Just because it’s always been that way doesn’t mean you’re doomed to a lifetime of Thanksgivings where you just grin and go to your happy place until, thank goodness, it’s over! You can make a difference. You may even be able to start to enjoy your personal dysfunctional crowd. With a little planning and some social engineering, you can take control of the situation and make this Thanksgiving feel better.

First, make an honest appraisal of the family. It’s not new information that your mother doesn’t like your sister’s husband or your grandmother is going to want attention for her latest ache and pain. It’s not news to anyone that so-and-so has to be the center of attention or so-and-so somehow gets her feelings hurt every year. Instead of denying these realities, plan for them. (You get extra credit if you can find a way to have a sense of humor about them too.) Then consider using the following tips to begin to avoid at least some of the usual family drama.

1. Line up some co-conspirators. Chances are you’re not the only one who is irked by your family’s dysfunctional routines. Figure out who you can call on to help make things different. Then do some pre-event strategizing. Agree to tag-team each other with the folks you all find particularly difficult. Set up a signal you’ll use to call in a replacement. Brainstorm ways to steer a certain individual’s most tiresome and troublesome antics in a different direction.

2. Ask your co-conspirators to brainstorm ways to give challenging relatives an assignment: Is someone always critical of the menu? Ask her if she would please bring that complicated dish that is her trademark so she’ll have a place to shine. Is there a teenager who mopes about, bringing everyone down? Maybe offer to pay him to entertain the younger set for a couple hours after dinner so the adults can talk.

3. Invite “buffers.” Most people’s manners improve when outsiders enter the scene. If you can count on your family to put their best feet forward for company, invite some. (If not, don’t.) There are always people who would love a place to go on holidays or who would like to experience a real American Thanksgiving. Think about elderly people in your church or community whose grown children live far away, or divorced friends whose kids are with the other parent this year, or foreign exchange students from your local high school or college.

4. Nowhere is it written that there shall be alcohol whenever a family gets together. If there are problem drinkers in the family, let everyone know ahead of time that you are holding an alcohol-free party. Serve sparkling cider and an interesting non-alcoholic punch. People in your family who can’t stand being at a gathering without an alcoholic haze will probably leave early or decline the invitation. Everyone else will be spared another holiday ruined by someone’s inability to handle their drinking.

5. Take charge of seating. Have some of the younger kids make place cards and assign seats. Folks are less likely to switch places when admiring kids’ handiwork. Put people who rub each other the wrong way at opposite ends of the table. Seat the most troublesome person right next to you or one of your co-conspirators so that you can head off unfortunate conversation topics as soon as they start.

6. Guide the conversation. If your family doesn’t seem to know how to talk without getting into arguments or if you’re not the most socially adept person yourself, give yourself some help by introducing The Conversation Game (see below). Announce at the beginning of the meal that you want to use the gathering as a time to get to know each other better. Ask everyone to indulge you by playing the game for at least part of the meal. Hopefully, people will like this change in family dynamics enough to want to keep it going.

7. Give kids a way to be included. Then set them free. Kids are simply not going to enjoy being trapped at a table with adults (especially dysfunctional adults) for extended periods of time. They get restless. They get whiny. They slump in their chairs. Yes, they should be expected to behave with at least a minimum of decorum during the meal but head off complaints and tantrums by planning something for them to do while the adults linger at the table. Have the materials for a simple craft project set up and ready to go. Remember that teenager in #4? Perhaps this is when she plays a game outside with the younger kids while older ones watch a movie.

8. No willing teens? Set up a childcare schedule ahead of time so the adults spell each other. Auntie oversees a kid project while the rest of the adults finish their meal. Uncle takes the kids out to run around between dinner and desert. Plan ahead to share the load and nobody feels martyred and everybody has a better time.

Holiday depression is common and perhaps up to 10% of the population suffers from it to some degree or another. Depression is associated with the holidays because this season brings back memories of a happier time in our lives. We may remember spending past holidays with a loved one who is no longer with us. Or we may get depressed by seeing so many others who have someone special in their lives — whether it be their family, close friends, or a significant other — to share the season. Or it may be a combination of these things and others, such as dealing with an ongoing mental disorder.

Stress is also increased during the holidays. Old family arguments are frequently reignited at holiday time, lines are longer everywhere you go shopping, parking spaces are impossible to find, and you often must schedule your life to try and get to three places all at the same time.

Overeating is another common holiday-related problem. With an abundance of food and drink available at many family gatherings, we often overeat. Many people also use overeating as a way of coping with the increased stress or feelings of depression during this time of the year.

Helpful Hints for the Holidays

Whatever the reason for these problems, there are some things you can do to try and ward them off, or at least minimize their impact on your life. The holidays are first and foremost a time of spirituality and recognition of special religious events. This may be a good time to renew your spiritual beliefs and spend more time in contemplation of religion and spirituality. If you haven’t been to church or synagogue in years, for instance, now may be a good time to think about going again. I don’t think spirituality alone has all the answers to any of the world’s problems or people’s personal problems. Nevertheless, it can help you understand your life, your motivations, and your relationships with others.

Beyond spirituality, you can consider turning to those activities and hobbies that have helped you in the past. This may mean volunteering more time at a local hospital or nursing home. Or devoting more time to writing, sewing, woodworking, fixing up things around the house, going to the library, reading, or any of a number of other activities. The point here is to try and keep your mind focused on those things which bring you pleasure and which you enjoy doing. This is certainly no “cure-all,” but can be worth a try. Try avoiding places or things that remind you of sad feelings or memories.

There are other things a person can do to ward off the holiday blues. Hanging out with friends or family members who don’t have sad or negative emotions attached to them may be helpful. If not in the real world, then you may also consider spending more time online in a support group or chat area that is to your liking. Spending more time with friends can also keep your mind off your depression and negative emotions. Some people avoid doing this, though, for fear of bringing the group of friends down with their mood. This is unlikely to happen in most groups and more likely than not, the togetherness will bring your mood up.

Obviously if you are suffering from a mental disorder which is worsened by the stress or additional emotions brought about by the holidays, you should look into increasing your coping skills. This can be done on your own, or you can ask your therapist to talk more about these skills and find ones that work best for you. The key here is to let your therapist know what you need to work on at this time of the year, and then proceed to work on it. If you’re not currently in psychotherapy and your problems are beginning to pile up on you, you may want to seriously consider participating in psychotherapy to help you at this time.

Overeating during the holidays is almost encouraged and an acceptable part of the holiday tradition. Contributing to holiday weight gain is our tendency to isolate ourselves and close ourselves up in our homes and apartments during the winter months because of the weather. This isolation can easily lead to bodily feelings of laziness, sluggishness, and difficulty concentrating. (Some of these are actually symptoms of depression as well.) Exercising regularly helps you to feel good about yourself and gives your body a helpful workout. It may also help to accept a certain amount of weight gain that is normal and natural during this time of the year. Accepting that gain rather trying to fight it or feeling guilty about it will help relieve some of the pressure and stress often associated with the holidays. There will always be time in the future to lose the weight. And, for obvious reasons, starting a new diet or exercise plan around the holidays is not a great idea.

You can help reduce the amount of stress you feel and the likelihood of resorting to some inappropriate coping skills by removing yourself from situations that increase stress. If getting together with certain family members makes you feel bad every year, why not simply limit the time you spend with them to a few hours this holiday season? Make other plans and arrangements to spend more time with the people (friends, other family members, etc.) you do enjoy. Nobody says you must spend a great deal of time rude, obnoxious, or mean people, just because they are your family! If you control the time you spend in such situations, then you are in better control of your emotions and the amount of stress you will have to face.

