Dubbed Confessions of a Worrywart: Husbands, Lovers, Mothers, and Others, and featuring such colorful chapter titles as “Shrinks are Like Boyfriends Who Can’t Dump You,” “Saving E-Mail, Saving Voicemail,” and “In Search of Grief,” Orlins’s story weaves through her life in rough chronological fashion. We learn of her kindergarten crush; her 20s as a single woman in Washington, D.C.; her 18-year marriage, which included stints of living in China and also produced three kids; her divorce; the loss of her parents; and, eventually, her life as an active and happily-independent divorcee with grown daughters.

Her writing is candid, vibrant, funny, and touching. Even so, I found myself reading more slowly than usual, simply because her stories were so evocative that they prompted near-constant daydreams, in which I’d remember similar personal incidents and ponder my reactions and feelings. I found myself alternately nodding along with recognition and recoiling in shock. As a woman in the same age range as Susan’s daughters (I feel I know Orlins so well by now that I can’t help but think of her as “Susan”), I can recognize that some things have stayed the same since the previous generation, but that, thankfully, others have changed drastically.

In the aforementioned “Shrinks” chapter, for instance, which spans 1967-1976, Orlins recalls snippets of her interactions with the various therapists she saw in her 20s. I cringed through her entire account of Dr. Miller. She begins, “When I walked into his office for my initial consultation, he hugged me — too long and too hard. As I unfolded the story of my life, he kept interrupting to tell me about his amorous triumphs” — and as I read I realized that my lip was curling back in distaste.

By the time she describes how Dr. Miller fell asleep in one session and later invited her to join a “nude group session,” which she declined (thank god!), as well as to try hypnosis, which she accepted (oh god, no, Susan!), I was completely keyed up, imagining being placed in those situations by a (male) therapist myself. I could not understand the sanguine manner by which she documented what seems to me outrageously unprofessional behavior. Perhaps we can chalk this up to “Wow, we’ve come a long way.”

But at many points in her story, I found myself chortling or nodding along in recognition. Early in the book, Orlins describes choosing her college major and minor based not on her passions, but on what she got her best grades in, and what would most likely lead to a job. She says, “…my father insisted I have something to fall back on. There was always this falling back, a requirement to stockpile safety nets, as if it were unthinkable to surge through life upright or tilting forward.” I loved her phrasing there, and empathized with her situation completely. Will that dynamic between parents and children ever change?

Likewise, on page 227 I groaned aloud at both the author and myself when I read this reference to a man she was seeing: “As with the no-soap, I quickly dismissed anything about his looks that detracted from my interest; I wanted to be gaga over him.” That hit a little close to home. I’d venture that many, many women identify with that tendency to want to want a partner more than one actually does want him, and to ignore the little twinges of misgiving.

No matter if I identified with her feelings or not, Orlins’s colorful prose made me smile. A few of my favorites: “My idea was that a psychiatrist ought to be able to mold my mind, the way a plastic surgeon could change a person’s nose” (p. 62); “ ‘When we’re engaged, you can pick me up.’ If you have never gone through a divorce, let me propose you prepare for this kind of gut-flip-flopping, bile-choking, brain-exploding remark to just fall out of your mouth without warning. Peter was decent enough not to break the date” (p. 169); and “Don’t mistake me for a sleek, zippy cyclist hunched over racing-style handlebars. I am none of that. I plod along high and upright, arms spread wide, more Mary Poppins than Lance Armstrong” (p. 249).

Orlins’s delightful writing style, combined with a touching look back at the major relationships and events she’s lived through, made this a captivating read. I was sorry to reach the last chapter, and I highly recommend her book to any “worrywart” looking to peek into the mind of a kindred spirit.

Confessions of a Worrywart: Husbands, Lovers, Mothers, and Others
Seneca Books, January, 2013
Paperback, 304 pages
$12.95

But he could pet our cats.

Our beautiful cats, Smokey and Ricky, both so lovable with distinct personalities, helped Dan immensely during those dark days. Whether they sat on his lap, curled up near him on the couch, or let him hold them, they allowed him to relax and brought him momentary peace. Sometimes they purred so loudly they sounded like engines revving, and this soothed Dan. Other times they would engage in various cat-like antics, inciting a rare, but oh-so-cherished laugh from our son.

They didn’t bombard him with questions, asking if he was okay, or if he was hungry, or what was wrong. They were just there with Dan, and for a short time, his focus was diverted from his obsessions and compulsions. Our pets were able to care for Dan in a way the rest of our family could not.

An article in the April 15, 2013 issue of Time magazine explored how animals grieve. I found it fascinating, and no matter how you might interpret the various studies discussed in the article, I think it is hard to argue with the belief that animals do indeed form relationships, and are empathetic. What more does it take to comfort someone?

For those obsessive-compulsive disorder (OCD) sufferers who struggle with germs and contamination issues, caring for a pet can elicit many triggers. Cleaning a litter box, letting a dog lick your face, or having to tend to a sick pet are just a few examples of what OCD sufferers might have to deal with. Surprisingly, I have heard from many with OCD who are amazed themselves that these situations do not cause their OCD to spring into action. Could it be that their love for their pets transcends the fear and anxiety of OCD?

When my son moved into his own apartment last year, one of the first things he did was foster a cat from a shelter. He has always been an animal lover, and was looking for a furry friend to keep him company. As he knows, life is full of surprises, and come to find out, his new companion has a host of medical problems and needs to take medication to control her seizures.

Instead of returning the cat to the animal shelter (something I very well might have done), he has embraced his role as her caretaker. Whether we have OCD or not, I believe this experience of putting another’s needs ahead of our own is worthwhile. Focusing outward instead of inward gives us a different perspective on our own lives and challenges.

So it works both ways. We take care of our beloved pets, and they take care of us. Whether our furry friend is a specially trained service dog who can sense an imminent anxiety attack (yes, it’s possible!) or an adored rabbit, pets can benefit us all in countless ways. They require us to slow down our lives, they make us laugh, and they give us unconditional love. And for those who are suffering, they provide the much-needed comfort and serenity that often can’t be found elsewhere.

However, “people with an anxiety disorder are essentially phobic about the feeling state of anxiety.” And they’ll go to great lengths to avoid it.

Some people experience generalized anxiety disorder (GAD), excessive anxiety about real-life concerns, such as money, relationships, health and academics, he said.

Others struggle with society anxiety, and worry about being evaluated or embarrassing themselves, he said. People with obsessive-compulsive disorder (OCD) might become preoccupied with symmetry or potential contamination, he said.

“The bottom line is that people can experience anxiety, and anxiety disorders, related to just about anything.”

Some people may not struggle with a clinical disorder, but want to manage sporadic (yet intrusive) bouts of anxiety and stress.

Whether you have occasional anxiety or a diagnosable disorder, the good news is that you can take small, effective and straightforward steps every day to manage and minimize your anxiety.

Most of these steps contribute to a healthy and fulfilling life, overall. For instance, “making some basic lifestyle changes can do wonders for someone coping with elevated anxiety,” Corboy said. Below, you’ll find 15 small steps you can take today.

1. Take a deep breath.

“Deep diaphragmatic breathing triggers our relaxation response, switching from our fight-or-flight response of the sympathetic nervous system, to the relaxed, balanced response of our parasympathetic nervous system,” according to Marla Deibler, PsyD, a clinical psychologist, executive director of The Center for Emotional Health of Greater Philadelphia and Psych Central blogger.

She suggested the following exercise, which you can repeat several times: Inhale slowly to a count of four, starting at your belly and then moving into your chest. Gently hold your breath for four counts. Then slowly exhale to four counts.

2. Get active.

“One of the most important things one can do [to cope with anxiety] is to get regular cardiovascular exercise,” Corboy said. For instance, a brisk 30- to 60-minute walk “releases endorphins that lead to a reduction in anxiety.”

