APA Releases List of Five Uses of Psychiatric Medication to Question

Continuing the Conversation about Choosing Wisely: The American Psychiatric Association Releases List of Five Uses of Psychiatric Medication to Question

Joel Yager, MD, 

Professor, University of Colorado School of Medicine

Chair of the APA Council on Quality Care

Recently the APA released a list of “Five Things Physicians and Patients Should Question” in Psychiatry as part of the Choosing Wisely^® campaign, led by the ABIM Foundation. The list identifies five specific evidence-based recommendations that can help physicians and patients make wise choices about their care.

The APA list contains the following five recommendations:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.
• Don’t routinely prescribe two or more antipsychotic medications concurrently.  
• Don’t prescribe antipsychotic medications as a first-line intervention to treat behavioral and psychological symptoms of dementia.    
• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.   
• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

Why was this list created?

This list was created to help clinicians and patients reduce the number of times that certain medications are routinely prescribed in situations where other initial treatments might be preferable, and where risks of these medications’ harmful side effects could be decreased or avoided. 

Does this list apply to the care of children or adolescents?

For any indication and for any patient, the potential harms of treatment must be weighed against the potential benefits. For the Choosing Wisely campaign, the APA recognizes that for some young patients in some circumstances an antipsychotic medication may turn out to be an appropriate choice of treatment if the clinical benefits are judged to outweigh potential harms after the patient receives appropriate initial evaluation and will receive ongoing monitoring. However, the APA advises physicians and patients to question the routine use of antipsychotic medications in children and adolescents for clinical circumstances where these medications are not endorsed by available clinical practice guidelines or lack explicit FDA approval indications for their use.

Why the Choosing Wisely Campaign?

The facts driving the Choosing Wisely effort are well known: Current health care practices in America spend too much money on unnecessary tests and procedures that do not benefit patients and that may even cause unintended harm. According to a report from the Institute of Medicine, up to 30 percent of health care delivered in the United States is wasteful. Providers and economists agree that these costly unnecessary practices threaten America’s ability to provide the highest quality of care possible to all patients.

Through the Choosing Wisely campaign and by publishing this list, the APA hopes to spark conversations between its members and patients about whether certain tests and treatments are really necessary or the best ones to choose. The APA joined the campaign because it recognizes that physicians have professional, moral and ethical responsibilities to take the lead in addressing these challenges.

While the APA has taken a bold step in identifying and developing the list, our work doesn’t stop here. Over the coming months and years, the APA will be working with the ABIM Foundation, Consumer Reports, and a variety of other Choosing Wisely campaign stakeholders to raise awareness of these lists and to make them available to patients and the public at large.     

Learn more about Choosing Wisely and read all the lists released to date at www.choosingwisely.org.

www.choosingwisely.org

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Cyberbullying: an Update on Intimidation in the Digital Playground

By Arshya Vahabzadeh, M.D.

Follow @VahabzadehMD

American Psychiatric Association Leadership Fellow

Resident Physician in Child and Adolescent Psychiatry at MGH/McLean/Harvard Medical School

What is cyberbullying?

Cyberbullying is bullying, intimidation, and harassment that happens with the aid of electronic technology. Cyberbullying can happen through text messaging, social media, and emails. The boundaries of cyberbullying continue to expand as new communication technologies emerge.

Cyberbullying is emerging as a major problem, with new research from the Bureau for Justice Statistics revealing that 9% of teenagers aged 12-18 have reported being cyberbullied in a given year.

Female students are more likely to experience cyberbullying. The most common forms of cyberbullying include harassment by text or instant messaging, or the posting of hurtful information on the internet. Despite the high levels of cyberbullying, an adult is notified in only a quarter of cases.

How is cyberbullying different than traditional bullying?

Cyberbullying can continue 24 hours a day and is not dependent on location. While traditional bullying often requires the physical presence of a bully, a child can be cyberbullied at anytime and anywhere they are in contact with communication technology, including their own cell phone. There may be no “safe” zone and this may intensify the level of distress that the cyberbullying can produce.

Material such as digital pictures, text messages, or social media posts designed to hurt an individual can be rapidly distributed to a large group of people. Often it is difficult to find out the source of the information, giving a degree of anonymity to the cyberbully.

Harassing and intimidating material, once distributed through digital means are also much more difficult to remove. Often videos or pictures may stay indefinitely available through digital means.

What are the effects of cyberbullying?

