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There is considerable evidence that exercise benefits our mental health. Research suggests that in addition to improving memory, lifting mood, moderating depression, and reducing attention fatigue, exercise is a significant stress reducer.Whether you are a varsity player, a daily walker, a gym rat or an avid golfer, it is likely that the exercise you do helps you psychologically as well as physically. What happens when you get injured?
In most cases physical injury happens in the two minutes we never see coming. It is physically and psychologically disruptive because it not only involves physical pain and concern about intervention and recovery; it reminds us of the unpredictability of life, and the reality of our vulnerability. For athletes, as well as those determined to exercise, it is a loss that insults our sense of self as well as our sense of mastery.
“ I can’t be injured, we are in the semi-finals. I have to play!”
“ I just got the motivation and the routine going and now I break my ankle?”
“ What will I do if I can’t golf?”
•If you have ever been taken off the court or out of your usual routine by injury, it is likely you have felt the constraints of a Catch 22.
•At a time when you are feeling more pain and stress than usual, the one thing you can’t do is use your usual stress reducer–Exercise will make matters worse!
How Do You Proceed?
No matter what anyone says in the first hours, days or week of an injury, it won’t feel right.
“ So You Won’t Run Anymore- You will Do Something Else!”
“ Don’t Worry—You will be back.”
It is difficult to suddenly adjust to the loss of something that has added value to your life and it is also difficult to suddenly believe you will be ok, when you don’t feel ok. But it does get better…
What seems impossible starts to become possible when you realize there are many ways to reduce stress if you are able to focus on healing, open options, risk possibilities, and draw upon your resiliencies.
Five Ways To Reduce Stress
Become Mission Focused
After an athletic injury or an injury that impedes your usual exercise routine, it is to your advantage both physically and psychologically to be mission focused.
•Physically, you want to know about the nature of your injury, necessary interventions, prognosis, treatment and rehabilitation.
•Drawing upon the support of family and friends as you weigh options adds a healing connection and often enhances problem solving.
•Having a purpose stirs energy and goal setting.
•Psychologically, a pro-active position is always a boon to healing because it restores a sense of control and mastery. Focusing on your healing with determination and positive expectation is the antidote to hopelessness and despair.
Move It Along
When injured, most athletes and those committed to an exercise routine miss the movement, aerobic benefits, and neurochemical surge that come with exercising. Finding a way to move it along might include:
•Cross Training- If physically possible, an important option in the aftermath of injury is cross training. In reality, cross training, i.e. the use of varying exercises or the focus on different parts of your body is beneficial whether injured or not. It reduces stress, boredom, burnout, repeated stress injury and challenges the body in a different way.
Each injury has introduced me (not by choice) to an alternative exercise routine that I came to value and never dropped.
•Physical Therapy- If indicated, physical therapy is not only a source of recommended therapeutic movement but of support, healing and achievable goals. As such, it is physically and psychologically relieving.
•Being Good At Being Bad at Something New- Getting good at this skill suggested by Otto and Smits, authors of Exercise for Mood and Anxiety, is invaluable after injury because it opens all the doors of possibility.If you are willing to try a new exercise or athletic experience without the expectation or need to be good at it, it is a win-win. In the best of situations you love it. In the worst of possibilities, you have had a novel experience and a ridiculous story to tell!
A one-time runner who resigned himself to walk the dog through the neighborhood was startled by what unfolded between the response of neighbors to the dog and to him.
Take A New Look At Your Old Exercise Routine
Very often after injury, you can miss your old exercise routine. It is worth considering what made it so important to you, so stress reducing, so restorative. It may well have been a function of a number of factors – not just the physical movement of the exercise itself. As such, it is valuable to identify those factors so that you can re-set them into your life–whether you are exercising or not.
•Maybe you loved being outdoors while you exercised.
•Maybe you enjoyed being away from the house and the family for a definite set time.
•Maybe you loved the music you listened to when you exercised.
•Maybe you really looked forward to sharing time with a group of men or women.
•Maybe you enjoyed doing something that was meditative.
A closer look at your favorite exercise routine expands stress reduction into many dimensions.
Work on a Different Goal
•There is something to be said about multi-tasking when it helps you not watch water boil or injuries heal.
•A valuable and often unexpected stress reducer that some people set in motion when they come to know that they will be away from the gym, road or bicycle club for awhile, is a completely different goal in tandem with their rehab and recovery.
•Be it taking or giving a course, refinishing furniture, making jewelry, planning a trip or studying a language, the competitive goal is valuable in that it offers a need to look away from the injury and loss.
•It offers a new and different perspective on the need and use of time.
Re-Open Your Drawer of Resiliency Traits
A valuable source of stress reduction that we often overlook can be found in the consideration of our own resiliency traits. Be it intelligence, creativity, social skills, spirituality, musicality, artistic ability, love of nature or culinary creations—any of these can be used as entrée to activities and relationships that refuel us, validate our talents and heal in many ways.

