Posts tagged dsm
Posts tagged dsm
Psychiatry a Key Player in Effective Health Reform, APA Says
By Megan Brooks, Medscape
An American Psychiatric Association (APA) work group on healthcare reform outlines key issues facing the field of psychiatry and offers recommendations for action in a report released today.
"Throughout this recent period of change, the focus on behavioral health, which includes mental illnesses and substance use disorders, has begun to shift from a compartmentalized provider approach to an integrated delivery system linking behavioral health and primary care services. This has led to a renewed awareness that mental health is critical to overall health and wellbeing," the report notes.
The work group was established by the APA board of trustees and chaired by Paul Summergrad, MD, chair of the Department of Psychiatry at Tufts University School of Medicine, Boston, Massachusetts, and president-elect of the APA. The group met numerous times during an 18-month period with input from the board of trustees, the assembly, and relevant councils and components.
Critical Role for Psychiatrists
According to the report, as healthcare reform expands insurance coverage and extends parity of benefits for behavioral health needs, it will be “critical to monitor new developments, models of care, and payment methodologies, and to enforce compliance to ensure patients and families receive the best quality of care.”
"Psychiatry must play a central role in the new patient care and delivery and payment models. These models must include an expanded emphasis on behavioral health," the report says.
The report also notes that integrated care models “hold promise” in addressing many of the challenges facing the healthcare system, but “more research is needed to build their evidence base, explore their financial impact and define the role of psychiatrists, primary care providers and other behavioral health providers.”
"Psychiatrists, alongside primary care providers, must play a major role in formulating integrated care solutions by defining their role and benefit to patients," the report recommends. It encourages the National Institutes of Health, the Centers for Medicare and Medicaid Services, and other federal agencies to continue their ongoing research and evaluation of these models.
The work group also tackled issues of financing of psychiatric care, concluding that fundamental payment issues, including implementation of parity laws, “must be addressed” to achieve the coverage, access, and new care delivery goals of the Affordable Care Act. This includes the economic impact of integration, Medicaid reimbursement policies, Medicare fee schedule distortions, fee for service payment methodologies, and the structure and management of payment.
IT Challenges Ahead
They conclude that payer and systems’ budgeting mechanisms must include management of psychiatric care within the broader medical healthcare budgets, while protecting core services for those with mental illnesses.
On the subject of quality performance and measurement, the group notes that healthcare reform has accelerated the development and use of performance indicators and recommends that the behavioral health field “become more fully engaged in the development of performance measures.”
"The field must lead on quality metrics for psychiatric care and their consistent adoption across payers and other regulatory entities. This can be accomplished by identifying a few priority areas for improvement, as well as establishing a series of goals covering various areas of practice," the group advises.
On health information technology (HIT), the group says several “challenges” lie ahead in the behavioral health field. The success of integrated care models is particularly dependent upon the deployment of electronic health records and patient registries, the report says.
The report concludes that HIT “should be a priority focus of communication and education for the psychiatric field, healthcare providers in general, patients, policy makers and the public.”
The report also addresses workforce, work environment, and medical education and training. Its key finding: “Without changes in the workforce, the field will have difficulty meeting the increased demand for specialty psychiatric physician services. Curriculum, accreditation standards, new Continuing Medical Education (CME) trainings and collaboration with primary care practitioners are needed to meet newly insured patient needs as well as provide for new care delivery models.”
The recommendations of the work group “serve as a springboard for discussion and action within the field of psychiatry,” the authors say.
APA. Integrated Care. Full article
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Interview: Borderline Personality Disorder, Fear Of Abandonment, And Relationships
By Richard Zwolinski, LMHC, Casac & C.R. Zwolinski
Today we’re talking with therapist Lisa Bahar about Borderline Personality Disorder and how it can affect relationships.
Welcome, Lisa. BPD makes it difficult to be involved in a stable, healthy relationship. What are some kinds of behaviors that people with BPD have that are a challenge to a relationship?
A person with BPD desires and responds to structure, predictability and communication. When there is lack of predictability, anxiety or fear of abandonment can potentially set in, and disruptive and unstable behavior can escalate into controlling and aggressive reactions.
These reactions can occur when their partner’s behavior even slightly differs from what is expected. For example, if a partner, who is “always” on time is 15 minutes late, breaking a pattern of predictability, feeling of anxiousness increase. These feelings trigger feelings of abandonment, which can then lead to disproportionate reactions. These feelings are all rooted in fear.
For example, when the partner shows up, the person with BPD might accuse them of cheating, leaving or have a plan to leave them. Or the person with BPD might act out with behaviors used as a way to give the message that the other is being “punished”. These might include not speaking, slamming doors, pouting, and so on. They all communicate I am angry.
Tell us more about what this type of manipulative behavior looks like?
Manipulation is a way to create control. If it is unconsciously motivated through a conscious act, such as an outward behavior like tantrums, crying, threatening, and attacking, it is what I call sloppy manipulation.
Or, it can be sophisticated manipulation. When manipulative behavior takes the form of crafty questions which are intended to trap the other person into saying something that they really did not know mean to say, or give an answer that they really didn’t realize they were giving.
The individual with BPD does not always use direct and healthy communication skills and instead acts out behaviorally and/or communicates indirectly.
Are people with BPD consciously manipulating others? Sometimes, it seems like these manipulative behaviors are habits or knee jerk reactions rather than conscious emotional manipulation. Can you explain what is really going on?