Additional tips offered in the book, When Holidays Are Hell: A Guide to Surviving Family Gatherings (by Mariana Caplan) include the following:

• Temper your expectations. The notion of the “perfect” reunion can set you up for frustration and depression.
• Call a friend if the family setting becomes unpleasant.
• Take heed of alcohol consumption. It may seem relaxing in the short term, but its physiological effect can compound stress and depression.
• Set comfortable limits. Determine how involved and accommodating your plans should be well in advance, and make your limits known to others involved.
• Reach out to those with whom you have healthy, nurturing relationships. Get together with friends if a family setting is not feasible.
• Change gift-giving procedures. Consider setting a limit of one gift per person.

There is no quick cure here, nor an easy method you can use to ward off holiday depression, stress or overeating. However, I hope that some of these things may be helpful to you during this stressful and possibly upsetting time of the year.

This article was originally published in 1998.

Holiday depression is common and perhaps up to 10% of the population suffers from it to some degree or another. It is usually related to the holiday season because it brings back memories of a happier time in our lives. We may remember spending past holidays with a loved one who is no longer with us. Or we may get depressed by seeing so many others who have someone special in their lives — whether it be their family, close friends, or a significant other — to share the season with. Or it may be a combination of these things and others, such as dealing with an ongoing mental disorder.

Whatever the reason for suffering the holiday blues, there are some things you can do to try and ward them off, or at least minimize their impact in your life. The holidays are first and foremost a time of spirituality and a recognition of special religious events. Often this may be a good time to renew your spiritual beliefs and spend more time in contemplation of religion and spirituality. If you haven’t been to church or synagogue in years, for instance, now may be a good time to think about going again. I don’t think spirituality alone has all the answers to any of the world’s problems or people’s personal problems. But it can be an important aspect to understanding your life, your motivations, and your relationships with others.

Beyond spirituality, you can consider turning to those activities and hobbies which have often helped you in the past. This may mean volunteering more time at a local hospital or nursing home. Or devoting more time to writing, sewing, woodworking, fixing up things around the house, going to the library, reading, or any of a number of other activities. The point here is to try and keep your mind focused on those things which bring you pleasure and which you enjoy doing. This is certainly no “cure-all,” but it can be a helpful thing to try and do more of. If public places remind you of sad feelings or memories, you may just want to avoid them as much as possible this holiday season.

Many times a person experiences these sad feelings and memories as a natural part of the loss or grieving process. Sometimes this process can be unresolved, and therefore you can become more upset by triggering events or times of the year. Like the holidays. This may be a sign that you need to find acceptance of the loss, which is the final step in the grieving process. This can often be done on your own, and might be helped along by a book on grief.

Besides keeping busy and accepting loss, there are other things a person can do to keep away from the holiday blues. Hanging out with friends or family members which don’t have sad or negative emotions attached to them may be helpful. If not in the real world, then you may also consider spending more time online in a support group or chat area which is to your liking. Spending more time with friends can also keep your mind off of your depression and negative emotions. Some people avoid doing this, though, for fear of bringing the group of friends down with their mood. This is unlikely to happen in most groups and more likely than not, they will bring your mood up by the togetherness.

Obviously if you are suffering from a mental disorder which is worsened by the stress or additional emotions brought about by the holidays, you should look into increasing your coping skills. This can be done on your own, or you can ask your therapist to talk more about these and find ones which work best for you. The key here is to let your therapist know what you need to work on at this time of the year, and then proceed to work on it. If you’re not currently in psychotherapy and your problems are beginning to pile up on you, you may want to seriously consider participating in psychotherapy to help you at this time of the year.

Eating right and exercising is always an important part of living, and the holidays are no different. While it’s fine to stuff ourselves with turkey and ham during Thanksgiving and the December holidays, we should also be careful not to overdo it. It’s very easy to do so and it can contribute to a poor self-image and lowered self-esteem. Exercising regularly helps a person feel good about themselves as well as giving your body a helpful workout. We tend to isolate ourselves and close ourselves up in our homes and apartments during the winter months because of the weather. This isolation can easily lead to bodily feelings of laziness, sluggishness, and difficulty concentrating. Some of these are actually symptoms of depression as well. So exercise and eating right (most of the time!) are important.

There is no quick cure here, or easy method you can use to ward off holiday blues which is guaranteed. However, I hope that some of these things may be helpful to you during this stressful and possibly upsetting time of the year. Good luck trying them out and I hope you make it through okay. Take care this holiday season & best wishes from all of the people here at Psych Central.

This article was originally published in 1996.

Memory is critical to our daily lives. Memory is the capacity to retain information about past events, and helps us plan future events. We should be aware of how our memories work, what changes occur in memory over time, and how we can improve our memories as we get older. Fortunately, most changes in memory are normal changes of the aging process, or may be caused by temporary or treatable problems.

Our brains are amazing organs and the part of our brain that controls memory is a complicated system of numerous functions. Our brains can stay strong and healthy well into old age. But as people get older, memory changes bring on the concern that something may be “wrong” with your mind.

It is important to understand that there are memory problems in all age groups. Children and teenagers seem to forget everything they’ve just been told. Many adults are so busy and have so many distractions, they just don’t have time to remember everything. Seniors are more likely to have difficulty remembering names, items on a list, or where they put things.

In general, no one has a “perfect” memory. Most of what happens around us is forgotten because there’s no need to remember everything. We are bombarded with information all the time and the memory processes only the information that we need to remember.

How Does Memory Work?

The five senses (vision, hearing, touch, taste, smell) help us to receive and record information. If information is not recorded in our brains, we cannot recall it. Using the senses to record information is called Sensory Memory. Think of your brain as a filing cabinet where you store this information.

Short Term Memory is remembering something you just recently saw or heard. For example, remembering the name of someone you just met, or a phone number you just looked up involves short-term memory. Short-term memory only lasts an average of 5 seconds. In order to remember the same information at a later time, your brain transfers this information to Long Term Memory. This is done by repeating the information, or visualizing it. Your long-term memory contains information that you have recorded in your brain in the past. Long-term memory has no limit on capacity and can store vast amounts of information.

Although long-term memory always remains intact, it may take longer to go through the memory filing cabinet to find the exact information you want.

Recall is the final process of remembering. Recall means finding and pulling out information that is stored in your brain’s long-term memory filing cabinet. We often need cues to trigger the recall of certain information.

Age-Related Memory Changes

There are many myths and stereotypes regarding memory problems. Most Seniors have some decrease in memory function but that is not necessarily a sign of declining mental health. Severe memory loss can be caused by Alzheimer’s Disease, stroke, acute alcoholism, and some neurological illnesses. However, minor memory lapses are not indications of dementia. Most seniors will never suffer severe memory loss and the degree and type of any loss varies with the individual.

Age-related memory changes may include:

Slower thinking - as we age, everything slows down a bit, including the speed of processing new information to our brains, and the speed of recalling information. The older we get, the more information is packed into that filing cabinet so it may take a bit longer to retrieve certain memories. It is important to be patient when trying to recall long-term memories and not get frustrated.

Decreased concentration - our ability to pay attention to things decreases with age and we are more easily distracted, especially if we are interrupted. To compensate, we need to strengthen our powers of concentration by paying attention, using our senses, and avoiding interruptions. For example, if the phone rings, turn off the TV so that you can pay attention to the caller. Being a good listener is essential to help you remember. Often the problem is “not listening”, rather than “not remembering” (this principle applies to all ages). Just remember, many memory problems are related to attention, not
retention.

Decreased Use of Memory Strategies - visualizing, organizing, and associating are all strategies used by your brain to recall memories. As we age, these strategies slow down and it may require more time to organize and store information. It helps to visualize and think about the object, person, etc. in your mind, over and over.

Need For More Memory Cues - as we get older, we need more cues, or triggers, to jog our memories. For example, if you can’t remember someone’s name, visualize what the person looks like, what job they have, what your last conversation was about, what they wore, etc. The more visualization cues, the more assistance you will give your brain to recall the name.

You are probably experiencing a lot of emotions right now, but your brain has also kicked into high gear as you search for an explanation. You want to know “Why?” Where did it come from? Isn’t Asperger Syndrome an Autism Spectrum Disorder (ASD)? Is it genetic? Is it due to a poor diet or childhood immunizations? Could our toxic environment be a contributor?

