asperger Syndrome takes charge of their life. Also, though the individual does not meet all of the criteria for this syndrome, they can have many of the aspects of the disorder. This person needs to be treated as if they do have Asperger Syndrome. An example would be a young adult who repeatedly gets into conflicts with most students at school because they are too direct with their observations of others and makes a comment about issues at inappropriate times. This person has an "Asperger-like syndrome" but may not meet the full criteria for the Syndrome. Another child may have problems with reciprocal social interactions as well as poor communication skills but not have an abnormal preoccupation with such things as train schedules (stereotyped behavior).

Most psychiatric treatments are verbal and require the patient to (1) recognize that they have a problem; (2) want to change this problem; (3) be able to verbalize how they feel and comprehend what is being said to them; and (4) be on time for their appointments as well as be awake during the session. As any parent knows, even in the best situation, any young adult has problems with one or all of the above. When a young adult also has a Learning Disability, a Personality Disorder, etc., the challenge is helping them to change in a meaningful way so that the mental health issues can be treated. In spite of all of these problems, with time, the young adult can improve if they will eventually work with the therapist.

9 - Mood Disorders

- Bipolar Disorder

See Appendix A: Treatment of Bipolar Disorder: A Guide for Patients and Families

- Cyclothymic Disorder

- Mood Disorder secondary to:

- Medical Condition

- Medication, Alcohol, other drugs of abuse

Mood Disorder

A mood disorder is a mental state that has a disturbance in mood as the predominant feature. In practice, when the term "mood disorder" is used, it suggests the above list. (A more accurate list includes the depressive disorders which is a “disturbance of mood” but this is not usually included in the list of Mood Disorders.)

Bipolar Disorder is a medical illness and there are of two types:

• Bipolar Disorder, Type I (historically known as Manic-Depressive Illness) requires that the person has had at least one manic episode in their life. Mania is a mental state when someone has thoughts that race sometimes faster than what they can process. They may believe that they have abilities that are beyond what other people can do. In the extreme form of mania, the person can have hallucinations or

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delusions (psychosis). Usually, they do not sleep for 3 or more days in a row and do not feel the need to sleep. See Appendix A in the website for a more complete description of this illness.

Treatment of a manic episode occurs in two phases. Phase one is the inpatient stabilization of the manic episode. This may last a week or two during which the patient is usually resistant to treatment because they believe they do not have a problem. During the inpatient stay they are placed on a mood stabilizer to treat their delusions. They begin to sleep better and speech is no longer pressured.

Phase two occurs in the partial hospitalization program and lasts about a month. During this phase the patient is hypomanic. Hypomania is a mental state when the individual feels extra good or has an irritable mood that lasts for at least 4 days. In general, this mood usually consist of an inflated self-esteem, a decrease need for sleep (i.e. 4 hours) and either an increase in goal-directed activities or an excessive involvement in pleasurable activities that have a high potential for negative consequences. They do not believe they have special powers, though their judgment is impaired. They do not see why they cannot drink alcohol or smoke marijuana which always makes their mania worse. During this time they may make some poor financial decisions because of impulsive spending. They are usually easily insulted when anyone questions their judgment, and do not see the need for treatment including taking medication that slows down their thinking. It is very hard to force this patient into treatment against his will since they are not imminently dangerous in the same way that they were when they came into the hospital. They may be over the more florid manic symptoms but their brain needs to be saturated in the mood stabilizer for about a month before they come out of the hypomania and their judgment is normal. Phase two is very difficult for the family as they try to prevent this person from hurting themselves through their poor judgment.

• Bipolar Disorder, Type II is more of a depression diagnosis with episodic hypomanic episodes. They may be up at midnight cleaning out their closet, or they may buy that car that they would not buy prior to the hypomanic episode because they knew that they could not afford it. Usually after this hypomanic episode, they become severely depressed. Antidepressants alone do not manage this depression. A mood stabilizer such as Lithium or Abilify must be added in order for the antidepressant to work.

A Cyclothymic Disorder is a mood disorder with the essential feature of a fluctuating mood disturbance. This disorder begins early in life involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms but there are not enough criteria to meet the diagnosis of Bipolar Disorder. This series of fluctuating mood must last for at least 2 years with a stability of mood that does not last longer than 2 months at

a time during this 2 year period. 15%-50% or individuals with this disorder will subsequently develop Bipolar I or II Disorder.