Exactly, these behaviors can be habits. Generally until awareness sets in, the individual may not know that they are unconsciously motivated. Once awareness sets in, and insight is gained, usually through various mindfulness practices, then there can be an opportunity for behavior change.
Behavioral change is the real test of insight. Of course, the individual with BPD needs to actually know how to change and that is where the Dialectical Behavior Therapy skills become helpful.
What are the underlying reasons and/or mechanisms driving manipulative behavior in someone with BPD?
Fear of abandonment. Also, a feeling of disconnect particularly with a sense of self. This happens when an individual feels they don’t have an identity without the other there to define them. When the partner demonstrates behaviors that are interpreted as “leaving” by an individual with BPD it can feel like a loss of identity.
Fear of abandonment can feel almost like death to the individual with BPD since it is a kind of “death of self.” That is why some people with BPD have a pattern of jumping from relationship to relationship—they do this in order to sustain sense of self.
How does Dialectical Behavior Therapy help those with BPD resolve these issues?
Dialectical Behavior Therapy is a set of skills that are very concrete and clear. They allow the individual to decrease emotionally intense reactions by providing a way to decrease the symptoms.
DBT teaches a set of skills including:
Core Mindfulness skills which help to calm the mind.
Interpersonal Effectiveness skills which are designed to help you effectively communicate what you want, express feelings and say no clearly.
Emotional Regulation skills which help you manage and deal with emotions rather than emotions controlling you.
Distress Tolerance skills which help you be able to handle crisis situations more effectively and deal with reality and it’s terms, as opposed to resisting what reality is.
What are some suggestions for people who want to overcome manipulative behaviors that drive people away?
The first part is that the person has to want the change—they have to be the one to do the work! Of course, someone else such as the person the client is in a relationship might also want the change, and that is fine—but it can’t be the primary motivation.
Next, there must be a willingness and dedication to learning skills that can help. For example the client must be willing to practice the skills he or she learns from DBT. They have to understand: This is a not a quick fix, but the development of a pattern of life skills.
What advice do you have for family, friends and colleagues who are trying to cope with these behaviors and who, understandably, don’t want to feel attacked or manipulated?
Education is key.
Significant others must be aware of their part in interactions and reactions and must learn how best to respond. DBT is most effective if all family members are involved. Each person involved should practice a self care plan. It is so important for clients and family members to not point the finger at any one person.
Thanks for speaking to this topic.
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Children who have lots of bad dreams and nightmares are at a greater risk of suffering psychosis, a study has shown.
Research showed that for 12-year-olds, nightmares more than tripled the occurrence of psychotic symptoms such as hallucinations and delusions.
And children aged between two and nine who were most plagued by bad dreams were 56 per cent more likely to experience later episodes of psychosis than those whose sleep was undisturbed.
However, scientists have moved to reassure parents that nightmares are common in young children, and that they usually grow out of them.
Lead researcher Professor Dieter Wolke, from the University of Warwick, said: ‘We certainly don’t want to worry parents with this news; three in every four children experience nightmares at this young age.
'However, nightmares over a prolonged period or bouts of night terrors that persist into adolescence can be an early indicator of something more significant in later life.'
The study, part of a wide-ranging health investigation called the Avon Longitudinal Study of Parents and Children (Alspac), recruited more than 6,700 children.
By the age of 12, around a quarter of the group reported having nightmares in the previous six months.
Fewer than one in 10 experienced night terrors, which are often signified by a loud scream and the individual sitting upright in a panicked state, though unaware of any of the involuntary action.
Nightmares and night terrors are often confused but very different forms of sleep disturbance.
The former tend to occur during the shallower REM (rapid eye movement) part of the sleep cycle, when most dreaming takes place.
Night terrors happen during deep sleep, causing the unaware sleeper to sit bolt upright in a panicked state, thrash about or scream.
The children were assessed six times between the ages of two and nine. Higher rates of nightmares during this period were found to increase the likelihood of psychosis.
Children who reported persistent nightmares at only one of the assessment time points were 16 per cent more likely to experience adolescent psychotic episodes than those who had no nightmares.
Three or more nightmare periods were associated with a 56 per cent increased risk.
At 12 years of age the risk of psychosis was more than tripled by having nightmares and almost doubled by night terrors.
Lucie Russell, from the charity YoungMinds, which campaigns to improve the mental health of children and young people, said: ‘This is a very important study because anything that we can do to promote early identification of signs of mental illness is vital to help the thousands of children that suffer.
'Early intervention is crucial to help avoid children suffering entrenched mental illness when they reach adulthood.'
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For some people their psychoses or nervous breakdowns come at the transition between youth and adulthood. It may be in the final years of school or the moving away from home to go to university or a new job in the big city. It was like this for many members of my family although not for me. My psychoses were to do with hormones and body transitions. But there could be a similarity I suppose, in terms of moving from one mind/body state into another.
I’ve heard from other parents who describe similar altered mind states for their sons and daughters which are translated into disorders by psychiatrists who are keen to pin the tail on the donkey or the diagnosis on the psychotic. Quickly followed up by anti-psychotics, forcibly given if resistant, then if refusing the schizo disorders label, seen as anosognosia or lacking insight. A no-win situation whatever way you look at it. I got away with it in 1978 and 1984, after painful induced childbirth blew my mind, because back then there wasn’t perinatal psychiatry or drug cocktails to hand. A narrow escape.