You can start today by taking a walk. Or create a list of physical activities that you enjoy, and put them on your schedule for the week. Other options include: running, rowing, rollerblading, hiking, biking, dancing, swimming, surfing, step aerobics, kickboxing and sports such as soccer, tennis and basketball.

3. Sleep well.

Not getting enough sleep can trigger anxiety. If you’re having trouble sleeping, tonight, engage in a relaxing activity before bedtime, such as taking a warm bath, listening to soothing music or taking several deep breaths. (You’ll find more tips here.)

And, if you’re like many people with anxiety whose brains start buzzing right before bed, jot down your worries earlier in the day for 10 to 15 minutes, or try a mental exercise like thinking of fruits with the same letter. (Find more suggestions here.)

4. Challenge an anxious thought.

“We all have moments wherein we unintentionally increase or maintain our own worry by thinking unhelpful thoughts. These thoughts are often unrealistic, inaccurate, or, to some extent, unreasonable,” Deibler said.

Thankfully, we can change these thoughts. The first step is to identify them. Consider how a specific thought affects your feelings and behaviors, Deibler said. Is it helpful or unhelpful?

Unhelpful thoughts usually come in the form of “what ifs,” “all-or-nothing thinking,” or “catastrophizing,” Deibler said. She gave these examples: “What if I make a fool of myself?” “What if I fail this exam?” or “What if this airplane crashes?”

These are the types of thoughts you want to challenge. Deibler suggested asking yourself:

“Is this worry realistic?” “Is this really likely to happen?” “If the worst possible outcome happens, what would be so bad about that?” “Could I handle that?” “What might I do?” “If something bad happens, what might that mean about me?” “Is this really true or does it just seem that way?” “What might I do to prepare for whatever may happen?”

Then, “reframe or correct that thought to make it more accurate, realistic and more adaptive.” Here’s one example: “I would feel embarrassed if I tripped on the stage, but that’s just a feeling; it wouldn’t last forever, and I would get through it.”

5. Say an encouraging statement.

Positive, accurate statements can help to put things into perspective. Deibler gave these examples: “Anxiety is just a feeling, like any other feeling.” and “This feels bad, but I can use some strategies to [cope with] it.”

6. Stay connected to others.

“Social support is vital to managing stress,” Deibler said. Today, call a loved one, schedule a Skype date or go to lunch with a close friend. “Talking with others can do a world of good.” Another option is to get together and engage in an activity that improves your anxiety, such as taking a walk, sitting on the beach or going to a yoga class.

7. Avoid caffeine.

Managing anxiety is as much about what you do as what you don’t do. And there are some substances that exacerbate anxiety. Caffeine is one of those substances. As Corboy said, “The last thing people with anxiety need is a substance that makes them feel more amped up, which is exactly what caffeine does.”

8. Avoid mind-altering substances.

“While drugs and alcohol might help to reduce anxiety in the short term, they often do just the opposite in the long term,” Corboy said. Even the short-term effect can be harmful.

Corboy and his team have treated countless clients whose first panic attack occurred while they were taking drugs such as marijuana, ecstasy or LSD. “Panic attacks are bad enough if you are straight and sober, so imagine how bad they are if you are high, and can’t get un-high until the drug wears off.”

9. Do something you enjoy.

Engaging in enjoyable activities helps to soothe your anxiety. For instance, today, you might take a walk, listen to music or read a book, Deibler said.

10. Take a break.

It’s also helpful to build breaks into your day. As Deibler said, this might be a “simple change of pace or scenery, enjoying a hobby, or switching ‘to-do’ tasks.” “Breaking from concerted effort can be refreshing.”

11. Problem-solve.

Deibler suggested considering how you can address the stressors that are causing your anxiety. Today, make a list of these stressors and next to each one, jot down one or two solutions.

12. Pick up a book.

There are many valuable resources on anxiety, which teach you effective coping skills. Corboy recommended Dying of Embarrassment for people with social anxiety; The BDD Workbook for body dysmorphic disorder; The Imp of the Mind and The OCD Workbook for obsessive-compulsive disorder. Deibler suggested Stop Obsessing for adults with OCD (and Up and Down the Worry Hill for kids with OCD).

For people with panic attacks, she suggested Don’t Panic: Taking Control of Anxiety Attacks. For a general overview of cognitive-behavioral therapy for anxiety, Corboy recommended The Anxiety and Phobia Workbook. He also recommended Get Out of Your Mind and Into Your Life and The Wisdom of No Escape.

(You can find more book recommendations at Corboy’s website.)

13. Engage in calming practices.

According to Corboy, “meditation, yoga, or other calming practices can help minimize anxiety in both the short and long term.” Sign up for a yoga class or watch a yoga video online. (Curvy Yoga is a wonderful resource for yoga for all shapes and sizes.) Meditate right now for just three minutes. (Here’s how.)

14. Contact a therapist.

“Sometimes anxiety can be difficult to manage without professional help,” Deibler said. Many organizations include databases of providers who specialize in anxiety (along with helpful information). She suggested these organizations: www.ocfoundation.org, www.adaa.org and www.abct.org.

15. Accept your anxiety.

“If you really want to effectively manage your anxiety, the key is to accept it,” Corboy said. This might sound counterintuitive. But anxiety, “in and of itself,” isn’t the real problem. Instead, it’s our attempts at controlling and eliminating it, he said. “Not accepting these unwanted inner experiences is the actual source of so much of our self-induced suffering.”

Accepting anxiety doesn’t mean “resign[ing] ourselves to a life of anxious misery. It simply means that we are better off recognizing and fully accepting the existence of anxiety and other uncomfortable emotional states that are inevitable, but transitory,” Corboy said.

So if you experience anxiety today, simply observe it, Deibler said. “Think of it like a wave of the ocean; allow it to come in, experience it, and ride it out.”

Anxiety can feel overwhelming. It can feel like chains around your feet, weighing you down. But by taking small steps – like the ones above – you can minimize your anxiety and cope effectively.

Treatment is warranted when mental illness strikes. It could be as simple as acknowledgement (vs. denial) and getting involved in exercise, support groups, hobbies, anything that noticeably lessens the burden and eases the mind. If the illness is debilitating, ongoing medication or short-term hospitalization might be needed. Study and application of effective behavioral strategies and therapy are middle-ground treatments that can bring needed understanding, relief and coping mechanisms for symptom flare-ups or deeper issues.

The people behind Mental Health First Aid (MHFA), a relatively new program in this country, hope to educate laypeople about mental health concerns. Their focus is relatively simple: training people how to spot acute mental health symptoms in friends, neighbors and colleagues and guide them to treatment. Mental health advocacy also is rolled up in this equation.

My work as vocational coordinator at a psychosocial rehab agency years ago involved finding meaningful work for folks with mental health diagnoses. But due to necessity I had to be an advocate, first, for mental illness. Whether minor depression or schizophrenia, if you are talking to employers, you quickly realize that mental illness needs to be destigmatized in order for any progress to be made.

MHFA’s goal of guiding people to treatment also involves identifying the difference between functional and temporarily nonfunctional states. If only this continuum of real distress could be better understood by a broad public, acute mental health care in this country could be vastly improved, advocacy could be championed, and people would begin to see that true health is more than just physical.

Mental Health First Aid had its beginnings in Australia in 2001. A professor, Tony Jorm, and nurse, Betty Kitchener, created it in affiliation with the University of Melbourne. Studies soon documented its effectiveness in saving lives and improving the mental health of the layperson giving the care and guidance. According to MHFA program material, “just as CPR training helps a layperson without medical training assist an individual following a heart attack, Mental Health First Aid training helps a layperson assist someone experiencing a mental health crisis.”