While there are many contributing factors (such as environmental toxins and dietary sensitivities) and scientists are still uncovering the mystery of ASDs, one often overlooked factor is that one or both parents probably have an Autism Spectrum Disorder or at least some of the traits. Since we did not start diagnosing Asperger Syndrome until 1994 here in the United States, there are many parents with the disorder who were not diagnosed as children. Now when one of their own children is diagnosed, and as the parents start learning more about the traits of autism, the dawning light of recognition begins. Many of the Asperger traits that they see in their children are very similar to the traits of the parents, grandparents and other family members. Undeniably there is a strong genetic component to Asperger Syndrome.

Here is one example.

Beverly waltzed into my office, her long full skirt swishing as she walked. She was wearing flip flops and a much-too-tight blouse that was not a match for her skirt. No matter, you don’t have to be a fashionplate to see a psychologist. I noticed that Beverly had smudged “coke bottle” glasses, betraying her nearsightedness. Her blonde hair was her most attractive feature, especially because it was arranged in one of those contemporary mussed-up hairdos . . . or was it mussed because she didn’t comb it this morning? Nevertheless she presented a warm and friendly smile as she greeted me.

Beverly was already 20 minutes late for her appointment with me and yet she didn’t seem to realize it. She chatted amiably about the weather, while she arranged herself in the armchair, and placed her extra-large carryall at her feet. She rummaged through her bag looking for something–her cell phone, I think, since it began making noise just as she sat down. She apologized profusely for the ringing cell phone, pulled it out of her bag, checked who the call was from, then smiled at me . . . and took the call. She chatted aimlessly with the caller and only after several minutes did it occur to her to tell the caller she was in an appointment with me. Again she apologized and we started our session, with about 15 minutes left of the therapy hour.

Beverly has two children on the Spectrum and her husband has been formally diagnosed with Asperger Syndrome. Yet Beverly has no idea she has Asperger Syndrome too. She jokes that she is like Einstein and can’t stand to wear socks, even in the winter. She is anxious most of the time. She misjudges time. She has trouble reading facial expressions. But she is so bright and well educated that until her children were diagnosed she never saw the symptoms in herself.

Then there is George.

George is a tense and driven entrepreneur. He is highly successful in business. In fact, he was a multimillionaire before he turned 40. George has two children, all of whom have special needs. One has ADHD (Attention Deficit Hyperactivity Disorder) and dyslexia. The other has Asperger Syndrome. Yet George denies that he has any traits of the Autism Spectrum. He works 24/7, leaving all of the childcare to his wife. Fortunately she can hire private tutors and household help or she would not be able to keep up with her children’s special needs.

Liza, George’s wife tells me, “I love my husband but he wears me out. He works nonstop and expects me to take care of everything else. He is willing to pay for private schools for the children, but never once has he come to a school conference. He won’t learn about the children’s special needs and as the kids get older I worry about his temper. As it is, he seems kind of clueless about the kids. For example, when the kids get tired of waiting for Dad to get home for dinner, they can have meltdowns. George insists that we wait for him to eat dinner but sometimes he doesn’t walk in until 10 p.m. or later. Then he gets angry that we didn’t wait for him. I fed the kids and put them to bed long ago to avoid their tantrums. Now I have to listen to his! Sometimes it is a nightmare.”

Both Beverly and George have symptoms of Asperger Syndrome, which is a type of very high-functioning autism. They are bright, well-educated people, so they are very successful at careers or other vocations. But when it comes to interpersonal relating, such as showing up on time . . . or recognizing the needs of children to eat at a regular hour . . . or the needs of a spouse for emotional support . . . well, they have not acquired these skills. These types of skills are the very ones their children struggle with also. A hallmark of Asperger Syndrome is a lack of social radar that leads both children and adults with AS to miss the social reciprocity that is so essential to making relationships work.

A diagnosis of Asperger Syndrome for your child is the beginning of a major transformation for a family. Now at least you have a direction to start exploring for some answers. Hopefully you will find a team of professionals to help you reconstruct a medical, psychological and educational plan for your child. But all of your hard work will go up in smoke if you do not come to terms with the fact that most likely one or both parents are on the Autism Spectrum too. How can you parent effectively if you have not resolved the confusion and misdirection from your own undiagnosed childhood? It’s true for all parents, not just AS parents, that to be an effective and loving parent, you have to clean up your own bad habits and insecurities. If our goal as parents is to raise children with strong self-esteem, which leads to a “can-do” attitude in adult life, then we need to take stock of our own behaviors first.

As a relationship becomes more serious, the money conversation becomes more serious as well. Being open about money matters and negotiating who pays for what and what each expects from the other regarding how money is used reveals a lot about each other’s values, maturity, and responsibility. As the relationship progresses and the couple begins to think about a future together, differences in attitudes and habits around money become more important. How they work together to resolve those differences is one of the many indicators of how the two of them will handle important and sticky issues as they become a couple.

Avoiding these conversations results in stress for the individuals and uncertainty in the couple. The issue won’t go away. Eventually something will happen that will surface the ways in which money matters for both.

Jason, for example, has been seeing me for several months for help with his intermittent depression. He tends to overthink and ruminate on issues that trouble him, habits that contribute to his generally pessimistic approach to life. He’s been dating Emmy for three months and is starting to feel like this romance might go somewhere. When, he asks, should he tell her that he has a trust fund of a half million dollars? A prior girlfriend started treating him differently once she knew he was loaded. If he tells Emmy, she may look at him in a different way too. If he doesn’t tell her, she may think he was lying to her by omission. “No wonder I’m depressed,” he says. “I can’t win no matter what I do at this point.” I worry that he’s going to create the very breakup he is dreading by withdrawing from the issue – and from Emmy.

Deb, another 20-something client, has a different money issue – and a different reason for avoiding conversations about money. She owes $48,000 is school loans and has two credit cards that have a combined debt of $8,000. Her boyfriend wants to talk about moving in together, maybe even getting married. He has little debt and big dreams for buying a house as soon as they can. She wishes she had told him about her financial situation a long time ago. There never seemed to be a good time. Now she’s scared his feelings about their relationship will change if she is honest with him about her debt load.

Ed’s issues about money are a reflection of his shaky self-esteem. He buys his girlfriend, Carey, flashy presents, giving her the impression that he is very well off. He’s not. He’s on a full athletic scholarship at the local state college. Since academics are hard for him, his parents struggle to send him spending money so he doesn’t have to have a job and can use his time to study.

Carey, on the other hand, is very careful with money. She waitresses on weekends to have spending money. Carey has told Ed that she feels bad that she can’t reciprocate with presents for him but he tells her not to worry about it. Privately, Ed worries that Carey may not be as interested in him if he tells her he is having a hard time keeping up with his own standards for how to treat someone he really does love.

How these people handle their financial issues will have a major impact on their relationships. None of them is a bad person. All of them are aware that they have painted themselves into a corner by not sharing important information from the start. What seemed like a good idea at the time is now haunting them. Even though they haven’t been out-and-out lying, they have allowed their partners to believe they are in different financial shape than is the case. At this point, they’re upset with themselves and scared about what will happen in their relationships. Rightfully so. Trust issues around finances are among the top reasons that relationships fall apart.

A lie, even a lie of omission, can undermine the trust in a relationship. The longer it goes, the worse it gets. If these people’s relationships develop to the point that they start talking about moving in together or marrying and building a mutual life, the truth about their financial status will have to come forward. When that happens, their partners are likely to be taken aback and to wonder what else hasn’t been shared.

By keeping silent about money matters, Jason, Deb, and Ed have created the very challenge to the relationship that they were trying to avoid. To move their relationships forward, they’re going to have to step up and fess up. They each owe their partner a huge apology and the best explanation they can provide. Sharing that their fear of losing the relationship was what overwhelmed their good judgment may help their partners forgive. They will undoubtedly need reassurance that the dodging around money issues isn’t a sign that other important information is also being withheld. Hopefully each of them has a partner who can understand that a good person can make a bad mistake and still be worth loving.