But it’s got harder and harder I think to get out of a psychosis without being tied in to the system and tied up with psychiatric drugs. Especially if you have resisted the label and challenged the system on behalf of others. In 1995 my oldest son had a transitional breakdown or psychosis, after leaving home to go to university. He went into the local acute psychiatric ward voluntarily and wasn’t looked after well. We lived at that time very near the hospital, in fact on the farm that used to belong to the asylum. I kept a close eye on my son and made complaints about his treatment when necessary.
I had head-to-head disagreements with my son’s psychiatrist who wanted to pin a disorder label on him, something to do with “cyclical depression”. This was because the anti-psychotic, as with me, depressed my son. I advocated on behalf of my son, we resisted the labels, he recovered after a year, got back on with his life and has never looked back. I joked at the time that if ever I had to engage with them as a psychiatric patient then they’d have me straitjacketed. Then in 2002 I found myself going in voluntarily to the same psychiatric hospital, in a menopausal psychosis, to be chemically straitjacketed.
I knew that the game was up when I tried to leave and was detained for 72 hours. The “heavy” (large male nurse with arms folded) at the emergency door meant I wasn’t going to be able to make a run for it. I’d have to swallow the drugs and did so under duress, inwardly defiant. Within 24 hours the drugs started to take effect and I was entering never never land. A place I never did want to go back to.
I had enjoyed my childhood but didn’t want to return there. I had no choice. The psych drugs entered my brain and psyche, gradually taking away my decision-making abilities, maturity and life experience. Some folk might like to be free from responsibility but I really don’t like the feeling of infantilisation. Having to rely on psychiatric “professionals” and be dependent. It made me depressed and resulted in psych drug cocktails, my continued resistance giving way to disorder labels. I didn’t like being Peter Pan and preferred to get back to being Wendy.
“All children, except one, grow up. They soon know that they will grow up, and the way Wendy knew was this. One day when she was two years old she was playing in a garden, and she plucked another flower and ran with it to her mother. I suppose she must have looked rather delightful, for Mrs Darling put her hand to her heart and cried, ‘Oh, why can’t you remain like this for ever!’ This was all that passed between them on the subject, but henceforth Wendy knew that she must grow up. You always know after you are two. Two is the beginning of the end.”
― J.M. Barrie, Peter Pan
As a mother of 3 sons who have experienced psychoses and psychiatric treatment at transition between youth and adulthood, I didn’t want them to be caught up for too long in the Peter Pan effect of psychiatric treatment. I’d been there, got the tee-shirt, and had known other folk in the past who’d got stuck on the psych drugs which, to my mind, were to be avoided if possible, if not then tapered when possible. I didn’t ask psychiatrists about tapering and did it myself when I could, although there was a community psychiatrist in 1985 who supported my coming off psych drugs.
I’ve found out though that my sons have to make their own journeys through never never land in the way that suits them. I’d prefer if they got out quick. Easier for me I suppose because I really don’t like having to engage with psychiatry in any shape or form. Never did. Ironically I now find myself in a continual engagement, up to my neck in it, on groups and committees, sitting next to them at events.
Even last week I attended an event and a female psychiatrist chose to sit next to me and tried to advise and direct at every opportunity. At one point, when I was tweeting, she said that she hoped I wasn’t tweeting about her. I wondered if she thought that my world revolved around her? Godlike. I soon put her right. But I couldn’t put her off and she stuck like glue. I just had to ignore her and get on with my own agenda. I’m used to doing this with psychiatrists.
And now we have psychiatrists who are also neuroscientists and claim to have found the holy grail, the proof of mental illness by examining the brains and eyes of people who have been on psychiatric drugs for many years and been forcibly labelled with schizophrenia. There’s a group doing this at Aberdeen University in Scotland. I sent an Email to them the other week but I haven’t had a response and likely won’t get one. I’d read some of their research a while back and their “guinea pigs” are people who have been in the psychiatric system for some time. It’s obvious, to me anyway, that the psych drugs will have caused brain and eye changes. It stands to reason.
If they could scan our brains when we first enter a psych ward with a psychosis and show us the broken bits then I might believe them. When I broke my fibula in 3 places in 2005, not long after coming off maximum doses of venlafaxine, which causes bone loss, I was shown the X-ray of my fractured bone by the consultant. Not a pretty sight but proof of the damage and justification of the 6 inch metal plate insertion and screw going through the ankle at right angles. About 6 weeks in plaster and in a wheelchair followed. I had to get the plaster changed when my foot swelled up.
The screw got taken out about 2 months later, by local anaesthetic, and the consultant prior to the op showed me the foot long screwdriver that he said had been made in Sweden. He recommended I let him know if I could feel any pain and they would give me more anaesthetic. During the procedure he told me he was having a bit of difficulty finding the end of the screw. I trusted that he would eventually get a grip. And so he did. The screw came out, the plate stayed in. I got physiotherapy and got back to walking and driving again. A collaborative relationship with the consultant doctor from start to finish. If only it could be like that with consultant psychiatrists.