So successful was this Australian pilot program that other countries followed suit, including the U.S. in 2008, and communities are now offering the training course. Hospital, nursing home and school personnel initially took part. (One might think professionals in these arenas might not need the training, but mental illness often is out of the scope of those who deal with physical illness and trauma.) It’s envisioned that someday the training will be as common as that for cardiopulmonary rehabilitation (CPR).

Typically a 12-hour course over two days, it includes identification of risk factors and “warning signs of mental health problems.” An overview of treatment options is given, including individual information on depression, anxiety, psychosis, substance abuse, and even eating disorders and self-injury.

Integral to MHFA is a five-step action plan regarding skills needed for situation assessment, implementation of appropriate interventions, and connecting the person in distress to available resources on a spectrum of professional, peer, social and self-help. Part of the training reinforces nonjudgmental listening, as well as reassuringly imparting information about available resources in the gentlest, yet most effective manner.

An excellent video of a MHFA role-play can be found on the national website. Two individuals are seen acting out dialogue as if neighbors talking on a porch. The man raps on the door of a woman who he feels has not been doing well. He asks nonthreatening questions in a soothing, helpful manner, and asks her to come out on the porch to talk to him. His words seem comforting and he acknowledges that her feelings (which seem to be paranoiac) must be very scary. He suggests a call to the crisis team, to come and simply talk to her. He says, tellingly, “If I were this upset, wouldn’t you want to help me?” The role-play comes to a good conclusion and the actors reflect, for the camera audience, on what went well.

Mike Gruber is just one of many professionals teaching MHFA in Allegheny County, Penn. Quoting a Pittsburgh City Paper reporter in a recent article, Gruber feels that what is the experiential approach of MHFA makes it “more effective at reducing stigma than would a public-awareness campaign.”

The National Council for Community Behavioral Healthcare is asking for the public to sign, on their website, letters of support for MHFA legislation. (Staffer Meena Dayak is available to answer related questions.) H.R. 274 would authorize $20 million for the program in 2014. One of three templates to congressional leaders mentions that MHFA was endorsed as a best practice for state and local governments, and this is indeed the direction that the National Council would like to gain momentum in, according to the organization, striving for training across as many local communities as possible in the U.S.

To find MHFA near you, visit this website

According to Dr. Marchand, the risk of recurrence — “relapse after full remission” — for a person who’s had one episode of depression is 50 percent. For a person with two episodes, the risk is about 70 percent. For someone with three episodes or more, the risk rises to around 90 percent.

That’s why having a prevention plan is critical, he said. “Depression is often a chronic illness, but with a good prevention plan in place, it is often possible to prevent recurrences entirely or limit the severity and duration if depression does return.”

A prevention plan must include maintenance treatment, which is “treatment that is continued after symptoms are in remission to prevent recurrence.” This includes medication, psychotherapy or both, Marchand said. (If you’re currently receiving or have received treatment, make sure you have a prevention plan.)

It’s also important to understand what might trigger a possible relapse, and how you can prevent or minimize the influence of those triggers. Below, you’ll find three common triggers for depression, along with information on navigating a relapse.

Trigger: Not Following Treatment

“The biggest issue regarding relapse has to do with children and adults not following through on their treatment plan,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression. This includes anything from skipping therapy sessions to missing doses of your medication to ending therapy too soon, she said.

If you don’t want to take your medication because of side effects (or other reasons), talk to your prescribing physician about these issues. They may reduce your dose, prescribe a different medication or recommend another strategy to minimize side effects and respond to your concerns. Similarly, if you’re dissatisfied with your therapy sessions (or you’re having a hard time getting to your appointments because of logistics), speak up.

Depression, like other chronic illnesses, requires “commitment and management. [Y]ou have to learn to live with it every day but not allow it to define you,” Serani said. How? Focus on celebrating your strengths. “While your life may involve psychotherapy, medication and the need for a protective structure that keeps your illness at bay, also realize that you have passions, desires, gifts and talents that require just as much attention.”

Also, “make sure you take extra special care of your mind, body and soul,” Serani said. “This means being attentive to your sleep cycle, moving your body with exercise [and] eating wisely and well.”

Trigger: Ruminating

“Negative self-referential ruminations play…a key role in recurrence,” Marchand said. For example, individuals with depression tend to dwell on their (supposed) flaws and failures. They also may view neutral events with a negative lens.

That’s why it’s important to develop a strategy for managing these thinking patterns, he said. “Cognitive therapy or mindfulness-based interventions are particularly useful in this regard.”

Trigger: Not Knowing Your Personal Vulnerabilities

“Triggers may be very specific to each individual’s situation, since all of our emotional responses are unique to some extent,” Marchand said. To identify your triggers, “learn how to recognize the who, what, whys and whens of your emotional and physical life,” Serani said.

Look at your calendar for potentially difficult periods. For instance, this might be an anniversary of a divorce or death or anxiety about a mammogram, Serani said. Highlighting these days “allows you to anticipate and plan for threats to depression recovery.”

Also important is to “take an inventory of all the hats you wear in your life.” Serani suggested considering these questions: “What circumstances at work affect your mood and behavior? At home, do certain actions of those around you tend to upset you? Are you feeling supported or overwhelmed? What happens when you don’t get enough ‘me’ time?”

Check in with your physical state, Serani said. “If you find yourself excessively fatigued, irritable, having trouble eating or sleeping, you might be in the midst of a trigger event.”

Finally, you can identify triggers by “think[ing] about previous depressive episodes and determin[ing] if there were specific triggers,” Marchand said.

Navigating a Relapse

Sometimes it’s not possible to prevent a relapse. But by knowing the early signs and getting treatment right away, you can prevent a full-blown episode or lessen its severity and length.

“Generally, early relapse will take hold with subtle signs, like mild irritability and sadness,” Serani said. Tracking your mood states every day helps you spot these early, not-so-obvious signs. “Through journaling, mindful reflection, and even apps on the computer, keeping a running tab on mood states can help offset relapse.” For example, if you’ve logged in 7 to 10 days of negative measurements, contact your practitioner to get evaluated for a relapse, she said.

Marchand also stressed the importance of contacting your doctor or therapist “at the first evidence of recurrence. Interventions may include restarting medication or psychotherapy… [I]f [you’re] in maintenance treatment [it’ll include]…adjusting [the] frequency of therapy or the medication dose.”

If you have a relapse, you might feel overwhelmed, frustrated and deeply disappointed. But “don’t measure your success living with depression on whether relapse happens or not. Instead, realize that if relapse occurs, true success comes from rising after the fall,” said Serani, who’s had depression herself. Her mantra is the Japanese proverb: “Fall down seven times, get up eight.”

And, again, whether you have a relapse or not, take good care of yourself, seek support and show yourself some compassion. Depression is a difficult illness. But, with treatment and healthy strategies, you can manage (and possibly eliminate) your symptoms and get better.

These professionals practice in an area best described as community psychiatry, or as it is often called, public service psychiatry.

Now, community mental health is not such a foreign concept. However, one tends to think of social workers, agency directors, caseworkers, addiction counselors, psychologists and therapists as those who hash out details of mental health consumers’ needs. Indeed, it is the psychiatrist who must be called upon to do the initial assessments and diagnose disorders, but their active role usually diminishes, as they bow out (for the most part) of the developing psychosocial picture.

Not so for public service psychiatrists. In addition to their regular duties, they truly partner with urban and rural health service providers and consumers in their region. They look to the unique psychological needs that arise in specific environments and individual communities, and always aim to serve the underserved.