The Gift of A New Worldview
It is difficult to journey from our necessary illusion of control and body mastery through injury, disruption, stress and healing without personally changing.
For many, the change is beyond physical and psychological restoration.
It is a sense of humility for what we can and cannot control and a sense of gratitude for what we can.
It is a respect and appreciation for those whose suffering persists.
It is the gift of a worldview that you can rarely find in easy places.

Whether you are struggling in your job, in your relationship with your mate, or friendship with your brother, we all try to manage our struggles in life. But, sometimes we think we let things go, but we don’t. We harbor bad feelings and tiny irritabilities along the way can turn into a full-blown explosion.Here are tips to consider to avoid blowing your top:

What’s a bad day? – Am I having a bad day, or a bad life?
When a bad day becomes a bad week then turns into a bad month, we need to step back and take a good look. If months turn into a year you are heading toward a blow-up. Keep track of your bad days and when they turn into weeks take a good long hard look at your life and why it’s bad. When you do that, you may recognize a pattern. Little things set you off in your day, and your week. Know what they are and find a way to problem solve so a day doesn’t turn into a year and results in a snap.

Communicate – I put up with it…why?
Often times we “put up” with things that irk us. Why are you putting up with it? It’s only a temporary mental solution that is inevitably going to fail. Putting up will put you out. Stop putting up with things you don’t need to, and communicate with the person or situation in your life that causes you to do so.

Waiting for the rumble – It’s not that bad, right?
Wrong. Sometimes we are living in a lull and it’s not bad enough to do anything about it, but, it’s not getting better. Don’t wait for the rumble of a storm to approach before you take care of business. Your blow up will be bad. Know that. It can only be tempered with acute attention and awareness to your life.
Blowing up usually has terrible consequences. Don’t let your life become a bad consequence because of your lack of effort. You know the signs of a storm. You know yourself, so you owe it to yourself to take time to understand what sets you off, even if it’s minor. Minor becomes major fast. Remember that.
Erica

Diagnosis and its Discontents: The DSM Debate Continues

By Ronald W. Pies, MD | March 29, 2013

Dr Pies is Editor-in-Chief Emeritus of Psychiatric Times, and a professor in the psychiatry departments of SUNY Upstate Medical University and Tufts University School of Medicine. He is the author of The Judaic Foundations of Cognitive Behavioral Therapy; a collection of short stories, Ziprin’s Ghost; and a poetry chapbook, The Heart Broken Open. His most recent book is The Three-Petalled Rose: How the Synthesis of Judaism, Buddhism, and Stoicism Can Create a Healthy, Fulfilled and Flourishing Life (iUniverse: 2013).

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“As to diseases, make a habit of two things—to help, or at least to do no harm.”
–Hippocrates, Epidemics, in Hippocrates, trans. W. H. S. Jones (1923), Vol. I, 165 [italics added]
“An agnostic is someone who doesn’t know, and di- is a Greek prefix meaning “two.” So “diagnostic” means someone who doesn’t know twice as much as an agnostic doesn’t know.”
–Walt Kelly, Pogo
A funny thing happened to me on the way to the New York Times “Sunday Dialogue”—I made myself unclear.1 This is not supposed to happen to careful writers, or to those of us who flatter ourselves with that honorific. So what went wrong.

In brief, I greatly underestimated the public’s strong identification of psychiatric diagnosis with the categorical approach of the recent DSMs. But whereas my letter to the Times was indeed occasioned by DSM-5’s release in May, my argument in defense of psychiatric diagnosis was not a testimonial in favor of any one type of diagnostic scheme—categorical, dimensional, prototypical2 or otherwise. (I hope the present essay will save “The Committee to Boycott DSM-5” some time!). Each of these diagnostic schemes has its advantages and disadvantages. My personal preference is for a prototype-based schema, for everyday clinical use; and a DSM-type categorical schema for purposes of psychiatric research.2 The categorical approach is usually preferable for most research studies, because it provides precise “cut-points” for entry criteria. But we should not suppose that our diagnostic categories necessarily “carve Nature at its joints,” in Plato’s famous phrase. Indeed, as philosopher Alexander Bird quipped, “The classifications of botanists do not carve nature at its joints any more than the classifications of cooks.”3 DSM-IV itself understood this, and explicitly recognized its own limitations. In the often-ignored introduction, DSM-IV stated:
Making a DSM-IV diagnosis is only the first step in a comprehensive evaluation. To formulate an adequate treatment plan, the clinician will invariably require considerable additional information about the person being evaluated beyond that required to make a DSM-IV diagnosis.4(pxxv)