The condition is also known as labile affect, pseudobulbar affect, emotional lability, and pathological laughing and crying. It can have a severe impact on the lives of both patients and caregivers, as symptoms may leave sufferers feeling guilty, awkward, embarrassed and reluctant to take part in social interaction.

IEED is seen most often following brain injury or in people with dementia, motor neuron disease, and multiple sclerosis. It can appear at any stage of the associated diseases.

Its prevalence was estimated in 2007 by Walter Bradley, MD, of Miami University. His team surveyed 2,318 patients, or their caregivers, with the neurological diseases or injuries previously linked to IEED. They used two reliable tools for diagnosis: the Pathological Laughing and Crying Scale and the Center for Neurological Study Lability Scale.

Overall, the rate of IEED was approximately ten percent, suggesting that the condition affects between 1.8 and 1.9 million patients with neurological disorders in the U.S. It was most common alongside amyotrophic lateral sclerosis, at 33 percent, and least common in those with Parkinson’s disease, at four percent.

IEED is underdiagnosed, said Bradley, as the symptoms mimic other clinical emotional disorders, including depression, bipolar disorder, schizophrenia, generalized anxiety disorder, and even epilepsy. Of the 59 percent of patients who told a physician about their symptoms, less than half received a diagnosis or treatment, and the diagnosis was most often depression.

Bradley said, “This is unfortunate because IEED seriously hampers social interactions and can have a significant deleterious effect on patients’ and their families’ quality of life.”

IEED is often missed by physicians because they assume the crying outbursts are a manifestation of depression, points out Peter Rabins, MD, of Johns Hopkins University School of Medicine in Baltimore. He adds that many patients are unable to describe their emotions due to dementia. “So, what you see is someone who suddenly cries intermittently. It is hard to know whether he is depressed, has IEED, or is having what is called a catastrophic reaction.”

He suggests that physicians look for emotions that are expressed very suddenly and usually stop very quickly, as well as crying in the absence of thoughts of helplessness, hopelessness, and guilt, or disturbances in sleep or appetite.

Scientists investigating the possible causes of IEED have devised several different theories. Hillel Panitch, MD, of the University of Vermont College of Medicine in Burlington, explains, “Because it occurs in so many different disease states, it is hard to say what areas of the brain are affected and which neurotransmitters are involved. But there is probably some kind of a disconnection between the frontal lobes, which normally keep emotions under control, and the brain stem and cerebellum, where these reflexes are mediated.”

In treating the condition, selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are both at least partially effective. This indicates that receptors on the surface of the cerebellum and brain stem may play an important role. The widely-used cough suppressant dextromethorphan, which is also beneficial for IEED, works in a similar way.

Tricyclic antidepressants including amitriptyline and nortriptyline have been used for many years to treat IEED, but they are not fully effective. SSRIs such as citalopram may be better, but Panitch believes, “nothing really appears to be as effective as the new compound Zenvia (or dextromethorphan/quinidine), which is currently being developed by Avanir Pharmaceuticals.”

This combination is thought to “help regulate excitatory neurotransmission.” In a 2006 trial of 150 multiple sclerosis patients with IEED, it led to significantly greater reductions in symptoms than placebo, was deemed to be safe, and improved quality of life and quality of relationships.

Panitch reports that, unlike the older antidepressants prescribed for IEED, this drug combination is associated with few significant side effects and rapid efficacy. It was considered to have the most therapeutic benefit, in terms of the mechanism of action in the brain, in a 2007 review.

Symptoms were reduced or eliminated by the drug combination in a recent trial presented at the 134th annual meeting of the American Neurological Association. The 12 week randomized trial of 326 patients with amyotrophic lateral sclerosis or multiple sclerosis found that IEED episodes reduced in frequency by nearly 50 percent.

Lead researcher, Benjamin Rix Brooks, MD, of the Carolinas Medical Center in Charlotte, North Carolina, said, “The impact of pseudobulbar affect on social function is severe and may result in social withdrawal. We observed that dextromethorphan/quinidine at 30mg/10mg significantly improved quality of life as related to mental health.”

But the US Food and Drug Administration is delaying approval for the combination to treat IEED due to safety concerns.

References

http://www.psychiatrictimes.com/display/article/10168/57621?verify=0

Brooks, B. R. et al. Presentation title: Double-Blind, Placebo-Controlled Study of AVP-923 for Pseudobulbar Affect. Abstract WIP-24. Findings presented at the American Neurological Association 134th Annual Meeting held in Baltimore, Maryland from October 11-14, 2009.

Cummings, J. L. Involuntary emotional expression disorder: definition, diagnosis, and measurement scales. CNS Spectrums, Vol. 12, April 2007, pp. 11-16.

Werling, L. L. et al. A comparison of the binding profiles of dextromethorphan, memantine, fluoxetine and amitriptyline: treatment of involuntary emotional expression disorder. Experimental Neurology, Vol. 207, October 2007, pp. 248-57.

Drs. Jeff Brunstrom and Peter Rogers of the University of Bristol, UK, investigated the theory that we eat larger amounts of tasty foods, and that these foods tend to be energy-dense.

They explain that highly palatable food is more widely available than ever before. This is one aspect of the so-called “obesogenic environment,” thought to contribute to rising levels of obesity. But they ask: does this necessarily lead to the selection of larger meals?

To answer the question, they carried out a study to measure ideal portion sizes of several popular and well-liked foods. Crucially, they also measured “expected satiation,” that is, to what degree each food would satisfy diners.

In the experiment, 28 normal-weight men and women assessed images of 16 foods at lunchtime, having not eaten for three hours. The foods were: fish fingers, pasta and tomato sauce, raw banana, crackers, chicken tikka masala, Jaffa cakes (chocolate covered sponge snack), pretzels, fries, Pringles, peanut M&M’s, cashew nuts, Crunchie bar (honeycomb covered in chocolate), KitKat, potato salad, chicken chow mein, and baguette with cheese.

Participants chose their ideal portion size for each food, as if they were eating only that food for lunch. They then selected an equally filling portion of a comparison food (pizza). Next they rated their anticipated liking for each of the foods, and reported how much money they would spend on a typical portion.

Results showed that foods with a high expected satiation tended to be selected in smaller portions (fewer calories). The actual energy density of a food was not linked to its ideal portion size. But high energy-dense foods were expected to be less filling per calorie than low energy-dense foods.

Surprisingly, better-liked foods were not chosen in greater quantities. The lack of a relationship between liking and ideal portion size is “particularly striking,” the researchers state.

Participants were willing to spend more money on foods they thought would be more filling. They chose larger portions of foods they would spend less money on because they were regarded as less filling.

Overall, low expected satiation was a much better predictor of choosing a bigger portion than was how much the participant liked the food.

The authors write, “For many, the reason why energy-dense foods promote weight gain is so obvious that it barely merits investigation. This is perhaps because two basic facts are widely accepted: energy-dense foods are more palatable and are therefore more rewarding (desired), and these palatable foods tend to be selected in relatively larger portions.

“Neither assumption was supported by our data.”

This study is unique in that it compares palatability and reward (measured as monetary value) across foods. It also compared foods on a like-for-like (calorie-for-calorie) basis, to understand their relative effect on energy intake.

“It is now widely assumed that palatability plays a key role in decisions about meal size,” they researchers write. “However, an alternative, and previously unexplored possibility, is that decisions are largely motivated by non-affective beliefs, such as those relating to the post-ingestive consequences of consuming food.”

Foods differ considerably in their expected satiation. Per calorie, some foods have been rated as five to six times more filling than other foods. “In particular, foods with low expected satiety tended to be highly energy-dense snack foods (e.g., cashew nuts, chocolate, potato chips, and cakes),” say the experts.

Given the magnitude of these differences, could such expectations play a role in portion size decisions? Dr. Brunstrom’s previous work suggests this is true; high energy-dense foods are indeed consumed in larger portions (more calories) because they have low expected satiation.