The department of psychiatry at the University of Pittsburgh (Penn.) Medical Center, along with their esteemed affiliate Western Psychiatric Institute and Clinic (WPIC), operates one such Center for Public Service Psychiatry (CPSC). The Center is “dedicated to the development and practice” of this subset of psychiatry, “providing leadership, collaboration, education and community based research.” Input from consumers and others ‘affected’ is especially fostered, with weekly discussion meetings open to community service providers, family members and interested others. Along with graduate fellowship students in the program under the mentorship of Dr. Wesley E. Sowers, CPSC director, and associate director Robert Marin, it makes for a colorful mix of an informed and invested population of consumer-providers both.

Wes Sowers certainly is not the stereotypical psychiatrist. He doesn’t attend the CPSC meetings in white coat or even suit and tie. Both he and his colleague Dr. Marin are unassuming leaders of this relaxed weekly gathering on the periphery of the Pitt campus, albeit with ambitious three-part curriculum content (and suggested reading material) and teleconferenced seminars with their colleagues around the United States.

“Wes,” as fellows and others in the group call him, has a background that naturally fits the mold of a person dedicated to applying his expertise in underserved communities. He began international work in public health after his internship, spending a year in Sudan, working with Ethiopian refugees, and helping to train local health workers in Nigeria and El Salvador.

Once back in Pittsburgh, in the early to mid-1990s, he became the medical director of St. Francis Hospital. It is one of two major institutions in the region (WPIC the other) that served the psychiatric and substance abuse populations in surrounding Allegheny County. This writer once worked with a psychosocial agency in the Oakland area on the Pitt campus, interfacing with doctors, clinicians and therapists from both institutions. St. Francis had a reputation as humane, compassionate and collaborative.

Although St. Francis no longer exists, to this day, individuals comment favorably in support groups and other forums about the unique care that came out of its rehab facilities. Well-respected clinician and author Abraham Twerski, former rabbi, served as clinical director of the department of psychiatry there, and he would later found Pittsburgh’s award-winning Gateway Rehabilitation Centers.

How does Dr. Sowers describe public service psychiatry and his connection to this work he does? It is in his opinion “what psychiatry ought to be.” He brings up the words “value-based, social justice, and a desire to serve the underserved” (and that this subset of psychiatry is underfunded). The reward to him from his service and leadership — besides natural gratification in healing within populations that he has had “pretty consistent interest in” since early days working in public health and prevention — comes also from just getting to know these “interesting and culturally diverse” people whom he comes into contact with regularly.

Dr. Sowers also serves as medical director for the Office of Behavioral Health in the Allegheny County Department of Human Services, as well as clinical associate professor of psychiatry at WPIC. He became especially interested in addictions when “superiors early in his career apparently didn’t know much about them.” Yet he found himself in the field of psychiatry when co-occurring addictions and mental illness were becoming better known. While at St. Francis, and beyond, Dr. Sowers saw that “the more he became immersed in mental health, addictions became a more relevant paradigm…” related to all mental illnesses.

“A focus on health, instead of illness” is Dr. Sowers’ stake on his and colleagues’ research and practices in public service psychiatry. Indeed, “holistic” is what Dr. Sowers offers up as descriptively distinguishing his program. This mindset even approximates some of that of the anti-psychiatry movement so well-known from the 1960s and 1970s. Discussed in one of the weekly CPSC meetings, the theories of Thomas Szasz, R.D. Laing, Elaine Showalter and Phyllis Chesler, “though a bit extreme,” according to Dr. Sowers, have “important implications” for modern-day community psychiatry.

Dr. Sowers unabashedly states that diagnoses are perhaps best useful for billing purposes (a fact that other clinicians, liberal or otherwise, have no problem expressing equal agreement to, at least behind closed doors); as well, he feels that Western medicine “pathologizes a lot of things that are really problems in living.” As such, the work of public service psychiatry truly speaks to and significantly serves not only myriad people but many other facets of American society.

But successfully treating bipolar disorder can involve several medication trials, and it can take years to achieve remission. Even if remission is attained, recurrence is the rule — not the exception. It’s not uncommon for all first-line treatments to be exhausted.

People in this situation may be considered by mental health professionals to be treatment-resistant. Luckily, there are treatments that can be tried when first-line, and even second-line, treatments for bipolar disorder fail.

What is Treatment Resistance?

There is no consensus among clinicians and researchers on one definition of treatment resistance. Generally, patients in an acute state (manic, depressed or mixed) whose symptoms do not improve after at least two evidence-based medication trials are considered treatment-resistant in research studies. In the maintenance phase, patients are considered treatment-resistant if they continue cycling despite several adequate medication trials.

In some studies additional criteria must be met in order to truly be considered treatment-resistant. These include functional measures of remission.

Dr. Prakash Masand, psychiatrist and founder of Global Medical Education argues, however, that “Treatment-resistance is more common than most clinicians think since a sustained response to treatment rarely includes an assessment of functioning. When functioning and residual depression are taken into consideration, far more patients would be considered treatment-resistant.”

First-Line Treatments for Bipolar Disorder

First-line treatments for bipolar disorder have been shown to be the most reliable. They are approved by the Food and Drug Administration (FDA). First-line treatments vary, depending on the phase of bipolar disorder the patient is in.

First-line treatments for mania include:

• Valproate (Depakote)
• Carbamazepine (Tegretol, extended release)
• Lithium
• All atypical antipsychotics such as risperidone (Risperdal), quetiapine (Seroquel) and aripiprazole (Abilify)

In the depressed phase of bipolar disorder, only quetiapine and an olanzapine (Zyprexa)/fluoxetine (Prozac) combination are approved as first-line treatments, although lurasidone (Latuda) is awaiting FDA approval.

For mixed episodes of bipolar disorder, carbamazepine and most atypical antipsychotics are approved. For the maintenance phase of bipolar treatment, lamotrigine (Lamictal), lithium, aripiprazole and olanzapine are FDA-approved.

Second-Line Treatments for Bipolar Disorder

According to Dr. Masand, many treatments are still available for people considered treatment-resistant. “People should not give up hope just because several treatments have failed. We have many tools in the toolbox outside of first-line monotherapy treatment.”

Primary second-line treatments in bipolar disorder include adjunctive treatments such as the addition of an atypical antipsychotic to lithium or valproate or vice versa. Dr. Masand notes that “patients in a manic or mixed state may actually respond more quickly to lithium or an anticonvulsant combined with an atypical antipsychotic.”

And while antidepressants should never be used alone to treat bipolar disorder, adding them to an existing mood stabilizer or antipsychotic is considered a second-line treatment and is sometimes helpful for bipolar depression. “Additionally, adjunctive armodafinil (Provigil) may also be useful in bipolar depression,” Dr. Masand. said

Additional Treatments for Bipolar Disorder

There are additional therapies that can be considered even if both first-line and second-line treatments fail. According to Dr. Masand, third-line treatments include clozapine (Clozaril), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), calcium channel blockers, high-dose thyroid augmentation, omega-3 fatty acids and other anticonvulsants.

“Novel treatments are also being researched,” Dr. Masand said. “Agents such as n-acetylcysteine, mexiletine (Mexitil), pramipexole (Mirapex), ketamine and others have shown promise for the treatment of the various phases of bipolar disorder. It’s also critical that all patients with bipolar disorder receive an adjunctive proven psychotherapy such as psychoeducation, family-focused therapy, interpersonal and social rhythm therapy or cognitive behavioral therapy (CBT), as relapse rates have been shown to be lower when therapy is added to medication treatment.”

The best teachers are essentially mentors (and counselors of sorts), drawing out any little glimpse they can sense and intuit that someone near them has even the smallest seed of will or fascination to learn a new fact or method. Such learning may not come easily, though, especially with a learning-disabled student or individual.

There are coaches who specialize in helping those with attention deficit hyperactivity disorder as well. One such coach in Pittsburgh, Penn., Susan Lieber, is an impassioned counselor for those struggling to make sense of their debilitating neurobiological condition.