And—while I have not seen the text—I expect that DSM-5 will be similarly cautious. I would add to this cautionary note the need for more than a symptom-based approach to diagnosis. In order to gain a full and deep understanding of the patient, psychiatrists must also delve into the patient’s “world view”—her way of “being in the world.” The phenomenologists therefore focus on the structure and contents of the patient’s conscious experience.5,6 For example, does he or she invariably experience the world as a hostile and threatening place? Are all her relationships perceived as threats to her autonomy? And how do the patient’s spiritual concerns and beliefs shape his world-view?7 From the psychodynamic perspective, as Dr James Knoll observes, what are the wishes, fantasies, experiences, fears, and desires that shape the patient’s conscious and unconscious life? (written communication, March 26, 2013). Such depth-psychology is unlikely to be captured in either a categorical or a dimensional “diagnosis” of the patient. Deeper understanding demands that we enter into the patient’s way of “being in the world.”
Physicians, of course, have been reaching diagnostic conclusions since the time of Hippocrates—quite without the help of diagnostic manuals. The word “diagnostic”—notwithstanding Walt Kelly’s sardonic jab—may be understood as “knowing (gnosis) the difference between (dia-)” one condition and another. So, when we recognize that a patient’s auditory hallucinations are related to complex partial seizures and not a psychosis, we are engaging in diagnosis.
A diagnosis, however, need not name a “disorder” or disease. Our diagnosis of Mr. Smith may be, “Perfectly happy chap—nothing to treat here!” Sometimes, in my consultative practice, a patient would ask me for my diagnosis, and I might reply, “Well, I think you have a serious problem with regulation of your mood and your anger. I can give you a formal name for your condition, but I’d rather hear what kind of information you would find most helpful.” That, too, is a “diagnosis”—though not necessarily the “CPT code” an insurance company would accept.
Kudos and brickbats

Reaction to my letter was decidedly mixed. While most colleagues were very supportive, many comments in the blogosphere ranged from the dismissive to the abusive. Predictably, some critics trotted out the old war horses of anti-psychiatry (were these not led out to pasture decades ago?): psychiatry is not “scientific,” because it doesn’t have verifiable laboratory tests or biomarkers for its disorders; psychiatric diagnoses are just the “subjective impressions” of the clinician; psychiatry amounts to “totalitarian oppression,” etc.
These canards and slurs have been addressed in many other contexts,8(pp327-353)-10 and I won’t belabor their fallacious assumptions here. Yet psychiatrists should not underestimate the deep currents of public anger and resentment toward our profession, and we must acknowledge that sometimes we have not served our patients well. Psychiatric diagnosis—like diagnosis in other fields of medicine—is sometimes premature. Psychiatric treatments—like many treatments in general medicine—are sometimes ineffective or injurious, despite our best intentions. Patients who have been hospitalized against their will—even when justified on the basis of imminent “dangerousness” and ordered through due process of law—may still have bitter memories of that experience. I truly believe that psychiatry is a force for genuine good—and sometimes quite literally a lifesaver11—but I am also aware of the many challenges we face in building trust with the general public.

The public’s misconception of “science”
One thing was abundantly clear from responses to my letter: the general public still does not understand that “science” is fundamentally a habit of mind and method—not a microbe in a dish, or a shadow on a CT scan. Recently, the British Science Council spent a full year developing a definition of “science.” Their conclusion was radically insightful: “Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence.”12 Specifically, science entails careful and systematic observation; hypothesis-formation; and repeated testing of one’s hypothesis, using empirical methods. In this sense, there is no question that psychiatry and psychology are sciences—though they are also more than that.

A Case of Attention Deficit Disorder?