I did wonder how I managed to shatter my fibula when only walking downstairs, after a job interview in a library. I got the job and started after getting back on my feet. Fortunately a test for osteoporosis was negative. The mystery of the leg break was solved recently when I read some information online about venlafaxine and bone loss:
“Bone Fractures: Epidemiological studies show an increased risk of bone fractures in patients receiving serotonin reuptake inhibitors (SRIs) including venlafaxine. The mechanism leading to this risk is not fully understood.” Medsafe NZ, page 10
“Conclusion: The increased bone loss associated with high dose venlafaxine may possibly be a result of synaptic inhibition of serotonin uptake” Journal of Negative Results in Biomedicine, June 2010
I want to see alternative ways of working with people in and through a psychosis that don’t involve psychiatric drugs and coercive treatment towards those of us who are unbelievers in the biomedical model of mental illness. Help us transition through our psychoses with our psyches intact or restored. Whatever trauma or crisis brought us to the point of emotional collapse please don’t retraumatise us, replacing new pain with old. Let us come to terms with our humanity and human frailty.
“Peter was not quite like other boys; but he was afraid at last. A tremor ran through him, like a shudder passing over the sea; but on the sea one shudder follows another till there are hundreds of them, and Peter felt just the one. Next moment he was standing erect on the rock again, with that smile on his face and a drum beating within him. It was saying, “To die will be an awfully big adventure.”― J.M. Barrie, Peter Pan
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From the related article, Sawyer, A. (2011). Let’s talk: a narrative of mental illness, recovery, and the psychotherapist’s personal treatment. Journal of clinical psychology, 67(8), 776-788:
This article describes the author’s experience in psychotherapy, beginning as a suicidal teenager with a dismal prognosis, through 5 years of hospitalization, including shock treatment that erased most memory before age 20, through an Ivy League education, and successful professional career. Retraumatization triggered by reading her hospital records 40 years later adds a unique perspective, as the author watched, but could not control, a process within herself that she regularly addressed as therapist with her own patients. Healing aspects of relationships with three psychodynamic psychotherapists (two psychiatrists and a social worker), credited with her survival and success, are examined. A dramatic interview with Harold Searles, her psychiatrist’s supervisor, and its role in her recovery is considered. Lasting lessons concerning the healing aspects of psychotherapy, the effects of repressed early trauma encountered late in life, the need to counter stigma, and the value of personal psychotherapy are discussed.
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[Article of Interest] Mental Health and Insurance: Commonly Misunderstood Illnesses
When people think of care and treatment for mental illnesses, often times the more severe disorders such as depression or schizophrenia come to mind, and other lower-level chronic disorders get overlooked. The truth is there are several other mental illnesses that affect and impact a person’s quality of life and misinformation associated with them often makes it difficult for patients to navigate the world of insurance coverage for their illnesses.
Attention Deficit Hyperactivity Disorder (ADHD) is a condition characterized by inattention, hyperactivity, and impulsivity. It most commonly affects children and adolescents, but can persist into adulthood.
“This disorder is considered a global learning disability — as opposed to a specific learning disability in reading or math — because it affects children’s ability to learn and successfully function in multiple areas,” said board certified neuropsychologist Karen Postal.
A Time health article addressed the myth of ADHD being “just another childhood behavior problem” and the need to recognize it as “a chronic serious health problem that deserves a lot more attention than it has received.”
About 40% of children with ADHD have other disorders occurring as well, Postal said, which include specific learning disabilities such as dyslexia, mood disorders like anxiety, and behavioral disorders. This makes it difficult to diagnose ADHD. Often, ADHD is correctly diagnosed, but the co-occurring disorder is missed.
“Treatment for just the ADHD is therefore not effective in solving the child’s academic and daily problems,” she said. “Many other times, ADHD is mistaken for one of the other disorders. As an example, a child with a primary anxiety disorder might be restless, inattentive, and unable to complete tasks — not because they have ADHD — but because they are very anxious.”
Insurance industries will typically cover a diagnostic evaluation, which consists of a doctor talking to the child and parents. The parents and the child’s teachers will also fill out symptom checklists. However, Postal said this clinical interview based diagnosis often misses the mark because many insurance companies won’t allow access to neuropsychological testing of cognitive function, mood, and other specific learning disabilities when the concern presented is attention problems. The lack of clear knowledge often leads to ineffective treatment for those with ADHD.
Autism is the most debilitating in a group of disorders called Autism Spectrum Disorders (ASDs). It is a complex developmental disorder of brain function in which sufferers have difficulties with communication, social skills, connecting interpersonally, and getting stuck in routines. Symptoms are usually recognized in children between two and six years of age, but because symptoms vary, children displaying any of the symptoms should receive further evaluation. Comprehensive assessment is critical to planning treatment, so it’s imperative to get an accurate diagnosis and early identification of autism.
“Individuals on the autistic spectrum might have intellectual or other cognitive limitations, mood disorders, or attention problems that complicate treatment,” Postal said. “Understanding that a child has high intellect but profound problems understanding language will allow therapists to interact with them in a useful way. Many states require insurance companies to fund neuropsychological assessment for autistic individuals. This ensures that treatment plans are targeted to the child or adult’s specific set of difficulties.”
Identifying a Need for Changes in Insurance Coverage Laws
With the difficulty patients often have of receiving diagnosis and treating mental illnesses such as ADHD and autism, getting the proper insurance coverage can often seem like a nightmare.