The authors conclude that high energy-dense foods are selected in larger portions not because they are especially liked, but because they are expected to be less filling per calorie. This is backed up by earlier studies that found relatively low feelings of satiation after consuming energy-dense foods.

They add, “We are not claiming that liking plays no role in energy intake and other aspects of dietary behavior. Clearly, hedonic responses can be highly relevant. When an unlimited amount of food is available, palatability appears to be closely associated with the weight of food that is consumed.

“By contrast, our analysis relates to everyday decisions about portion size, across a range of foods, and before a meal begins. These findings challenge the role of palatability in meal size selection, and they highlight the importance of expected satiation, a ‘non-affective’ component of food reward.”

Reference

Brunstrom, J. M. and Rogers, P. J. How Many Calories Are on Our Plate? Expected Fullness, Not Liking, Determines Meal-size Selection. Obesity, Vol. 17, October 2009, pp. 1884-90.

How do we set limits on our teenagers so that the limits are actually protective and not just a reaction to anger? It’s easy to take teens’ provocative behavior personally and react with punitive measures, anger, panic, shaming, lecture, or blame. When such feelings are the driving force behind parents’ responses, communication breaks down and measures to control teenagers’ behavior backfire. Similar to their kids, at these times parents are reacting reflexively instead of thoughtfully – losing sight of their child. These reactions, instead of fostering communication inadvertently pull teens deeper into a control struggle, leaving them with nowhere to turn. Following punishment, force, or admonishment, it’s prudent to think about what “lesson” was actually learned. Though teens can be forced to outwardly comply, they inevitably find a way to “win” these battles –for example through secret rebellion or, more tragically, by hurting themselves, directly or indirectly, until it is clear to them that parents “get” the message.

Intent and motive (easily sensed by teens) are what differentiate consequences and limits [protective] from punishment and control [reactive]. Honest self-reflection — including noticing one’s tone, feelings and demeanor will help parents be onto themselves as well as their kids. Some teens want limits imposed by parents so they can restrict themselves and still save face. But limits should be informed by understanding the teen’s particular unspoken needs and vulnerabilities — and tempered by a calm tone, uncritical language, and positive message.

Helpful Hints About Talking to Your Teens About Drinking

• Be proactive. Don’t attempt to set limits or talk to your teen when either of you is angry.
• If you’re in a struggle with your teen leading up to any important conversation about protecting them, consider attempting repair by owning up to your part. Set an example of taking responsibility in this way.
• When talking to teens consider what your goal is, and hold that in mind. Stay calm. Once the alliance is ruptured, it’s difficult to have the impact needed to protect.
• Decide beforehand on your approach, and consider what effect, knowing your teenager, your approach is likely to have. Consider modifying it if necessary. Ask questions in a curious, not leading or accusatory way. It’s more important to listen and understand than to talk.
• Be informed. Ask your teens their views on alcohol and find out how educated they are.
• Explain in a forthright way what you are worried about and why.
• Find out whether your teen is worried, what they want of themselves for that night, and where the risks lie for them. This can guide the limits you ultimately set. Think through together what situations present risk and ways to manage them.
• Make rules, consequences and expectations clear and consistent and not punitively based. Explain in a direct and nonjudgmental way why you are enforcing them. Assume they are doing the best they can, rather than seeing them as bad.
• Stay informed about the details of where your teen will be, who will be transporting them, and what adults will be present.
• Be aware of your power as a role model. Teens unconsciously internalize values about alcohol, and managing frustration and anger from observing your behavior, not what you tell them to do.

Reference

National Institute of Alcoholism and Alcohol Abuse, National Institute of Health. (2007). Alcohol alert: Underage drinking Fact Sheet (NIH Publication No. 67). Bethesda, MD.

As the doctor in charge of Bellevue’s psychiatric emergency room (known as CPEP), Dr. Holland had a front row seat to the “madness” and mayhem from 1996 to 2005. Her job was to decide who was admitted — whether voluntarily or involuntarily — and who was released, which didn’t necessarily bring relief to everyone, especially those who came to Bellevue for a night’s sleep.

Bellevue has a long, rich history. Dr. Holland writes:

Bellevue is the oldest public hospital in the United States, with a long tradition of “serving the underserved.” Its origins date back to a six-bed infirmary which opened in 1736. Bellevue has been an alms house, a penal institution, and most infamously, an asylum: In 1878, a dedicated pavilion for the insane was christened. The world’s first hospital ambulance service, maternity ward, pediatric clinic, and emergency ward all got their start here, but it’s the asylum that gets remembered, the ultimate symbol of bedlam that is most strongly yoked to Bellevue’s name.

“Take him to Bellevue,” is the line I remember best from the old TV cop show “Barney Miller.” It was Hal Linden’s answer for any arrestee who was off his rocker. I remember watching that show and wondering, ‘Where is this magical place?’

Recounting her experiences at this magical place, Dr. Holland reveals Bellevue’s (and her own) inner workings. She thoroughly defines hospital jargon, letting the reader learn the lingo and feel part of the Bellevue team. As she deciphers the mental state of each patient, Dr. Holland takes readers through her brainstorming process, just how she deduces whether a patient is truly psychotic, a danger to him- or herself or to others. She demystifies the world of psychiatry in plain English. While trying to coax a manic patient — who was found naked, barking and growling in Times Square — to voluntarily stay at Bellevue, she writes:

“So, you just sit there in judgment of me. You think you can decide who is crazy and who isn’t,” he [the patient] says.

I picture myself standing on the corner of Sane and Insane directing traffic. You’re in, you’re out. Step over the invisible line and see what happens.

“Actually, that is exactly what I do here.”

The book promises to deliver intriguing, tragic cases, and it doesn’t disappoint. Dr. Holland includes a variety of stories, from a high-profile serial killer (who isn’t named) to the man with untreated schizophrenia who pushes a woman toward an oncoming train (which resulted in Kendra’s Law) to a “trust-fund guy” who stockpiles his excretions to a patient who thinks he’s God.

(On a side note, as Dr. Holland acknowledges in her Note to the Reader, “this is a skewed sampling of patients.” She chooses to write about these patients because they’re “more colorful, dramatic, provocative or violent than the average Bellevue patient.” This is an important distinction, because violence and mental illness commonly — and mistakenly — get lumped together.)

When reading about these patients, you feel like you’ve been transported into a detective/mystery page-turner, as you rush through the words to learn what happens next. But, unfortunately, while we get interesting tidbits about the patients, we rarely learn anything beyond the initial interview, which is used to decide whether patients get admitted (and to which floor) or released. A followup rarely follows, so if you’re curious about what happens with these patients long-term, your curiosity won’t be satisfied. This is the nature of Dr. Holland’s job; however, she also makes the decision early on not to follow up, after hearing that the girlfriend of an abusive patient — who has threatened and attempted to kill her — is back with her “bad boy”:

I hang up the phone feeling exactly the way I used to when I worked at Filene’s Basement. I’d spend an hour meticulously folding a bin full of tangled button-down shirts, only to come back later in my shift to find the bin as sloppy as it was when I started, all because someone was searching for a seventeen-inch neck. It was like I’d never been there, organizing the mess. Like I hadn’t done my job.

I remember learning about entropy in college physics class: The natural order of things is disorder. Chaos reigns supreme throughout the universe, especially at Bellevue. I can’t beat it, so I may as well join it.

Most importantly, I learn not to call patients for follow-up. I’d rather pretend the shirts remain neatly folded and organized.

Even if a person is admitted to Bellevue, we seldom learn about his or her time at the hospital. If you go into the book thinking you’ll receive a deep look into each patient’s journey from diagnosis to treatment, you may be disappointed. Weekends gives readers snippets from Dr. Holland’s extensive collection of case files, with an occasional history, if she’s provided with that information. At times, it also can feel like you’re reading through a laundry list of stereotypes (the violent schizophrenic, the raving manic, the “get-me-outta-here” socialite), not three-dimensional people — again perhaps because of the fast-paced, quick decision-making nature of Holland’s job.