By H. Steven Moffic, MD | January 14, 2013

Dr Moffic has spent a long career studying and advocating for effective interaction between primary care and psychiatry. He was a recipient of early federal grants devoted to integrating some aspects of training for primary care and psychiatry residents, and to establishing clinical sites that integrated primary care, psychiatry, and anthropology. He also led research in managed care practice that compared the impact of mental healthcare when integrated into general medicine versus behavioral health managed as a stand-alone service. Based on this experience he wrote The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997), the first book of its kind. Dr Moffic continues to present on and write about new clinical models to integrate psychiatry into primary care settings and primary care into specialized mental healthcare settings.

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Your nurse’s note about your next patient indicates that the mother is bringing in her 18-year-old daughter. The note says something about the daughter not doing well in her first year of college. . . maybe she’s doing too much daydreaming. The mother noticed a newspaper article on ADD and had asked her daughter to answer the questions on a simple screening questionnaire. The results suggested that her daughter had ADD.

In recent years, more and more young and older adults are wondering if they have ADD. The media continues to inform the public that most children do not “outgrow” ADD, as was once thought, and that many adults who would have benefitted from therapy as a child were never treated.

Attention to ADD seems to be escalating. It almost seems to be a fad. Doesn’t everyone want to be able to focus better?

Recent headlines read that two football players from the Seattle Seahawks were being banned for 4 games for taking a banned substance,1 which just happened to be Adderall. The players were said to be appealing their case. Would they claim they were using it for ADD, or was it just to get more energy and focus during the football games?2 Medications like Adderall are controlled substances. You wonder once more about whether there is any possibility of getting into trouble for wrongful prescribing.

The best diagnostic tool for ADD is sophisticated psychological testing, but this is too expensive for most people. And even if such testing could be paid for, it is difficult to find psychologists expert enough to do the neuropsychological testing.

Well, here goes, you think. If you are uncertain about your diagnosis and or treatment plan, you can always check with one of your consultant or referral psychiatrists.

Dr: Mrs. Y, how are you? I gather you wanted me to see your daughter today.

Mrs. Y: Yes, thanks. She’s not doing as well as we think she can in college. We did one of those newspapers and on-line questionnaires about ADD and Annie has most of the symptoms we read about.

Dr: Sure, we can look into that. Annie, do you want your mother to stay in here as we talk?

Annie (pauses): OK. This isn’t personal stuff. I just can’t seem to focus. I’m daydreaming or getting distracted. And the classes are harder.

Dr: That’s helpful to have your mother here, because often the perspective of others helps with the diagnosis. (You might now be thinking of a medical disorder or an anxiety or depressive disorder.) You haven’t been more nervous or sad, being away from home now? Or having other new big stress?

Annie: Not really. I’m enjoying college otherwise, and feel that I’ve adapted well. I didn’t think I had something like ADD because I wasn’t hyperactive and did well in school until now.

Dr: That can still fit. Especially with girls, there’s a more inattentive type of ADD, rather than hyperactive. And, if you’re smart and emotionally engaged in what you’re studying, you can find creative ways to learn well-enough and easily-enough—at least up to a point.

Annie: That does fit! I’m pretty well-focused right now, maybe because I’m so concerned with what’s wrong and there are no distractions in this office. (Brief pause). And, you know, I have to admit – and I did tell my mother this—and thanks, mom, for not saying anything— that my roommate gave me an Adderall pill, and I could focus better for quite a while afterwards.

Dr: That makes sense, Annie, and I can understand why you did that, but that response isn’t diagnostic of ADD. You can give Adderall to most anybody and they will temporarily focus better. The question is whether that response will continue over time if the medication is continued at a given effective dose, and whether there are any significant side effects. If misused, Adderal can be a dangerous medication.

Mrs. Y: And didn’t I read somewhere that there are risks to the heart, especially among children?

Dr: Yes, I think that’s correct, though I’m not completely up-to- date on the literature.3 As far as I know, it’s safe with adults unless they have some sort of cardiovascular disease. Apparently, you don’t, Annie, but I’ll schedule that as part of your medical work-up. We should do a baseline medical check-up anyway, today.

Mrs. Y: So, will you prescribe something now, before she returns to school?

Dr: (feeling a bit anxious) If you both agree, we can do a trial, unless you want to get more verification with psychological testing or see a psychiatrist who specializes in treating people with ADD, although that will delay things and cost more.

Annie: Is it safe to try without more evaluation?

Dr: Yes, if we go slow, but sure. And, with most of the medications that can help ADD, it doesn’t take too long to see.

Annie: OK. Good.