Though some states require insurers to provide coverage for the treatment of autism, there are arguments as to who should be responsible for the care of autistic patients — some say parents, others say the school system.
Though Utah has the highest prevalence of autism in the nation, it’s one of the states that does not require insurance to cover treatment for autism.
But lawmakers are looking to change that. Recently a bill was introduced that mandates autism spectrum disorder be included in the state insurance code. This will require health benefit plans to cover up to $50,000 annually for children with autism who are younger than nine and up to $25,000 for children ages nine to 18 for treatment of the condition.
Unfortunately, laws themselves don’t always solve the problem, as is the case in New Jersey, where gaps in existing laws have prevented children from receiving expensive autism therapy. Family members cited different reasons: problems finding providers, a lack of widely accepted medical billing codes, and struggles dealing with insurers.
No matter the issue, families and patients should stay persistent in dealing with insurers for mental health claims.
A few tips to remember:
-Read Your Policy. It’s important to become familiar with your insurance policy and determine what mental health benefits are included — inpatient and outpatient care, serious or non-serious diagnoses, etc.
-Learn the laws in your state. Contact local mental health associations and ask about your state’s parity laws in regards to mental health.
-Provide written documentation, when necessary. For example, ADHD may vary in severity. If a patient has an extreme case, they may need to show written documentation to validate required services.
Pulling the Curtains Back on Eating Disorders
Eating disorders are some of the most challenging and misunderstood types of mental illnesses. Common misconceptions of eating disorders are that they only affect women; they’re a choice, not a disease; and that a person must be severely underweight or skinny to have one.
Eating disorders are classified by symptoms with the most common types being anorexia nervosa, bulimia nervosa, and those that do not meet the same criteria, which are diagnosed as EDNOS (Eating Disorder Not Otherwise Specified). Binge-eating disorder is an example of an EDNOS.
According to the National Alliance on Mental Illness, diagnosis of eating disorders are made by trained professionals based on symptoms. However, eating disorders are often underdiagnosed, which can delay necessary treatment and sufferers often receive inadequate insurance coverage for treatment.
“Eating disorders are the most deadly of all mental illness. The death rate from anorexia is higher than any other diagnosis,” said Jessica Setnick of the International Federation of Eating Disorder Dietitians. “Physical symptoms are the most common killer — cardiac arrest or other heart complications — and suicide is the second most common reason for death. That is why eating disorders must be treated with both medical care and mental health care.”
Beginning in 2014, mental health and substance abuse services must be included in the essential benefits package covered by all new health plans, but mental health parity provisions do not require coverage for all mental illnesses. This means that health plans may be able to decide whether or not to cover eating disorders.
Though some states require private insurers to cover eating disorders on the same basis as other mental health policies, the majority of states do not have this requirement.
“The way insurance companies are set up is a huge barrier. In most companies, the mental health benefits are administered by a totally different company — someone your carrier has contracted with,” Setnick said.
For example, a patient may have insurance with Blue Cross Blue Shield, but mental health care coverage through United Behavioral Health. The patient may not realize this until he or she tries to access benefits, which can really complicate things in the case of eating disorders.
Then it’s the back and forth. The medical side sees the diagnosis of the eating disorder and sends the claim to the behavioral side, which only covers psychiatrists, counselors and psychiatric nurse practitioners so they don’t know what to do with a claim for seeing a dietician.
Though it can get discouraging, it’s important patients and family members stay persistent in getting the health coverage they need for eating disorders.
Setnick offers the following tips:
-Don’t be deterred by being told you have X number of visits. Even if patients are told they have three covered visits with a dietician or counselor — which is not going to be adequate 99% of the time — they should make an appointment anyway. After three visits, the professional team, including the doctor, can get the payer’s permission for more covered visits on a case-by-case basis based on the patient’s progress and continued needs for care.
-Consider “ad-hoc” coverage. When looking at in-network providers, be sure to check credentials. If none of the doctors, dieticians, or counselors are specialists in eating disorders, patients should tell their insurance providers they want “ad hoc” coverage for specialists. This means finding eating disorder specialists in the area and telling the insurance company to cover the out-of-network provider at in-network rates with the in-network deductible because there are no in-network specialists available within the patient’s network.
-Keep records of everything. Patients should take note of everything they’re told over the phone, especially if it is contradictory to information they were told previously. If any problems arise later, the notes will be very valuable.
-Get benefits personnel involved, if necessary. If the insurance company is impossible to communicate with, the patient s
Persistence is key when attempting to get the proper coverage for mental illnesses that are often misunderstood. Patients and their families will help themselves by staying educated on current laws and policies and remaining cool, calm, and collected when dealing with insurance claims.
For more mental health news, Click Here to access the Serious Mental Illness Blog
For more mental health news, Click Here to access the Serious Mental Illness Blog
Avatars Ease Voices for Schizophrenia Patients
By Lorna Stewart
BBC Health Check
Use of an avatar can help treat patients with schizophrenia who hear voices, a UK study suggests.
The trial, published in the British Journal of Psychiatry, focused on patients who had not responded to medication.
Using customized computer software, the patients created avatars to match the voices they had been hearing.
After up to six therapy sessions most patients said their voice had improved. Three said it had stopped entirely.
The study was led by psychiatrist emeritus professor Julian Leff, who spoke to patients through their on-screen avatars in therapy sessions. Gradually he coached patients to stand up to their voices.