People who are cyberbullied are thought to be at risk of the same consequences of traditional bullying. These effects include increased depression, decreased self-worth, hopelessness, and loneliness. There is some evidence to suggest that being cyberbullied may result in suicidal feelings in 20% of teenagers, a higher rate than in traditional bullying.

What can we do about cyberbullying?

Promote Good Digital Habits

• Keep your children informed about the risks of the technology they are using.
• Engage your children in a discussion on how to best deal with cyberbullying by formulating a plan for dealing with text messages or other digital content that is upsetting to them. Children should be made to feel as comfortable as possible in discussing their experiences with trusted adults.
• Review and teach them about privacy settings for digital media. Talk to them about limiting the amount of private information they share about themselves.
• Tell children to keep their passwords safe and not to share them with friends or people they don’t know.

Take Action

• Approach a child if you notice signs of changing behavior, especially if it is happening when they are using the computer, their cell phone, or any other communication device.
• Consider discussing the situation with the suspected bullies’ parents, the child’s school, and other organizations they may be involved in.
• Identify and archive the cyberbullying material, it may be useful when contacting the Internet service provider, cell phone company, or in severe circumstances, the police.
• Consider closing down targeted social media accounts or changing cell phone numbers.
• Some cyberbullies thrive on obtaining a reaction, avoiding replying to messages or engaging with the cyberbully may also be useful in some situations.

Public Service Announcement:
Where can I get more information?

More on cyberbullying from stopbullying.gov and girlshealth.gov  and onguardonline.gov

More on bullying

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What You May Not Know about ADHD

By Ahmed Khan, MD 
@AhmedRazaKhanMD

Attention-Deficit/Hyperactivity Disorder (ADHD) is an illness that affects many people living in this country. It's reported that 7-10% of Americans have ADHD - a disorder that alters one’s attention and concentration in a negative manner. 

Oftentimes, parents and children conceptualize this lack of attention and concentration leading solely to problems at work and school. Unfortunately, ADHD has a number of adverse health outcomes that you may not be aware of. Hopefully my post will help you understand the various adverse health outcomes associated with ADHD.

Substance Use and Smoking: Several studies show a significantly increased rate of substance abuse disorders and smoking in patients with ADHD. This could be due to the increased impulsivity apparent in many people with ADHD.

Sleep Problems: It's pretty clear that ADHD leads to dysregulation of sleep. This is often displayed by resisting sleep at bedtime, difficulty falling asleep once in bed, and problems awaking in the morning.

Car Accidents: Did you know people with ADHD have a higher risk of traffic violations and car accidents? Some studies found this to be due to increased risk-taking behavior and poor frustration tolerance.

Physical Injuries: Studies have also revealed children with ADHD can have almost twice the injury rate as those without it (20.4% vs. 11.5%). A study looking at an insurance data base of over 100,000 people, from children to adults aged 64, found that those with ADHD had 1.55 times greater chance of injury versus those without ADHD.

Risky Sexual Activity: Studies suggest that the impulsivity, poor self-esteem, and risk-taking behaviors that are prevalent in people with ADHD can lead some to engage in risky sexual behavior and increase their risk of receiving and transmitting sexually-transmitted diseases.

Obesity: There is no direct correlation between ADHD and obesity yet, but some studies show that children with ADHD are more likely to be obese than those without it. This could be due to various reasons, but researchers are looking at genetic similarities between the two conditions which could provide more insight in near future. 

So, did you learn something new about the often misunderstood ADHD? I hope my post provided you with a better idea of the toll that ADHD can take on one's life. With a thorough diagnosis and proper treatment by a trained psychiatrist, a person with ADHD can greatly limit these adverse events and, many times, avoid such negative health issues all together. 

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How to Help Loved One w/ Postpartum Depression?

By Nada Stotland, MD, MPH

Postpartum depression simply means depression occurring after childbirth---any time from days after to up to a year after the birth of a baby. 

When we diagnosis depression---at any time in life---we don't mean the kind of "down" mood everybody experiences from time to time. We mean a real disease that causes symptoms including interference with sleep and appetite; thoughts of death; guilt; lack of interest in the activities of life; inability to feel pleasure---every day for weeks. It's a very painful, but fortunately very treatable, disease. 

Depression is particularly painful for a mother with a new baby. People are often telling her that this should be the happiest time of her life, that she should appreciate her good fortune in being able to conceive and bear a child when many others have so much trouble. 

Other people---and even the new mother herself--may also confuse the symptoms of depression with the inevitable interruptions of sleep and meals by the demands of a newborn and the common concerns about being a good mother. 