Dr: What we can do is to start a short-acting stimulant like Ritalin, and then gradually increase the dosage, unless there are side effects and/or no more improvement. You can return to see me in a week. Then if this seems helpful, we can even try a more convenient pill that will last most of the day, unless you just want to take something like Ritalin on and off.

Annie: Well, maybe on and off for now, when I’m in classes or studying. I don’t think I need its effects to help me socially.

Dr: OK, although you may find out it helps in relationships, too. Let’s try a 5 mg pill. It usually lasts 2 to 4 hours, and you can then repeat the dose. If you notice nothing, try 2 pills at a time, until you return. If we meet within a week, we can probably get something in place before you go back to college. And, at college, you may find they have some special resources for students with ADD that you can check into.

Mrs. Y: But what side effects should we watch for? I suppose we can look on-line for that information.

Dr: Well, watch for a little tremor, feeling restless, and maybe a headache. If you get something like this and it is mild, stick with the medication. Later, whatever dose you may stay on, we’ll check your blood pressure to be sure it doesn’t increase.

Mrs. Y: OK. Can we call your office in the meanwhile?

Dr: Sure, especially if you read or hear something that concerns you. Everything about today’s visit will be on the computer, so even if I’m not available, our nurse may be able to help. By the way, don’t take a pill within several hours of going to sleep, because it may make it more difficult to sleep. Any other questions (you notice you have exceeded your allotted time. . . )?

Mrs. Y and Annie: No.

Dr : If this option doesn’t work well, there are other ways to try to help. (On the way out, you remind yourself to brush up on ADD.)

How frequently do you find yourself prescribing antibiotics for inpatients with schizophrenia and related psychotic disorders during hospitalization? While working as a psychiatrist on our acute care inpatient unit, I asked myself this question and came up with an (anecdotal) answer of, “For somewhere between 1 of 5 and 1 of 3 patients.”I had treated patients with comorbid urinary tract infections (UTIs), cellulitis, and occasionally, upper respiratory tract infections (URIs). The more I thought about my answer, I was struck by 2 observations: (1) I have diagnosed schizophrenia and comorbid UTI in males, but the combination is more common in females; and (2) some patients with comorbid infections had relapsed despite good adherence with medications and in the absence of other specific psychosocial stressors. For these patients, psychosis often improved following antibiotic treatment for the infection, often without need for changes in psychotropic medications.
In my clinical training, I had learned to screen vigilantly for UTIs in geriatric patients with psychosis in the context of dementia or delirium. But it turns out that my simple clinical observation is backed up by quite an intriguing literature regarding infections and schizophrenia.
Prenatal maternal viral and bacterial infections1 and childhood viral encephalitis2 are risk factors for psychotic disorders. Infection with Toxoplasma gondii is highly prevalent in patients with first-episode psychosis.3 In patients with schizophrenia, there is also an increased prevalence of HIV infection and infectious hepatitis.4 Importantly, schizophrenia is also associated with increased mortality from all infectious diseases, including pneumonia and influenza.5
Our research team explored whether the association between UTI and acute psychosis extends to patients with primary psychotic disorders. Even with my clinical experience of treating comorbid UTIs on the acute care inpatient unit, the results were striking. In a sample of 57 acutely relapsed inpatients with DSM-IV schizophrenia, 35% of the patients (38% of females and 28% of males) had a UTI on admission, detected by urinalysis and urine microscopy.6 After controlling for effects of gender and smoking status, our patients with schizophrenia were almost 29 times more likely to have a UTI than controls. By contrast, there was no association with UTI between a sample of 40 stable out­patients with schizophrenia and 39 controls. Furthermore, only 40% of the UTIs in acutely relapsed inpatients in our study were recognized and treated with antibiotics during hospitalization.
For clinicians, this association raises the possibility of infections as a potentially modifiable risk factor for relapse in schizophrenia. Acute psychotic relapse is common and relapse prevention represents an important treatment issue in schizophrenia. Illness relapse is associated with adverse outcomes, including increased treatment-resistant symptoms, cognitive decline, and functional disability. Given the myriad of associations between schizophrenia and infections, this relationship appears to be more than just a “chance” finding, and it may be relevant to the pathophysiology of illness relapse. Our findings also highlight the potential importance of monitoring for comorbid infections in acute inpatients with schizophrenia, because fewer than half of the UTIs in our study were recognized and treated during hospitalization. Untreated infections pose an increased risk of morbidity and potentially increase the duration of hospital stay