"I encourage the patient saying, ‘you mustn’t put up with this, you must tell the avatar that what he or she is saying is nonsense, you don’t believe these things, he or she must go away, leave you alone, you don’t need this kind of torment’,” said Prof Leff.
”The avatar gradually changes to saying, ‘all right I’ll leave you alone, I can see I’ve made your life a misery, how can I help you?’ And then begins to encourage them to do things that would actually improve their life.”
By the end of their treatment, patients reported that they heard the voices less often and that they were less distressed by them. Levels of depression and suicidal thoughts also decreased, a particularly relevant outcome-measure in a patient group where one in 10 will attempt suicide.
Treatment as usual
The trial, conducted by Prof Leff and his team from University College London, compared 14 patients who underwent avatar therapy with 12 patients receiving standard antipsychotic medication and occasional visits to professionals.
Later the patients in the second group were also offered avatar therapy.
Only 16 of the 26 patients completed the therapy. Researchers attributed the high drop-out rate to fear instilled in patients by their voices, some of which “threatened” or “bullied” them into withdrawing from the study.
New treatment options have been welcomed for the one in four patients with schizophrenia who does not respond to medication. Cognitive behaviour therapy can help them to cope but does not usually ease the voices.
Paul Jenkins, of the charity Rethink Mental Illness, said: “We welcome any research which could improve the lives of people living with psychosis.
"As our Schizophrenia Commission reported last year, people with the illness are currently being let down by the limited treatments available.
”While antipsychotic medication is crucial for many people, it comes with some very severe side effects. Our members would be extremely interested in the development of any alternative treatments.”
A larger trial featuring 142 patients is planned to start next month in collaboration with the King’s College London Institute of Psychiatry.
Prof Thomas Craig, who will lead the larger study, said: “The beauty of the therapy is its simplicity and brevity. Most other therapies for these conditions are costly and take many months to deliver.
”If we show that this treatment is effective, we expect it would be widely available in the UK within just a couple of years as the basic technology is well developed and many mental health professionals already have the basic therapy skills that are needed to deliver it.”
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[Article of Interest] Good Marriage Can Buffer Effects of Dad’s Depression On Young Children
Story reprinted from materials provided by University of Illinois College of Agricultural, Consumer and Environmental Sciences
What effect does a father’s depression have on his young son or daughter? When fathers report a high level of emotional intimacy in their marriage, their children benefit, said a University of Illinois study.
“When a parent is interacting with their child, they need to be able to attend to the child’s emotional state, be cued in to his developmental stage and abilities, and notice whether he is getting frustrated or needs help. Depressed parents have more difficulty doing that,” said Nancy McElwain, a U of I professor of human development.
But if a depressed dad has a close relationship with a partner who listens to and supports him, the quality of father-child interaction improves, she noted.
“A supportive spouse appears to buffer the effects of the father’s depression. We can see it in children’s behavior when they’re working with their dad. The kids are more persistent and engaged,” said Jennifer Engle, the study’s lead author.
In the study, the researchers used data from a subset of 606 children and their parents who participated in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development.
When their child was 4½ years old, parents ranked themselves on two scales: one that assessed depressive symptoms and another that elicited their perceptions of emotional intimacy in their marriage. Parents were also observed interacting with their child during semi-structured tasks when the children were 4½, then 6½ years old.
“At this stage of a child’s development, an engaged parent is very important. The son’s or daughter’s ability to focus and persist with a task when they are frustrated is critical in making a successful transition from preschool to formal schooling,” Engle said.
Interestingly, depressed mothers didn’t get the same boost from a supportive spouse.
That may be because men and women respond to depression differently, she added. “Men tend to withdraw; women tend to ruminate. We think that high emotional intimacy and sharing in the marriage may encourage a woman’s tendency to ruminate about her depression, disrupting her ability to be available and supportive with her children.”
Depressed men, on the other hand, are more likely to withdraw from their partners. “This makes emotional intimacy in the marriage an important protective factor for fathers,” McElwain said.
The study emphasizes the need for depressed parents to seek support, if not from their spouses, from friends, family, and medical professionals, she added.
[Article of Interest] Psychiatrists under fire in mental health battle
By Jamie Doward
British Psychological Society to launch attack on rival profession, casting doubt on biomedical model of mental illness
There is no scientific evidence that psychiatric diagnoses such as schizophrenia and bipolar disorder are valid or useful, according to the leading body representing Britain’s clinical psychologists.
In a groundbreaking move that has already prompted a fierce backlash from psychiatrists, the British Psychological Society’s division of clinical psychology (DCP) will on Monday issue a statement declaring that, given the lack of evidence, it is time for a “paradigm shift” in how the issues of mental health are understood. The statement effectively casts doubt on psychiatry’s predominantly biomedical model of mental distress – the idea that people are suffering from illnesses that are treatable by doctors using drugs. The DCP said its decision to speak out “reflects fundamental concerns about the development, personal impact and core assumptions of the (diagnosis) systems”, used by psychiatry.
Dr Lucy Johnstone, a consultant clinical psychologist who helped draw up the DCP’s statement, said it was unhelpful to see mental health issues as illnesses with biological causes.
“On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse,” Johnstone said. The provocative statement by the DCP has been timed to come out shortly before the release of DSM-5, the fifth edition of the American Psychiatry Association’s Diagnostic and Statistical Manual of Mental Disorders.