The patients’ stories make up just one part of the book. Dr. Holland intertwines her own story and struggles: from a competitive, know-it-all resident to a single 30-year-old “smart-ass,” entering the doors of Bellevue to a married mother of two, “with a heart of mush,” who finally leaves. She documents her life outside Bellevue’s walls along with the relationships and deep friendships within them. She writes about the horrors and aftermath of 9/11 and how she begins to identify with some of her patients.

With the help of her psychotherapist, Mary Shears, Dr. Holland explores her often stone-cold, stoic reactions to her patients. Particularly with the uncooperative patients and the ones she catches malingering, Holland is sarcastic and dismissive. She writes:

Going up against big, scary guys persisted as one of my favorite pastimes, especially if I thought the patient was lying, pretending to be mentally ill. Discharging malingerers was a routine part of my job, and catching them at lying was easy. “You suck at lying,” I would say derisively. “Why don’t you try Beth Israel down the street. Maybe they’ll fall for it.” Sometimes, I’d even give them a few tips on how to make their story more effective. I’d pull them aside, conspiratorially. “Listen, just because I’m not buying what you’re selling doesn’t mean you can’t find someone who will. Here’s what you gotta do…”

She appears brash, unsympathetic. In another chapter, she explains:

I’ve been working at Bellevue for nearly nine years now. Because it takes more to break through and touch me, I will discharge patients that other doctors would surely keep. This frequently offends the medical students I am working with, and the residents as well. I know they think I am too harsh, unfeeling. I have a reputation for being callous and uncaring.

During her own therapy sessions, Dr. Holland works on unraveling the reasons for her hardened exterior and “sadism,” as she puts it. Hoping to become a more compassionate doctor to all her patients, she tries to understand her behavior, why she needs to be in control and why she has to tell the malingerers she’s onto them.

Heartless may describe Holland’s behavior, but she cares about her patients and tries to help them. She doesn’t sensationalize the situations, though she uses humor and a get-down-to-business kind of attitude as self-preservation tactics. In one chapter, she tries to help a “frequent flyer” who abuses PCP and “typically comes into Bellevue angry, shouting racial slurs, threatening everyone within earshot with body mayhem” and “requires heroic amounts of sedation.” They talk honestly about his abusive childhood and how he can move on, abandoning his addictions and anger. In her morning rounds, she details the session with him. “I plead with the staff to spend extra time with him today, to treat him gently, and to follow up on the plan to get him to Texas.”

Whether she’s writing about a patient or a slice of her life, Dr. Holland doesn’t hold back. We get an unadulterated look at both, with point-blank candor. Sometimes, however, this look is unnecessary. Specifically, in several sections, Dr. Holland recounts her sex life — segments that don’t seem significant to her story, except perhaps to substantiate her cavalier attitude. She brags about the various physicians she’s “bedded,” referring casually to a “steamy affair” she had with a “married neurosurgeon.” She sounds like a fraternity brother, tallying up his conquests. These passages may offend some readers, and make Holland less likeable.

In addition to her work at Bellevue, Dr. Holland also maintains a private practice, a stark contrast to her work at Bellevue. “In my office, without my cowboy chaps, I am softer, less protected, and more connected.” There, instead of putting out fires, she focuses on preventative care, she explains. As a psychopharmacologist, Dr. Holland specializes in prescribing psychiatric medications to her clients. In one chapter, she expounds on the benefits of medication, giving the impression that medication is utterly magical (“…I mostly prescribe the meds I really like, the ones that I’ve seen work like magic”). This chapter is somewhat misleading, because she glosses over side effects and that it can take several tries to find the right medication, among other concerns.

While the stories may seem skimpy or Dr. Holland too harsh for some readers, this is an interesting, well-written, jargon-free read that takes you into the unvarnished walls of Bellevue and into the psyche of a psychiatrist. Weekends gives readers much to think about, especially the tenuous line between sane and insane.

However mature and enlightened we may feel we are, the subject of money often is still related to the individuals’ self-esteem issues and power in the relationship. If a couple has avoided dealing with their attitudes toward money and how it will be earned and spent, it becomes a danger zone in the relationship. The more apart they feel in their values about money, the more they avoid talking about it. The more they avoid talking about it, the bigger the gap becomes. The bigger the gap, the harder it is to bridge it. The result? Couples who walk on eggshells around money.

Jane Crowley*, for example, outearns husband Tom by a wide margin. He could make a better living but he prefers to work part-time and work in his ceramics studio as much as he can, creating sculptures that somehow don’t sell at the crafts fairs he frequents. She thinks since she earns more, she should decide more. He thinks she knew who he was when they married and it’s unreasonable for her to want to control the family finances. To make his point, he goes out for lunch every day with his artist friends, spending money that Jane would rather see go into savings. Several times a month, Jane blows up about the extravagance of restaurant lunches. Tom accuses her of being unsupportive of his art and generally too uptight about money when they have plenty – to which she replies that the plenty they have is because she is out there earning it.

Is this couple doomed? Maybe not. Except for these fights, they enjoy each other immensely. They share interests in the arts, enjoy the same music and movies, and have a cozy intimate life. Talks about money have become an abyss they ignore until Jane can’t stand it anymore and they have their usual same old battle that leaves them both shaken.

Clearly the fight isn’t really about the $40 a week that goes to the local diner although that shouldn’t be minimized either. $2000 a year is a hunk of change. The conversation these two are really avoiding is about their expectations for each other as partners in building a life. He wants her support for his dreams of being a recognized artist. She thinks that was fine when they were younger but since the only person who seems to like his work is his mother, perhaps it’s time for him to “grow up” and be more responsible. Recent rumors about possible layoffs at her workplace are making her extremely anxious. No wonder they would rather fight about lunch money.

Kathy and Mel Brown have a different but just as serious conflict. They agreed from the beginning that Kathy would stay home with the kids and Mel would be the sole earner. Since she was thirty-nine at her first pregnancy, they had their two children close together. The kids are now 4 and 3. Mel gets furious when Kathy buys things like shoes for the kids without consulting him. Kathy feels like a kid with an allowance that is never quite enough and resents it. Attempts at discussion quickly move to arguments that neither want, so both avoid. Better to focus on their delight with what they both believe to be a miracle in their lives: two healthy, happy children both had believed they would never have.

Their fights aren’t really about the cost of kids’ shoes. Mel hasn’t wanted to tell Kathy that they can’t manage on his salary alone. He’s been hiding increasing debt because he feels a man “should” be able to support his family. Kathy had a teaching career and a paycheck until the kids were born. She misses the standard of living they once had. Even more important, she misses teaching but feels she “should” be happy to stay home with the children she is so blessed to have. Like Jane and Tom, their discussions about money go nowhere because they’re not talking about what needs to be talked about.

When there seems to be enough money (whatever “enough” means to the couple), the couple can avoid the conversation for a very long time. Bills somehow get paid. Neither one goes nuts buying things the family can’t afford. Both feel bad that they don’t have a real budget or savings account or retirement fund but neither can bring themselves to confront it. Having skirted the issue for years, it feels like addressing it could shake the whole relationship. So they continue avoiding until something happens—loss of a job, a whopping bill incurred by one or the other, an emergency that requires funds they don’t have—that pushes them smack into the issue.

Elderly people often experience damage to the small vessels in the brain, as shown on magnetic resonance imaging (MRI). Cerebral microbleeds can indicate that this type of damage has taken place.

Microbleeds in lobar brain sites demonstrates a type of small vessel disease known as cerebral amyloid angiopathy, in which the buildup of amyloid–a protein linked to Alzheimer’s disease–causes degeneration of smooth muscle cells and increases the chance of blood vessel ruptures and hemorrhages.