Lieber’s focus is to help her clients “develop a language to advocate for themselves.” This is no small task for those whose esteem is shredded by their lessened ability to prepare for important tasks, establish daily routines, see tasks to completion and remember where everyday objects were placed — not to mention having a loss for words other than the pat self-label ADHD to describe their challenges. “I have a hard time with managing unscheduled time” would be one way to define yourself to the outer world, Lieber posits, as opposed to saying “I am ADHD.”

A former occupational therapist versed in cognitive-behavioral strategies, as well as a former pain clinic researcher, Lieber decided to go into coaching for the reason many do — a deep interest in significantly applying her existing skillset and keen ability to effectively work one on one with folks. Many of her clients are high school students diagnosed with ADHD, and others have similar problems. In the case of the former, she tries to help them move toward an adult life on their terms and in a manner that “makes sense to them.”

This involves “developing an awareness” of behaviors and actions. It is apparent from talking with her that Lieber masterfully culls those slight seeds of desire for change and improvement in the lives of these young people who may be frustrated with themselves and their place in the world.

Her work as a coach is behaviorally-based and focused on education, as she has observed that really all ADHD individuals “want change… want better outcomes.” So Lieber figures out “what kinds of support the client needs.” She stresses here that the ADHD experience “is unique to each individual, and for a lot of reasons.” She has an apt term, pivoting — “getting clients back on track to where they need to be”– to describe the goal of her coaching sessions.

Through the coaching process, ADHD individuals can, according to Lieber, “gain a better understanding how their brain works” and learn tactics “to manage day-to-day demands.” Identifying solutions comes about in a mutual manner, with the coach encouraging honesty, humor, and “a steadfast belief” in themselves, which she exemplifies. “Coaching is all about asking questions and really listening,” she says.

Lieber also is a certified organizer coach, providing a more in-depth service to select individuals who are coming to her for ADHD counsel. Here she models and continues to identify effective strategies for the ADHD client, evaluates effectiveness and joins in helping that person develop some “habits for lasting change” in their home environment or elsewhere.

ADHD coaching, as addressed on Lieber’s website, “can help you sort through the physical and mental clutter that is limiting you….” She defines her help as empowering — truly helping people set up a life “which includes supportive persons, routines and spaces that is aligned with the things that matter most.” As Lieber also describes it, “Imagine replacing feelings of frustration with understanding and confidence… and developing a deeper awareness of what’s significant.”

After some coaching sessions, some family members have said things such as “now I understand my loved one doesn’t do this [lose keys or can’t get out the door on time] on purpose.” And the clients themselves? Instead of “feeling like you can do it all but falling short,” they are learning new behavioral approaches that speak to their unique lives, yet fitting those individual lives better into the larger whole of society.

The New York Times recently ran an article about the possible connection between sleep disorders and ADHD, suggesting that ADHD may be really be a sleep disorder in disguise. Nevertheless, the symptomatology is debilitating, and an ADHD coach such as Lieber can effectively address what is disrupting an otherwise fulfilling life.

A beautiful analogy Lieber makes with her coaching clients is about two different trees. The oak is universally admired for its strength, but rather than trying to emulate that, she encourages the ADHD individual to perhaps look toward the powerful image of the willow, for its flow and resiliency.

Susan Lieber can be reached via her website at leaveittolieber.com She offers presentations and talks and will soon be launching an educational series (with ongoing two-hour sessions) that will allow for 10-12 individuals in a group to get accurate information about ADHD, learn time management skills, and more. She has a resource list on her site that includes links to ADDA and the National Resource Center on ADHD, as well as some very choice book titles.

Whoops.

There is a fine line between helping and enabling, and what I was doing was enabling my son. As it turns out, following instincts when dealing with OCD is not always such a great idea. Once Dan began Exposure and Response Prevention (ERP) Therapy, he realized how important it was that we not enable him, and he’d actually let us know when we inadvertently did. He knew what he needed, and by communicating with us, he allowed us to help him.

Fast-forward about a year. At this point, Dan is taking a reduced course load in college and living at home. His OCD, while not as bad as it was, is still in control most of the time, and he seems listless and depressed. He is sleeping a lot, and whenever he is awake, he is anxious. It is upsetting and frustrating to me to see him this way, though I still work hard not to enable his OCD. But I don’t demand he help out around the house either, or do much of anything, for that matter. How can I insist he take out the trash? He is having such a tough time. Realizing we need guidance, my husband and I, along with Dan, meet with his therapist.

After expressing my concerns over my son’s lack of interest or involvement in anything, his therapist turned to him and said, “Dan, what do you think your parents should do?”

Without hesitation he replied, “I think they should push me more.”

While I was surprised at Dan’s answer, I was even more taken aback by the fact that it had never crossed my mind to ask him that very question myself. Why not? If he had a broken arm, or the flu, I would have asked him what I could do to help him feel better. Why hadn’t it occurred to me that the person who might just know what is best for Dan is Dan?

In the past, he had been honest about what he needed. While I wracked my brain trying to figure out how I could help him, I never once asked him. If I had, he would have told me that he didn’t really want to be pampered or tiptoed around. What he wanted was to be treated as normally as possible. What he wanted was to feel like a respected, contributing member of society. What he wanted was to recover from OCD and get back to the business of being an active college student.

I think as parents we instinctively want to protect and care for our children. We are supposed to fix them when they are broken. But there are times that just isn’t possible, or even optimal. Sometimes the best thing we can do for our children is to simply listen to what they have to say, offer our support, and ask “What can I do to help you?” These words need to be spoken, not just assumed.

I learned a valuable lesson that day we met with Dan’s therapist. Everyone deserves to be heard. I needed to listen to Dan, and he needed to listen to me, to hear my perspective.

I know now that by really listening to those who are suffering we are, at the very least, showing them respect, opening up the lines of communication, and letting them know their insights, thoughts, and feelings are valued. And who knows, asking them what they need from us might evoke some surprising answers.

Given my love for women’s fiction, I’m enthusiastic when I discover a new writer’s collection. Happily, best-selling author Kristin Hannah captured my interest immediately with Summer Island through her well-developed characters and compelling content.

Nora Bridge, a renowned radio talk show host living in Seattle is an advice–giver on family, relationships and other emotional matters. Her own experiences of heartbreak fuel her compassion toward others.

The novel centers on Nora’s strained relationship with her 27-year-old daughter, Ruby. Ruby is a struggling comedian in California who stopped smiling during her junior year of high school. She hasn’t spoken to her mother in nine years, ever since Nora left the family behind and relocated.

When Ruby is offered a large sum of money to write a ‘tell-all’ piece on her mother, and an opportunity to achieve celebrity status amid media hype regarding a scandal and the hypocrisy of her mother’s behavior, she decides to stay with Nora in her childhood home out on Summer Island.

Though Ruby initially has ulterior motives for rekindling communication with Nora, she begins to remember the past. As painful as those memories are, she starts to see her mom in a new light. She realizes that her mother didn’t abruptly leave the family for selfish desires; she was undergoing an internal battle of her own, even if at the time Ruby didn’t seem to notice. “My mother didn’t leave him – and us – for fame and fortune, but simply because she was human, and the man she loved had broken her heart,” Ruby realizes.

Summer Island raises the issue of family history: how much are we affected by our parents’ choices, even into adulthood? Nora’s father was an alcoholic, and she tried to run away from home. Is it difficult to fathom why her marriage was in trouble before it really began? She never felt loved by her father. That void, along with living with an alcoholic, stayed with her in the years to come. Nora left her own family when she was in a fragile and undeniably unrecognizable state. “I’d wake up, lying on the kitchen floor, with huge chunks of my day gone. I don’t know if you can understand that kind of depression,” Nora told Ruby.