The manual has been attacked for expanding the range of mental health issues that are classified as disorders. For example, the fifth edition of the book, the first for two decades, will classify manifestations of grief, temper tantrums and worrying about physical ill-health as the mental illnesses of major depressive disorder, disruptive mood dysregulation disorder and somatic symptom disorder, respectively.
Some of the manual’s omissions are just as controversial as the manual’s inclusions. The term “Asperger’s disorder” will not appear in the new manual, and instead its symptoms will come under the newly added “autism spectrum disorder”.
The DSM is used in a number of countries to varying degrees. Britain uses an alternative manual, the International Classification of Diseases (ICD) published by the World Health Organisation, but the DSM is still hugely influential – and controversial.
The writer Oliver James, who trained as a clinical psychologist, welcomed the DCP’s decision to speak out against psychiatric diagnosis and stressed the need to move away from a biomedical model of mental distress to one that examined societal and personal factors.
Writing in today’s Observer, James declares: “We need fundamental changes in how our society is organised to give parents the best chance of meeting the needs of children and to prevent the amount of adult adversity.”
But Professor Sir Simon Wessely, a member of the Royal College of Psychiatrists and chair of psychological medicine at King’s College London, said it was wrong to suggest psychiatry was focused only on the biological causes of mental distress. And in an accompanying Observer article he defends the need to create classification systems for mental disorder.
“A classification system is like a map,” Wessely explains. “And just as any map is only provisional, ready to be changed as the landscape changes, so does classification.”
[Article of Interest] National Institute of Mental Health Abandoning the DSM
by Vaughan Bell
In a potentially seismic move, the National Institute of Mental Health – the world’s biggest mental health research funder, has announced only two weeks before the launch of the DSM-5 diagnostic manual that it will be “re-orienting its research away from DSM categories”.
In the announcement, NIMH Director Thomas Insel says the DSM lacks validity and that “patients with mental disorders deserve better”.
This is something that will make very uncomfortable reading for the American Psychiatric Association as they trumpet what they claim is the ‘future of psychiatric diagnosis’ only two weeks before it hits the shelves.
As a result the NIMH will now be preferentially funding research that does not stick to DSM categories:
Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system.
As an alternative approach, Insel suggests the Research Domain Criteria (RDoC) project, which aims to uncover what it sees as the ‘component parts’ of psychological dysregulation by understanding difficulties in terms of cognitive, neural and genetic differences.
For example, difficulties with regulating the arousal system might be equally as involved in generating anxiety in PTSD as generating manic states in bipolar disorder.
Of course, this ‘component part’ approach is already a large part of mental health research but the RDoC project aims to combine this into a system that allows these to be mapped out and integrated.
It’s worth saying that this won’t be changing how psychiatrists treat their patients any time soon. DSM-style disorders will still be the order of the day, not least because a great deal of the evidence for the effectiveness of medication is based on giving people standard diagnoses.
It is also true to say that RDoC is currently little more than a plan at the moment – a bit like the Mars mission: you can see how it would be feasible but actually getting there seems a long way off. In fact, until now, the RDoC project has largely been considered to be an experimental project in thinking up alternative approaches.
The project was partly thought to be radical because it has many similarities to the approach taken by scientific critics of mainstream psychiatry who have argued for a symptom-based approach to understanding mental health difficulties that has often been rejected by the ‘diagnoses represent distinct diseases’ camp.
The NIMH has often been one of the most staunch supporters of the latter view, so the fact that it has put the RDoC front and centre is not only a slap in the face for the American Psychiatric Association and the DSM, it also heralds a massive change in how we might think of mental disorders in decades to come.
Fountain House is about the power of community. It was created to relieve the loneliness and stigma that affect so many people who are living with serious mental illnesses, like schizophrenia, bipolar disorder, and major depression. Serious mental illness disrupts lives - people lose their jobs, they drop out of school, they alienate their families and friends, and they end up alone.
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[Film of Interest] "Running from Crazy"
Mariel Hemingway Tackles Family History of Suicide, Mental Illness in New Doc
The new documentary “Running from Crazy” chronicles the life of actress Mariel Hemingway, the granddaughter of the great novelist Ernest Hemingway. The film focuses on Mariel’s family history of mental illness and the suicides of seven relatives, including her grandfather and her sister, Margaux.
iThe film is directed by the two-time Academy Award-winning filmmaker Barbara Kopple, whose documentary “Harlan County U.S.A.” has become a classic and won an Oscar in 1977.
By Elyn R. Saks, law professor at the University of Southern California and the author of the memoir “The Center Cannot Hold: My Journey Through Madness.”
Thirty years ago, I was given a diagnosis of schizophrenia. My prognosis was “grave”: I would never live independently, hold a job, find a loving partner, get married. My home would be a board-and-care facility, my days spent watching TV in a day room with other people debilitated by mental illness. I would work at menial jobs when my symptoms were quiet. Following my last psychiatric hospitalization at the age of 28, I was encouraged by a doctor to work as a cashier making change. If I could handle that, I was told, we would reassess my ability to hold a more demanding position, perhaps even something full-time.
Then I made a decision. I would write the narrative of my life. Today I am a chaired professor at the University of Southern California Gould School of Law. I have an adjunct appointment in the department of psychiatry at the medical school of the University of California, San Diego, and am on the faculty of the New Center for Psychoanalysis. The MacArthur Foundation gave me a genius grant.