Taking certain anticlotting drugs may lead to bleeding-prone brain vessels. So Dr. Meike Vernooij and colleagues at Erasmus MC University Medical Center, Rotterdam, the Netherlands, investigated the link. They used figures from 1,062 men and women taking part in the Rotterdam Scan Study. Participants were dementia-free and had an average age of 69.6 years.

The use of anti-blood-clotting (antithrombotic) drugs was categorized into “yes” or “no,” and the drugs were divided into platelet aggregation inhibitors or anticoagulant drugs. Participants’ cardiovascular risk factors were measured, and any known history of cerebrovascular disease was recorded.

Analysis showed that patients who took platelet aggregation inhibitors, that is, aspirin or other medications that prevent blood clotting by inhibiting the accumulation of platelets, were about 71 percent more likely to have cerebral microbleeds visible on MRI than nonusers of antithrombotic drugs.

The link was stronger for those taking the drugs at higher doses, which are often used to treat or prevent heart disease. It was also stronger for aspirin than for a similar drug, carbasalate calcium. A significant link was not found for anticoagulant drugs.

Results appear in the Archives of Neurology. The authors state, “We found that cerebral microbleeds were more prevalent in persons who had used or were using antithrombotic drugs. Furthermore, our data show a higher prevalence of strictly lobar microbleeds among aspirin users than among people using carbasalate calcium.”

They point out that some of the microbleeds may have occurred before use of antithrombotic drugs. Equally, antithrombotic drugs may have been prescribed more often to people with an increased risk of developing microbleeds. But overall, they suggest that the development of lobar microbleeds could be “accelerated by use of platelet aggregation inhibitors.”

They write, “There is currently major interest in bleeding risks with the use of antithrombotic or thrombolytic treatment in persons who have microbleeds that are apparent on MRI, because this may affect treatment in patients with cardiovascular or cerebrovascular disease.”

In contrast with this study, previous results have suggested that anticoagulant drugs are associated with an increased risk of bleeding. The reason for a lack of association in this study may be due to the lower number of people taking anticoagulants, or could be due to chance, so this issue requires further investigation.

“The beneficial effects of anti-clotting drugs for individuals at risk for heart attack and stroke should not be disregarded because these have been shown to outweigh any risks of bleeding. Nevertheless, it may be that in selected persons (e.g., those with signs of cerebral amyloid angiopathy), this risk-benefit ratio may differ for certain drugs (e.g., aspirin), thus influencing treatment decision.”

Commenting on the study, Dr. Philip Gorelick of the University of Illinois-Chicago writes, “These results remind us that physicians may be faced with practical and challenging decisions about the use of antithrombotic medications in elderly individuals who may be at risk of not only cerebral microbleeds but also more severe brain bleeds.

“In fact, cerebral microbleeds may be an important sign of more severe brain bleeds. For example, a study earlier this year indicated that microbleeds are much more common among patients who suffer intracerebral hemorrhage and are taking the anticoagulant drug warfarin. (Warfarin has long been known to increase the risk of hemorrhage.)

“Survey data suggests that use of aspirin increases with age, and is higher among people at greater risk of cardiovascular disease, so the challenge is now to clearly understand the role of antithrombotic drugs in the causes of microbleeds.

“Such information could help physicians and patients make informed decisions about the safety and efficacy of use of antithrombotic medications,” Dr Gorelick concludes.

References

MRI Analysis Could Prevent Brain Damage from Stroke, Stanford Study Finds

Vernooij, M. W. et al. Use of Antithrombotic Drugs and the Presence of Cerebral Microbleeds: The Rotterdam Scan Study. Archives of Neurology, Vol. 66, June 2009, pp. 714-20.

Gorelick, P. B. Cerebral Microbleeds: Evidence of Heightened Risk Associated With Aspirin Use. Archives of Neurology, Vol. 66, June 2009, pp. 691-93.

Lee, S. H., Ryu, W. S. and Roh, J. K. Cerebral microbleeds are a risk factor for warfarin-related intracerebral hemorrhage. Neurology, Vol. 72, January 2009, pp. 171-76.

Travis was 15. He’d always been a good kid – no trouble, unlike his brothers. His parents saw him as the perfect child.

That’s why it was jolting and perplexing to his parents that this semester he started breaking rules, getting into trouble, and seeming downright provocative. Travis was recently caught drunk after being at friends’ houses and engaging in risky and dangerous activities. He recently remarked to his father, “I can’t wait to get my dirt bike. Then I’ll be able to go anywhere I want and go scary-wild!” Travis’ dad was shocked by this comment and angry that Travis seemed to be purposely and intentionally rebelling. What should his parents do?

Let’s think about the vignette. How we interpret others’ actions - what we think their intentions are and what that means to us significantly guides our reactions. It’s not farfetched for dad to see Travis as a teenager trying to get away with as much as possible. Given this framework, dad reacted with understandable frustration and anger. Most parents of teenagers can relate to this.
But there’s more to the story here. The key to understanding Travis’ [unconscious] communication is noticing that: (a) he has been caught several times and (b) he is now actually TELLING on himself preemptively by saying he plans to go crazy-wild.

If kids really want to get away with something, they don’t squeal to parents. Travis is actually warning his father that he’s out of control and asking for help. Travis is in the throes of impulsive acting out and is himself confused by his behavior. He is uncontrollably drawn to the “rush,” unable to use restraint and judgment, and possibly has a drinking problem.

Contrary to popular belief, recent studies show that teens can accurately evaluate risk, but believe the rewards outweigh the risks. MRI research on brain development shows that teens are limited in their capacity to use good judgment under stress, and restraint in the face of reward’s temptation. Teenagers have also been found to be particularly sensitive to the pleasurable effects of drinking, and have the capacity to drink greater quantities of alcohol than adults before experiencing negative physical effects.

Adolescent brains show increased amygdala activity – the seat of primitive feelings, impulses, and gut reactions. At the same time, the prefrontal cortex - in charge of planning, voluntary control, and behavioral inhibition - is underdeveloped. Further complicating the situation is the potential for alcohol to affect adolescent brains short- and long-term.

These facts don’t mean that we shouldn’t help teens take responsibility for their behavior. But it reminds us that kids who seem to have adult capacities in other areas may still need us to operate as a stand-in and supplement the missing pieces.

Travis is in conflict. He feels compelled to act out, yet equally powerful is his unconscious need to get caught. Kids who are typically “good” and never caused trouble present a particular risk because their distress is often hidden and not seen by parents – painting a confusing picture. This can lead parents to misinterpret what’s happening, minimize the danger, and fail to take protective measures. Here, parents must see beyond the exterior and institute protective measures.

The need to be perfect may be maintained for a variety of reasons linked to family dynamics. Examples of why this happens include unconscious attempts by the child to conceal or disguise family secrets they may silently know about, such as parental alcohol problems and marital conflict. Other reasons include similar efforts to live up to perceived expectations, make parents happy, compensate for parents’ unhappiness, make up for their siblings’ chaos, or protect parents they see as fragile from being upset. But the pressure to be good and have an exterior self eventually becomes unbearable and untenable. The danger of the family’s blind spot here is that the self-destructive behavior will likely escalate until the parents “get” the message and can bear to decode the subtext of their child’s communication.

It’s easy to react out of one’s own feelings with anger, panic, guilt-tripping, punitive measures, lecture, or blame. But the essence of what’s needed is to listen and respond to danger in a firm and caring way. Protection occurs through interested, open, informed, proactive, nonjudgmental conversation and appropriate limits delivered in a nonpunitive way.

The research finding that a close, supportive relationship with parents (as perceived by teenagers) is the most protective measure against underage drinking, sexual activity and violence is good news for us and no surprise.

References

Substance Abuse Funding Targets Treatment, Not Prevention

Alcohol/substance abuse articles

ADHD Meds May Lower Substance Abuse in Teen Girls

ADHD Meds Do Not Increase Risk of Substance Abuse

Diagnosing ADHD among Substance Abusers

National Institute of Alcoholism and Alcohol Abuse, National Institute of Health. (2006). Make a difference: Talk to your child about alcohol. (NIH Publication No. 06-4314). Bethesda, MD.