Ruby broke up with her first serious boyfriend, only to enter a five-year relationship with someone she wanted to love but didn’t. Her self-worth deteriorated after her mother left, which not only instilled a fear of love, but a hesitation to have faith in love as well.

“My women are often in the same small boat,” Hannah said in an interview for another of her books on readinggroupguide.com. “I often am drawn to the moments in their lives when all that forgetting comes to a head. The day we realize how much of ourselves we’ve lost and the subsequent journey of re-discovery. Usually, I begin a book knowing where the woman is on that journey and where she will end up, but often the road itself is a mystery I uncover on a day by day, word by word basis.”

Nora’s eldest daughter, Caroline, also was about to follow in her mother’s footsteps and leave her marriage. “I let the bad times overwhelm me, and I ran,” Nora said. “It wasn’t until I’d gone too far to turn back that I remembered how much I loved your father, and by then it was too late. For all these years, I’ve been left wondering, ‘What if?’” She stresses the importance of fighting for your commitment and fighting for your family, with the desire to work on what’s worth saving.

Through it all, the pages of Summer Island illustrate a pertinent growth process — one where you could learn from the mistakes of the past. Hannah will leave readers feeling satisfied and fulfilled.

With her book, LaDonna Gatlin does just that. The author is the sister of the famous Gatlin Brothers country music group. The Song in You, which she wrote with the help of Mike Marino, is part memoir and part self-help guide.

A musician first and foremost, Gatlin shares her life lessons by using the solfège syllables of the major scale: do, re, mi, fa, so, la, ti, do. In a musical pun, Gatlin and Marino make each of the two-letter terms the beginning of a lesson Gatlin has learned: Do the right thing. Realize your potential. Mind your manners. Failures can become fertilizer. Solutions begin with me. Laugh! Time is valuable — and back to do.

Gatlin begins the book by explaining what it was like growing up in her famous family. She says they led a “double life” as kids. They went to school, played sports, and led basically normal lives during the week and school year. But during the weekends and summers, the Gatlin family traveled the country performing concerts and recording music. After she was married, the author and her husband made the difficult decision to leave the very successful Gaitlin Quartet to start a family. This decision eventually led to the author’s career “reinvention” from successful country singer to mother and finally to a successful author and public speaker.

This first decision is where the author introduces readers to her first lesson: Do the right thing. This big lesson is then broken down into more manageable steps. Because the book is part memoir and part self-help guide, the chapters are quite lengthy. However, Gatlin and her co-author write in such an easy and conversational style that it never feels like the book drags on at all. It makes for an enjoyable read.

At one point, Gatlin goes into great detail disclosing her battle with major depression and her suicide attempt. I appreciated her honesty about this because I think that depression (and mental illness in general) is either not seriously discussed enough or is treated with a flippant attitude, as if it’s “no big deal.” In reality, depression is one of the most common mental health issue people face. Few people talk about it seriously, so it’s difficult for a person who is not affected by it to understand the mindset and/or actions of a depressed individual. More people need to speak honestly about it.

The Song in You continues to follow this step-by-step memoir and self-help format, and encourages readers to forge their own path and “sing the song God gave them.” Another thing I loved about this book is that Gatlin is a Christian and she makes no apologies for it. While this is not a typical “Christian book,” Gatlin refers several times to God, His plan for her life, and her overall faith. She manages to do this while still being inclusive of her readers and not sounding preachy, which I suspect readers will find refreshing.

One can also tell from reading her book that Gatlin is a positive person. Her words radiate with joy and positivity. Even when speaking of her depression, she ends in saying, in essence, that her pain has a purpose. Her positivity made the book a joy to read.

Despite that each chapter seems long, the book is relatively short. It’s an extremely easy and encouraging read. As a musician and a country and gospel music fan myself, the book especially appealed to me.

If you feel stuck, unfulfilled in your career or in life, or are just plain unsure where you fit or what you should be doing, I highly recommend this little book. Gatlin’s conversational and straightforward writing style makes the reader feel an intimacy with her story. Her infusions of honesty, humor, and faith make the book much more down-to-earth than other self-help texts. Simply put, The Song in You is a joyful reminder of why none of us should ever stop trying to find the melody in our souls. Never give up.

The Song in You: Finding Your Voice, Redefining Your Life
Health Communications, Inc., November, 2012
Paperback, 264 pages
$14.95

Dr. Lindskog explains that depression “is characterized by both emotional and cognitive symptoms.” However, she adds, “the relationship between these two symptoms of depression is poorly understood.”

The team compared ordinary rats against a strain of rats that had been bred with a disposition toward depression. This strain of rats has recently been found to have decreased emotional memory, impaired brain plasticity, and a smaller hippocampus.

The idea was to investigate the glutamatergic system, which is a system of amino acids vital for information processing in the hippocampus, in order to “reveal the mechanisms underlying the emotional and cognitive aspects associated with the disease.”

Clinical studies have shown abnormalities in the glutamatergic system in depressed people, but it is not yet clear how this affects the brain and contributes to depression symptoms.

All of the rats were injected with D-serine, a substance secreted by support cells for brain neurons called astrocytes. The “depressed” rats showed an improvement in their previously impaired brain plasticity and on memory tests.

Apathy was tested by releasing the rats into a container of water and observing whether they immediately tried to climb out or stayed floating in the container. The “depressed” rats showed no improvement in their level of apathy following the injection with D-serine.

“We have shown that there are two symptoms that can be influenced independently of one another, which means they could be treated in tandem in patients with depression,” said Dr. Lindskog. She added, “It’s likely that astrocytes perform a very important function in the brain.”

The researchers also found that the hippocampus in the brains of depressed rats had a lower plasticity that left them unable to increase neuron activity when needed. But after being soaked in D-serine, the plasticity of the hippocampus in brain samples improved.

A reduction in the size of the hippocampus is one of the most common findings in depressed patients and in this depressed strain of rats. It has a “prominent role” in memory and a potential role in emotional symptoms, say the authors.

Reporting the findings in the journal Molecular Psychiatry, the authors state, “Both synaptic plasticity and memory impairments were restored by administration of D-serine.”

Dr. Lindskog says, “D-serine doesn’t pass the blood-brain barrier particularly well, so it’s not really a suitable candidate on which to base a drug. But the mechanism that we’ve identified, whereby it’s possible to increase plasticity and improve memory, is a feasible route that we might be able to reach in a way that doesn’t involve D-serine.”

She believes it is crucial to learn more about this process. “These findings open up new brain targets for the development of more potent and efficient antidepressant drugs,” Dr. Lindskog says.

In their journal paper, the team explains that current antidepressant drugs sometimes resolve emotional symptoms without benefiting depression-linked deficits in memory and learning. This discrepancy “suggests the involvement of different mechanisms in the origin of these two key aspects of depression,” they write.

Perhaps this study holds the key to these different mechanisms. As the researchers say, “Based on our results, we propose a mechanism in which dysfunctional astrocytic regulation of glutamate affects glutamatergic transmission, causing memory deficits that can be restored independently of the emotional aspects of depression.”

They can also account for the lower D-serine level in the hippocampus of depressed rats: it is due to changes in the shape and function of astrocyte neurons.

“In summary,” they write, “our data describe interactions within the glutamatergic system that should be considered when designing new therapies for depression.” Several different aspects of the system should be targeted “to effectively treat both the cognitive and emotional symptoms that are associated with depression,” they add.

More recently it has been confirmed that, as Dr. Lindskog suspected, astrocytes are of major importance in depression. Dr. Boldizsar Czeh of the Max-Planck-Institute of Psychiatry, Munich, Germany, and colleagues took a further look at astrocytes.