There are other examples of a disorder of mood that are not considered a mood disorder. Many females who start their menses during puberty may go through several years of mood swings that cause dysfunction in their life. The diagnosis would be called Mood Disorder Secondary to Puberty. Someone using alcohol or drugs and having corresponding mood swings is an example of a Mood Disorder secondary to a Substance. A 23 yo girl who develops hypothyroidism can have a severe depression with paranoia. This would be a Mood Disorder secondary to Thyroid Disease with Delusions.

10 - Psychotic Disorders

- Schizophrenia (See Appendix B: Expert Consensus Treatment Guidelines for Schizophrenia)

- Schizoaffective Disorder

Psychosis

Psychosis is a mental state such that the person is not in touch with reality. The term psychotic usually implies the presence of either hallucinations or delusions (i.e. paranoia).

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Most hallucinations from a psychiatric illness are auditory. The person actually hears someone talking when no one is there. Visual hallucinations are less common. In a delirium from a medical problem, such as a high fever, the patient may say that they can see people, animals or insects that are not there, but this is not

considered to be psychotic but an altered state of consciousness. Tactile (feeling that something is touching you) and olfactory (smell) hallucinations can occur in a psychosis though, again, these are less common and

many times have some other medical source. Hallucinations are caused by the brain creating the sensation as if they were real.

Delusions are false beliefs that are fixed (meaning not changeable by objective reasoning). A paranoid delusion is the false, fixed belief that someone, some force, or some organization is persecuting or humiliating them in some way. A grandiose delusion is the false, fixed belief that the patient has special powers or that they are superior to others. Anyone with a delusion has impaired judgment if part of their decision making is based on this delusion. This may greatly affect a person's ability to take care of themselves.

Schizophrenia is a disorder of the brain like epilepsy or multiple sclerosis. It is made up of at least two sets of symptoms: the positive symptoms (this does not mean desirable) and the negative symptoms. The positive symptoms include delusions (e.g. paranoia) and hallucinations, and the negative symptoms include emotional flatness, an inability to start and follow through with activities, speech that is brief and lacks content, and a lack of pleasure or interest in life (anhedonia). Disorganized symptoms, which include confused thinking, confused speech, and behavior that does not make sense, can also occur, but is usually seen when the person with Schizophrenia is not compliant with treatment and in a deeper level of psychosis. Even before the onset of the first psychotic episode around 18 yo, the person with Schizophrenia will have strange mannerism and movements, have difficulty connecting with their peers, and will isolate more than other children their age. In hindsight, these symptoms become clear after the first psychotic episode. Please see Appendix B in the website for a comprehensive description of this illness.

Schizoaffective Disorder is a less clearly defined disorder. This disorder is Schizophrenia with a predominant mood that causes dysfunction. An example would be someone with Schizophrenia who is frequently depressed and suicidal. Another example would be someone who has had a manic episode but has bizarre delusions (patient believes that he is an alien who is on earth to cure cancer) with frequent auditory hallucinations. An antidepressant or a mood stabilizer is needed along with the antipsychotic medication.

Delusional Disorder is a disorder that has the essential feature of the presence of one or more nonbizarre delusions that persist for at least one month without negative symptoms. Apart from the impact of the delusions, psychosocial functioning is not markedly impaired, and behavior is neither obviously odd nor bizarre. Examples of the delusions include:

• erotomania when the individual believes that another person, such as an actress or their supervisor, is in love with them

• grandiosity involving the conviction of having some great talent or insight

• jealousy with the belief that their spouse or lover is unfaithful which they believe is supported by small bits of "evidence” which they collect to prove their belief

• persecutory with the belief that they are being conspired against, cheated, spied on, followed, poisoned or drugged

• somatic when the delusion involves bodily functions or sensations such as the belief they are emitting a foul odor or that there is an infestation of insects on or in the skin or that there is an internal parasite or that parts of his body are not functioning.

Unfortunately, these delusions only have a minimal response to medication, if they respond at all. The individual with a Delusional Disorder is so convinced that their delusion is real, most attempts by anyone to convince them that they need to get treatment, is seen by them as a means to control or to humiliate them. Anyone who continues to push them to see a psychiatrist can become part of their delusional system. This is why many of these individuals end up living alone and have frequent changes in job. They move frequently

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because they are convinced that their neighbors are spying on them, stealing from them, or trying to humiliate them.

11 - Learning Disorders

Learning Disorders are diagnosed when the individual's achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age,

schooling, and level of intelligence. This problem significantly interferes with the academic achievement or activities of daily living that require that skill (e.g. reading, math or written expression). The prevalence of

Learning Disorders range from 2% to 10% depending on the definitions used to make the diagnosis, which can vary.