National Institute of Alcholism and Alcohol Abuse, National Institute of Health. (2007). Alcohol alert: Underage drinking (NIH Publication No. 67). Bethesda, MD.

Packard, Erika (2007). That teenage feeling. Monitor on psychology, 38 (4), 20-24.

Sabbagh, Leslie (2006, August/September). The teen brain. Scientific American Mind, 17 (4), 21-25.

A wise teacher of mine once said that the crazier in love a couple is, the more inappropriate the partners. He said that to love someone who makes you crazy is temporary insanity! I’m sure it’s not always the case but there is at least some truth to it. Romances that are a rollercoaster ride of falling head over heels, betraying or being betrayed, falling out, falling in again, and constant drama, drama, drama are relationships that are bound to fail. And yet – they do make the kind of story that makes a movie.

It’s hard to bring the high drama and romantic sentimentality of a chick flick home. Regular life with a regular guy is rarely as exciting as a wild fling in an exotic place with a totally inappropriate man who then dumps you only to return on his knees, begging for forgiveness. Sigh. Regular guys and gals who just might make a regular stable relationship are like Scouts: loyal, trustworthy, honest, helpful - and sometimes even a little boring.

Romances that have lots of promise are usually romances that evolve more gradually. The couple starts out as friends, or maybe as friends of mutual friends. They run into each other now and then. They hang out with the gang. They go for coffee and find they have more in common than they thought. They might go out. They find out they aren’t quite the fit they thought. They back up and go back to being friends. Over time, they realize the differences aren’t as important as they once thought and they come to be comfortable with each other. One day they realize they are more at ease with each other than with anyone else. They talk out their differences. They get together, this time for good. Once the commitment is made, neither would think of cheating. Neither one lies, yells, belittles, bullies, or throws dishes. As a movie, a plot like this would be a real snoozer. As the basis for love that will last, it’s a winner.

So why is it that so many young women throw off these promising relationships? Back to my daughter’s theory: The current generation has been brought up on Friends and Sex in the City. They have watched Say Anything, Vicky Cristina Barcelona, My Life in Ruins, and Twilight. TV sitcoms and movies promote the drama of searching for true and exciting love. They tap into our most basic, and primitive desire: to be someone’s everything. They seldom portray comfortable love with long days of simply going about the business of real life and being okay with being an important part of someone’s life, not all of it. Ordinary OKness doesn’t engage an audience.

Compounding the problem is the lack of role models for settled love. With a divorce rate hovering at 50 percent and with 40 percent of American mothers being single because they never married the child’s father, almost half of the 20- and 30-somethings of today are likely to have grown up in households with parents who were either searching for love or who had given up on it. Lacking models for stable relationships, they turn to the media. They come away believing something is wrong if sparks aren’t flying and violins aren’t playing. The result? When things get a little comfortable, even a little boring, they go searching again for the excitement of the pursuit and the intensity of romance. One of them cheats; the other finds out; they go through the angst of trying to re-establish trust; they cry to their friends; they fight; they make up; they fight again – and the relationship eventually falls apart. The drama is back but what could have been a perfectly good and lasting relationship got lost in the process.

If we got to see the relationships in chick flicks a year later, it would certainly be interesting. My guess is that the couples that thrived on intensity and drama, not stability and loyalty, would have fallen apart shortly after the credits finished rolling. But the rest of the couples would have settled into normal, everyday life; life that includes juggling time, divvying up chores, figuring out money, accepting each other when they don’t have their stage makeup on and taking each other for granted in that healthy, comfortable way that says “we’re together and we don’t have to constantly prove it anymore.”

I think my daughter has it right. Enjoy the emotional catharsis of the chick flick if you must. There’s nothing like a dose of fantasy and a good cry for entertainment value. But if you’re looking for lasting love, leave the romantic drama at the movies.

It is okay with me that I don’t have brothers or sisters, so why is it often not okay with the rest of the world? Why do people often think they know everything there is to know about me simply because I do not have siblings? I don’t profess to know anything about anyone else because they are the oldest child, middle child, or youngest child of their family. Why should anyone profess to know anything about me based on one thing?

Only children get a bad rap. We’re supposedly coddled, tantrum-prone, attention-hogging, and always have to have our own way. Hearing someone is an only child often conjures up images of a child growing up showered in attention and being constantly praised, being told they can do no wrong. Yes, sometimes this is true. But often it is not. It’s not okay to stereotype someone because of their race or gender, so why is it okay to assume that all only children are the same?

My Story

I am an only child because my parents got divorced before they had a second child. Not knowing anything about me or my family history, you would likely assume that I had a particular type of childhood. A childhood spent going back and forth between two parents who both wanted to be loved more than the other parent. A childhood spent with my parents competing to be most popular parent, each trying to outbuy each other for the reward of my love. While I have no doubt that this circumstance happens quite often, this was not my story.

My parents were high school sweethearts. After high school, my mother went to college and my father went into the workforce. They married young, then had a child. Neither of them had the opportunity to be young and single. This was the late 1960s and early 1970s, so people settled down at a younger age. It was common to marry your high school sweetheart.

My parents divorced in 1980. Socially accepted rules of age, marital status, and what was appropriate had changed drastically by then. My parents were in their early 30s and free for the first time. Both of them quickly took to their new lives and got involved in the bar and dating scene. From what I recall, they reveled in it. They began to experience the bar scene that many single people today experience in their early 20s.

The bar scene distracted my parents from the fact that they were parents. This often left me to fend for myself. I taught myself the art of self-entertainment. I watched copious amounts of television, read piles of books, and made forts out of couch cushions. I grew up relying on myself for most things instead of being reliant on my parents. It was the only life I knew, so I never longed for a brother or sister.

I did not have the picture-perfect childhood one conjures up when you hear the words “only child.” Yes, I do not have siblings that I had to share the spotlight with. In my case, there was no spotlight at all. My parents were so wrapped up in themselves that I was often an afterthought. Basically, I raised myself. This was not ideal, but I think I turned out okay.

Why This Is Important for Me

As an adult, my everyday life often reflects my childhood. Growing up the way I did provided me with important life skills a lot of people do not have. I am fine spending large amounts of time by myself. I can easily be entertained by reading a book or watching a movie alone. I’m not someone who needs constant stimulation or companionship to be happy. I make my own fun. I greatly enjoy my quiet, alone time. I am so used to having it that when I am unable to squeeze in any alone time, I sometimes get anxious. I have come to need this time away from other people.

Also because of the way I grew up, I am relatively easygoing. I am able to roll with most oddball situations that may come my way, because that is what I did when I was a kid. I am used to making peace with things that are not ideal.

Yes, I am an only child, but I am fine. People are often surprised when I tell them I do not have siblings. Of course, I also get slanted compliments like, “you’re really good for an only child,” but overall, I think I am a positive representation.

Until recently, I did not give my only child status much thought. I do not have children, but many of my friends do. Most of them have just one so far, but all of them plan on having more. Whenever they talk about reasons they would like to have more children, they speak of the great importance of having brothers and sisters. They make it sound as if it would be a horrible fate for their child if he or she did not have siblings. What they seem to forget is that having a sibling for your child guarantees nothing. The children may grow up disliking each other and have nothing to do with one another as adults. I have seen this happen with a number of friends who have siblings. As adults, they simply do not speak to one another. It is as if their sibling never existed because they are not involved in each other’s lives.

Regardless of what I see among my friends, American families are shrinking in size. According to my Internet research (which you always have to take with a grain of salt), the average American family has gone from an average of 2.5 children in 1970 to 1.8 children today. More and more people are choosing to have only one child.

When you come across kids who are only children, or an adult who is an only child, please don’t act like this factor completely defines them, that you know everything you need to know about a person because of this one fact. We are not all the same, so keep your assumptions to yourself and give an only child a chance. It is likely that our demeanors will surprise you.

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