They report that astrocytes “are regarded as the most abundant cell type in the brain,” but it seems they also regulate synapses, that is, the area that allows communication between neurons. They appear to control neuron development in the hippocampus.

In the journal European Neuropsychopharmacology, the team sums up all the evidence that antidepressant drugs affect astrocytes. “We propose here a hypothesis that antidepressant treatment activates astrocytes, triggering the reactivation of cortical plasticity.”

They believe that these astrocyte-specific changes probably contribute to the effectiveness of currently available antidepressant drugs, but they add that “better understanding of these cellular and molecular processes could help us to identify novel targets for the development of antidepressant drugs.”

References

Dysfunctional Astrocytic Regulation of Glutamate Transmission in a Rat Model of Depression. Gomez-Galan, M. et al. Molecular Psychiatry February 28, 2012 doi: 10.1038/mp.2012.10

Czeh, B. and Di Benedetto, B. Antidepressants act directly on astrocytes: Evidences and functional consequences. European Neuropsychopharmacology Volume 23 Issue 3 pp. 171-85 March 2013.

The last time I ran on my treadmill had been Friday; five days later, I was not my typical self. You could ask my husband! Nothing that he said or did was “good enough.” Something had come over me. One day a stranger at the grocery store said, “You look exhausted.” I wasn’t sure how to respond.

I seemed to unload all my frustrations on my loved ones. Before getting home I would do some positive self-talk: “Count your blessings. You have a wonderful husband. There is no reason to snarl at him for insignificant things. Be positive!” I would get home and — bam! — my volcano erupted.

In my private practice I’ve met parents who tearfully tell me they feel as if their children are abusing them emotionally. I tell them, their children’s behavior may not be acceptable, but they are the closest person in their children’s lives. By default, they will vent their emotions on their parents. However, there are no excuses for negative behaviors. I usually help the children and parents with this problem. But now I seem afflicted with the same difficulty. I could not snap out of it. Fortunately, my husband never asked me to do that.

One day, I finally realized what was wrong — I was missing my main outlet. A few extra events had taken me off my exercise routine I’ve been doing for years. The next day, I decided I would do whatever it took to squeeze my workout back in my schedule. I woke up early, stretched, plugged in my running music, and jumped on the treadmill. When I reached mile three, I was on cloud 9 and was able to finish five miles.

The physical activity I was used to doing was missing, and the effects were clear. It had not been the first time, though. The previous year, I had family in town and for one reason or another I was not able to run for two weeks. By the time they left, I just wanted to sleep and found myself being depressed.

It took the second time for me to recognize that without my workouts, my mood suffers significantly. I discovered that I simply cannot afford to miss my workouts.

The research has been there for years, but we often dismiss it when life gets too busy. Unless you notice a drastic change in your mood like I did, you may not think it’s a big deal. However, daily physical exercise is essential to our overall health.

Everyone is different and physical activity will vary as well as its effect. It is true, the most difficult situation for depressed individuals is to engage in some type of exercise. When individuals feel depressed, exercise is the farthest thing from their minds.

When we have an awful pain and the doctor prescribes a bitter medication, we often are willing to take it because it will clear discomfort. Is it possible to look at exercise the same way? It may not be pleasant, but in the long run, it can help alleviate the emotional pain.

Sometimes, it’s a hard sell. But, can you remember the physical activities you used to enjoy before becoming depressed? It doesn’t have to be strenuous, just do something.

Write up a plan that includes small steps towards your goal. Don’t expect to run a mile if you haven’t walked one. Decide what the activity will be that you can enjoy. You don’t need to go to the gym. Brisk walks, gardening, sweeping, vacuuming, and moving household items is a good way to get your heart pumping and your body moving.

If you can’t think of anything, just walk. Find ways to walk more and drive less. Decide to walk half a block the first day and lengthen the time and distance every week. Find a friend or family member to support you with your goals. When you share your thoughts, others will understand what you are going through. Teach your loved ones how to listen to you. Tell them that you don’t need a solution, you just need a listening and empathic ear. Nothing is worse than having someone tell you how to solve your challenges and to snap out of it.

Moods come and go. When sadness and irritability stay, it’s difficult to see the light. While in the dark, doing nothing will only take us deeper into the well of depression. To do nothing may be the easiest thing, but not the best thing. Willingness to do something even when you don’t feel like it is the first step.

Exercise is not the only solution, but it’s a sure way to begin the climb out of the gloom into the light that awaits. You can push through it, then watch the results!

Using brain samples from mice, the team looked at the progressive disintegration of synapses in the hippocampus when exposed to a protein called amyloid-beta, thought to be central to the development of Alzheimer’s disease.

“Synaptic loss mediated by amyloid-beta in early stages of the disease might contribute to cognitive impairments,” explain the experts. “However, little is known about the mechanism by which amyloid-beta induces the loss of synapses.”

Tests showed that Dkk1 is linked to abnormal deposits, or plaques, of amyloid-beta, triggering the loss of synapses, the connections between neurons. Laboratory tests showed that amyloid-beta causes greater production of Dkk1.

Further tests indicated that antibodies which block the function of Dkk1 can suppress this toxic effect of amyloid-beta. The hippocampus, a brain area associated with learning and memory, is in turn protected.

The findings are published in the Journal of Neuroscience. Dr. Salinas says, “Despite significant advances in understanding the molecular mechanisms involved in Alzheimer’s disease, no effective treatment is currently available to stop the progression of this devastating disease.

“These novel findings raise the possibility that targeting this secreted Dkk1 protein could offer an effective treatment to protect synapses against the toxic effect of amyloid-beta. Importantly, these results raise the hope for a treatment and perhaps the prevention of cognitive decline early in Alzheimer’s disease.”

Dr. Simon Ridley of the study’s funders, Alzheimer’s Research UK, commented, “We’re delighted to have supported this study, which sheds new light on the processes that occur as Alzheimer’s develops. By understanding what happens in the brain during Alzheimer’s, we stand a better chance of developing new treatments that could make a real difference to people with the disease.

“Studies like this are an essential part of that process, but more work is needed if we are to take these results from the lab bench to the clinic. Dementia can only be defeated through research, and with the numbers of people affected by the condition soaring, we urgently need to invest in research now.”

Dkk1 is described as a “Wnt antagonist,” that is, it blocks the Wnt signaling pathways. These pathways regulate many essential processes, and mutations in the pathways have been linked to a range of diseases including breast and prostate cancer and type II diabetes.

Because Dkk1 is present in higher levels in brains of Alzheimer’s patients, researchers believe that problems with Wnt signaling could contribute to the disease.

The role of Wnt signaling in neural development has long been understood. But in recent years, several studies have suggested that faulty Wnt signaling is involved in degenerative and inflammatory disorders of the central nervous system, including Alzheimer’s.

A team from King’s College London, UK, investigated the way in which amyloid-beta causes Alzheimer’s. They say, “Although the mechanism of amyloid-beta action in the pathogenesis of Alzheimer’s disease has remained elusive, it is known to increase the expression of the antagonist of wnt signalling, Dkk1.”

In tests on mice, they identified a molecular pathway in which amyloid-beta boosts the expression of several genes known to be linked to Alzheimer’s. This finding provides “new mechanistic insights into the action of amyloid-beta in neurodegenerative diseases,” they write in the journal Molecular Psychiatry.

In the light of these new findings, it is possible that drugs targeted at rebalancing the “tightly regulated” Wnt signaling pathway may eventually be a useful therapeutic strategy for Alzheimer’s disease.

Dr. Erin Scott and Dr. Darrell Brann of Georgia Health Sciences University, Augusta, GA, suggest one possible avenue of therapy. In the journal Brain Research they write: “Estradiol is an endogenous steroid hormone that is well known to exert neuroprotection.”