Although I fought my diagnosis for many years, I came to accept that I have schizophrenia and will be in treatment the rest of my life. Indeed, excellent psychoanalytic treatment and medication have been critical to my success. What I refused to accept was my prognosis.
Conventional psychiatric thinking and its diagnostic categories say that people like me don’t exist. Either I don’t have schizophrenia (please tell that to the delusions crowding my mind), or I couldn’t have accomplished what I have (please tell that to U.S.C.’s committee on faculty affairs). But I do, and I have. And I have undertaken research with colleagues at U.S.C. and U.C.L.A. to show that I am not alone. There are others with schizophrenia and such active symptoms as delusions and hallucinations who have significant academic and professional achievements.
Over the last few years, my colleagues, including Stephen Marder, Alison Hamilton and Amy Cohen, and I have gathered 20 research subjects with high-functioning schizophrenia in Los Angeles. They suffered from symptoms like mild delusions or hallucinatory behavior. Their average age was 40. Half were male, half female, and more than half were minorities. All had high school diplomas, and a majority either had or were working toward college or graduate degrees. They were graduate students, managers, technicians and professionals, including a doctor, lawyer, psychologist and chief executive of a nonprofit group.
At the same time, most were unmarried and childless, which is consistent with their diagnoses. (My colleagues and I intend to do another study on people with schizophrenia who are high-functioning in terms of their relationships. Marrying in my mid-40s — the best thing that ever happened to me — was against all odds, following almost 18 years of not dating.) More than three-quarters had been hospitalized between two and five times because of their illness, while three had never been admitted.
How had these people with schizophrenia managed to succeed in their studies and at such high-level jobs? We learned that, in addition to medication and therapy, all the participants had developed techniques to keep their schizophrenia at bay. For some, these techniques were cognitive. An educator with a master’s degree said he had learned to face his hallucinations and ask, “What’s the evidence for that? Or is it just a perception problem?” Another participant said, “I hear derogatory voices all the time. … You just gotta blow them off.”
Part of vigilance about symptoms was “identifying triggers” to “prevent a fuller blown experience of symptoms,” said a participant who works as a coordinator at a nonprofit group. For instance, if being with people in close quarters for too long can set off symptoms, build in some alone time when you travel with friends.
Other techniques that our participants cited included controlling sensory inputs. For some, this meant keeping their living space simple (bare walls, no TV, only quiet music), while for others, it meant distracting music. “I’ll listen to loud music if I don’t want to hear things,” said a participant who is a certified nurse’s assistant. Still others mentioned exercise, a healthy diet, avoiding alcohol and getting enough sleep. A belief in God and prayer also played a role for some.
One of the most frequently mentioned techniques that helped our research participants manage their symptoms was work. “Work has been an important part of who I am,” said an educator in our group. “When you become useful to an organization and feel respected in that organization, there’s a certain value in belonging there.” This person works on the weekends too because of “the distraction factor.” In other words, by engaging in work, the crazy stuff often recedes to the sidelines.
Personally, I reach out to my doctors, friends and family whenever I start slipping, and I get great support from them. I eat comfort food (for me, cereal) and listen to quiet music. I minimize all stimulation. Usually these techniques, combined with more medication and therapy, will make the symptoms pass. But the work piece — using my mind — is my best defense. It keeps me focused, it keeps the demons at bay. My mind, I have come to say, is both my worst enemy and my best friend.
That is why it is so distressing when doctors tell their patients not to expect or pursue fulfilling careers. Far too often, the conventional psychiatric approach to mental illness is to see clusters of symptoms that characterize people. Accordingly, many psychiatrists hold the view that treating symptoms with medication is treating mental illness. But this fails to take into account individuals’ strengths and capabilities, leading mental health professionals to underestimate what their patients can hope to achieve in the world.
It’s not just schizophrenia: earlier this month, The Journal of Child Psychology and Psychiatry posted a study showing that a small group of people who were given diagnoses of autism, a developmental disorder, later stopped exhibiting symptoms. They seemed to have recovered — though after years of behavioral therapy and treatment. A recent New York Times Magazine article described a new company that hires high-functioning adults with autism, taking advantage of their unusual memory skills and attention to detail.
I don’t want to sound like a Pollyanna about schizophrenia; mental illness imposes real limitations, and it’s important not to romanticize it. We can’t all be Nobel laureates like John Nash of the movie “A Beautiful Mind.” But the seeds of creative thinking may sometimes be found in mental illness, and people underestimate the power of the human brain to adapt and to create.
An approach that looks for individual strengths, in addition to considering symptoms, could help dispel the pessimism surrounding mental illness. Finding “the wellness within the illness,” as one person with schizophrenia said, should be a therapeutic goal. Doctors should urge their patients to develop relationships and engage in meaningful work. They should encourage patients to find their own repertory of techniques to manage their symptoms and aim for a quality of life as they define it. And they should provide patients with the resources — therapy, medication and support — to make these things happen.
“Every person has a unique gift or unique self to bring to the world,” said one of our study’s participants. She expressed the reality that those of us who have schizophrenia and other mental illnemesses want what everyone wants: in the words of Sigmund Freud, to work and to love.
The list links out to comprehensive neuroscience-focused definitions, treatment options, research endeavors, organizations, and more.