Sometimes a Learning Disorder can significantly affect a child's self esteem as well as their social and emotional development because of how the family, the school, and the individual perceives their abilities. If the

diagnosis is made early, the family and the school understand there is a Learning Disorder. The individual is given special instruction in that problem area, and the child will not see themselves as a failure. Albert Einstein had a Learning Disorder. At 12 yo, in his community, a decision was made concerning whether a child would go to academic high school or to vocational high school. The school board decided that, since Albert had a "low IQ" which they did not understand was actually a Learning Disorder in reading and not a low IQ, he should go to vocational high school. The family pressed for him to go to academic high school against the advice of the school, who was convinced that this would only set this child up to fail. The rest is history. Having a Learning Disorder and a person's ability to problem solve (IQ) are two different things.

If the child with a Learning Disorder is not diagnosed with the Disorder, they will not get the appropriate education to develop that skill. Demoralization, low self-esteem, and deficits in social skills may be associated with those individuals that have a Learning Disorder. The school drop-out rate for children and adolescents with Learning Disorders is reported at nearly 40% which is 1.5 times the average. Adults with Learning Disorders may have significant difficulties in employment or social adjustment. These facts can be a major contributor of young adult psychiatric problems.

Direct questions about the patient's understanding of their Learning Disorder may be an opportunity to educate them to what this is and help them to start seeing themselves in a more positive way. Also, expecting a young adult to read or write certain assignments when they have a Learning Disorder in those areas, will be a problem. The young adult may be too embarrassed to tell the therapdist that they are not able to do the assignment. They may then present an angry defensive posture, or they may not do the assignment at all which may be interpreted as apathy or defiance. The family needs to be sure that if their child does have a Learning Disorder, that this information is provided to the case manager. If there is any past testing that made this diagnosis, please make copies of this testing and provide this as well.

12 - Somatoform Disorders

The common feature of the Somatoform Disorders is the presence of physical symptoms that suggest a specific general medical condition but the objective findings (physical examination, x-rays or blood tests) do not support the diagnosis. The symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

• Somatization Disorder is a separate diagnosis in the category of Somatoform Disorders and is characterized by a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms.

• A Conversion Disorder involves unexplained symptoms affecting voluntary motor or sensory function that suggest a neurological or other general medical condition, but after comprehensive evaluation there is no medical condition.

• Pain Disorder is characterized by pain caused by psychological factors. The person does not have a medical condition though they think they do.

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• Hypochondriasis is the preoccupation with the fear of having, or the idea that one has a serious disease though it does not really exist.

• Body Dysmorphic Disorder is the preoccupation with an imagined or exaggerated defect in physical appearance which is not really there.

The treatment of these disorders is difficult in the early stages because the individual is convinced that they have a medical problem and is consumed with having multiple medical evaluations. Anyone who suggests that a depression or some other psychological issue may be the source of the symptoms means that they do not want

to understand the misery that they are in and think they are crazy. Eventually, the individual may be put on an antidepressant to manage their pain, and this will improve the physical symptoms. Reluctantly, then, that person may be open to psychological treatment, though they may rationalize that the depression or anxiety is the result of their "medical illness" because of the physical misery that it causes. They may seek treatment for these problems but still deny that a psychological issue is the "source" of their physical symptoms. Most of these individuals are set in their belief and they cannot be convinced otherwise.

Bibliography

1 - C. Lebel, C. Beaulieu. Longitudinal Development of Human Brain Wiring continues From

Childhood into Adulthood. Journal of Neuroscience, 2011; 31 (30): 10937 DOI:

10.1523/JNEUROSCI.5302-10.2011

2 - Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (June 25, 2009).

The NSDUH Report: Young Adults’ Need for and Receipt of Alcohol and Illicit

Drug Use Treatment: 2007. Rockville, MD.

3 - Diagnostic and Statistical Manual of Mental Disorders (DSM V), Published by the American Psychiatric

Association, Washington, DC

4 - Some of the information in the sections discussing Attention Deficit Hyperactivity Disorder and the

assessment of suicide was obtained from materials distributed to physicians from Magellan Behavioral

Health, Inc.

5 - Parts of the Treatment section were contributed by Paul Weaver, the Case Manager of the Young Adult

Psychiatric Team

6 - All other information was from the thirty years of clinical experience of Steven R. Lee, MD as a

Psychiatrist and an Addictionologist

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