Estradiol, the main form of estrogen in the body, protects the hippocampus from lack of oxygen by stopping levels of Dkk1 getting too high and encouraging healthy Wnt signaling in the hippocampus’ neurons.

The experts warn that this balance could be disrupted when individuals receive treatment that either reduces estrogen levels, such as some types of breast cancer therapy, or increases their estrogen levels, such as hormone replacement therapy.

In fact, the loss of estradiol that occurs naturally in women at menopause is known to lead to a raised risk of cognitive decline. But surprisingly, several clinical trials have found a detrimental effect of estrogen therapy after menopause, including increased stroke risk and dementia.

Dr. Derek Schreihofer of the University of North Texas Health Science Center at Fort Worth, TX, analysed these trials and discovered a “critical period” in which estrogen therapy must begin soon after the loss of natural estrogen production, or it will not have a beneficial effect.

It may be that these findings on estrogen and antibodies to block Dkk1 are of use in the future development of effective therapies for the treatment or prevention of Alzheimer’s disease.

References

Salinas, P. et al. The Secreted Wnt antagonist Dickkopf-1 is required for Amyloid B-mediated synaptic loss. The Journal of Neuroscience, March 7, 2012.

Killick, R. et al. Clusterin regulates beta-amyloid toxicity via Dickkopf-1-driven induction of the wnt-PCP-JNK pathway. Molecular Psychiatry, November 20, 2012.

Scott, E. L. and Brann, D. W. Estrogen regulation of Dkk1 and Wnt/beta-Catenin signaling in neurodegenerative disease. Brain Research, 19 December 2012.

Schreihofer, D. A. and Ma, Y. Estrogen receptors and ischemic neuroprotection: Who, what, where and when? Brain Research, 13 March 2013.

“Kids can impulsively run into the street. They can hit another student in line at school. They can climb up on the roof and jump off, hoping to fly like Superman,” said Terry Matlen, ACSW, a psychotherapist and author of Survival Tips for Women with AD/HD.

And they can have tantrums. There are many reasons why kids with ADHD have meltdowns. For instance, “for many children with ADHD there is no internal understanding of ‘later.’ It’s now or now,” Matlen said. They have a hard time putting their wants and needs on hold. Because they’re kids, they’ve also yet to learn how to calm themselves or express their needs and emotions appropriately, she said.

“A little disappointment becomes the end of the world and nothing seems to stop the child from, what looks like, obsessing over their intense needs of that moment.”

They also might feel overwhelmed by external events, such as “too much noise or excitement at a party… Combined, these symptoms make it very hard to stay calm when under stress or when they feel fearful or anxious.”

When your child has a tantrum, especially in public, it can be tough to know how to respond. Some parents vacillate from one extreme to another, from placating their child and giving in to punishing them and getting angry, according to Matlen.

But while it might seem impossible, you can navigate the rocky road of tantrums. Here are expert strategies to prevent tantrums or tame them when they start.

1. Pinpoint the source.

Psychotherapist Stephanie Sarkis, Ph.D, suggested looking “at what might be triggering your child’s behaviors.” When you can find the source of the behavior, she said, you can make strides toward changing it.

Knowing what triggers your child, Matlen said, can help you defuse their tantrum as early as possible. For instance, is your child hungry? Are they sleep-deprived? Are they experiencing strong emotions? Once you pinpoint the underlying problem try to solve it, she said.

This also is a good tool for preventing tantrums. For instance, if your child can’t handle the overstimulating environment of a local fair, just don’t take them, Matlen said.

2. Explain consequences in advance.

Before a tantrum ever starts, Matlen suggested talking to your child about the negative consequences of bad behaviors. She gave this example: “If you scream and cry when I turn off the TV, you won’t be able to watch it later today.”

Matlen took this approach when her daughter was 5 years old. She tended to have tantrums when she didn’t get a new toy at the store. “Before our next outing, I told her that if she had a tantrum, I would simply pick her up and take her home. No toys and no more visits to the store for a very long time.”

Her daughter still had a meltdown. But instead of getting furious or frustrated, Matlen picked up her daughter and took her to the car. She drove home without saying a word. And it never happened again.

“This, of course, may not work for all children, but it’s an example of planning ahead and having an outcome that everyone understands.”

3. Talk to your child, and encourage them to talk back.

Talk calmly and quietly to your child, and acknowledge their feelings, Matlen said. Doing so helps your child feel heard, Sarkis said.

For instance, according to Matlen, you might say, “I know you’re angry that I won’t buy you that toy today. It feels frustrating and it makes you feel like exploding inside, doesn’t it?”

Then, encourage your child to express their emotions, as well: “I’d be awfully upset too if I couldn’t get what I wanted right now — let’s talk about why this is so important to you so you can help me to understand.”

4. Distract your child.

For younger kids, distraction may work, Matlen said. “Talk about something completely different, like how excited you are to watch the TV show you planned, when you all get home.”

5. Give them a time-out.

“Sometimes, nothing seems to work, though, and a child will not stop no matter what you try,” Matlen said. When that happens, calmly explain that they’ll need to go to their room. They can come out after they’ve calmed down. This is a powerful way to learn self-soothing behaviors, she said. Because of that, it’s important to keep objects that promote healthy coping, such as a teddy bear or fidget toys, she added.

6. Ignore the tantrum.

“Sometimes the best reaction to a tantrum is no reaction,” said Sarkis, author of several books on ADHD, including Making the Grade with ADD: A Student’s Guide to Succeeding in College with Attention Deficit Disorder. That’s because “even negative attention is attention, and it gives a ‘payoff’ for the behavior.” So not giving your child an “audience” might help to lessen the length of the tantrum.

If your child has a tantrum in the middle of the store – and it’s not crowded – let them have the tantrum, Sarkis said. “You may get looks from others. It’s OK. Just remember that not paying attention to the behavior helps extinguish it.”

7. Give them reminders.

According to both experts, kids with ADHD have a hard time with transitions. They can have a meltdown when it’s time to leave the playground or stop playing their videogame to have dinner, Matlen said. “Things that are pleasurable are hard to stop, especially when the transition is into an activity they might not enjoy.”

This is when reminders are key. For instance, remind your child at 30, 15, 10 and 5-minute intervals that dinner is ready, Matlen said. Also, establish appropriate consequences if they don’t comply, such as not playing videogames after dinner, or playing them for 15 minutes instead of 30 next time, she said. (Or just ban videogames before dinner altogether, she said.)

Matlen gave this example of what to say to your child: “I know it’s hard for you to stop playing your PlayStation when it’s time for dinner. I will give you reminders so that you can wind down. However, having a tantrum is not acceptable, so if that happens, you will (fill in the blank).”

8. Praise your child when they do show self-control.

“Parents need to catch their kids being good much more than they catch them being ‘bad,’” Sarkis said. “Children with ADHD respond well to positive reinforcement.” Plus, “whatever you focus on grows,” she added.

According to Matlen, instead of saying, “You are such a good boy for not having a meltdown when I said no to ice cream,” a better response would be, “You must have really felt proud of yourself that you didn’t have a tantrum when you saw that we were out of cookies – good job!”

9. Avoid corporal punishment.

“It’s a normal reaction to get angry when a parent sees his or her child flat out on the floor lashing out, kicking and screaming,” Matlen said. You might grab your child or even spank them. But this only fuels the negative situation and everyone’s emotions, she said. “Corporal punishment may defuse the behavior temporarily – though usually, it only escalates the negative behavior – but it also sets the tone that it’s OK to hit people when you’re angry.” Also, a child needs to “get himself in control.”

Dealing with tantrums is difficult. But by planning ahead, staying calm and applying specific strategies, you can defuse them. And if the tantrum doesn’t quiet, try to ride it out.