It's important to distinguish postpartum depression from postpartum psychosis. Postpartum psychosis begins within days after birth. The new mother with postpartum psychosis is seriously agitated, unable to relax. She is haunted by irrational ideas about herself and the baby--ideas, for example, that God wants her to send the baby to heaven or that the baby is a devil of some kind---and sometimes by irresistible urges to harm the baby. Postpartum psychosis is rare; it occurs after far fewer than 1% of births. It is a medical emergency. 

When postpartum psychosis is suspected, the new mother must be seen immediately by a physician, preferably a psychiatrist. 

Postpartum depression seems to be caused by a combination of genetics, the abrupt changes in hormones after birth, physical exhaustion, and the strain of adapting to a new role and the reactions and demands of friends and family. Postpartum depression is often a continuation of depression that was present, but not recognized, during pregnancy. In our society, we take it for granted that we shower medical and social attention on the pregnant woman---frequent visits to the obstetrician, baby showers---when all she has to do for the baby is to take good care of herself. 

After her baby is born---when she is exhausted from labor and delivery and when she has responsibility for the 24/7 care of a helpless infant--all that attention falls away. She may live far away from supportive family members. She may either have to go back to work before she is ready, or may feel isolated, away from the familiar duties and social contacts of the workplace. Usually there are no postpartum visits from nurses, and quality childcare is expensive and hard to find. Postpartum depression, although it occurs everywhere in the world, may be more common in our country for those reasons (occurs in about 15% of U.S. births). 

Postpartum depression can be successfully treated with psychotherapy and/or medication. Group therapy reassures the new mother that she's not alone and others are going through same issues. Family and friends can play major roles in the new mother's recovery. They should remind her that she is not responsible for her depression, and she can recover from it. 

Helping with her baby can be useful, but it's not a good idea to take over baby care completely; that will just make her feel more inadequate. 

It's better to take care of the mother herself. Offer simple diversions, like an outing, but without expecting them to treat depression. We don't want to make her feel unappreciative. Sympathize with her grief over missing the joys of new motherhood. Remind her of all the lovely things she planned and did for the baby before it was born, and point out what a good mother she is working to be. 

Depression makes people feel helpless and hopeless, so she may need encouragement to get the professional care she needs. Friends and family can help by contacting her family physician or obstetrician and by locating a mental health professional available to treat the new mother. With proper care, she will probably start to feel better within a few weeks.

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Need to relax? How meditation can help you stay calm

By ElanaMiller, M.D., Resident Psychiatrist, UCLA Follow @ElanaMD 

Arshya Vahabzadeh, M.D., Resident Psychiatrist, Harvard University/Mass.General/McLean

Follow @VahabzadehMD

For many of us, daily life doesn't lend itself well to relaxation and reflection. We find ourselves running around from task to task. We wake up hurriedly, rush to work, get bombarded with calls and emails throughout the day, speed through meals, try to fit in a workout, and schedule time with friends / spouses / kids. . . which leaves us with little to zero time for ourselves. It's a tough way to live, day in and day out. Meditation is one tool we can use to find some calm.

Put simply, meditation is the practice of focused, mindful attention. One starts focusing on the breath, following the breath in and out. Inevitably, we get distracted, and our mind wanders: Did I feed the dog? That was so annoying what Bill did at work today. Oh, I'm getting distracted, I'm so bad at meditating! 

This is okay - and even expected. When the mind wanders we simply bring the focus back to the breath. When a very strong emotion of physical sensation calls our attention away, we can make that sensation the new object of meditation, watching as it gets stronger or weaker. When the sensation isn't so strong anymore, we return to the breath. Training the mind is like training a puppy - when it runs away, we bring it back, over and over.

So how does this simple practice help cultivate relaxation in daily life?

1. Meditation helps you stay in the present

So much of our time is spent in the past and the future that we rarely are present in the moment. We spend so much time remembering, regretting, planning, and worrying that we miss the moments of joy and spontaneity that are right in front of us.

Meditation helps train the mind to focus on the present moment. Instead of regretting things we can't change, or worrying about bad things that haven't even happened yet, we can learn to accept and appreciate our current circumstances.

2. Meditation teaches you how to redirect your mind

Sometimes we get caught up thinking (obsessing!) about a big problem, and we have the idea that if we just think hard enough we can solve it - but that's rarely the case. The best insights usually come in those "in between" moments - in the shower, when you're driving, when you're enjoying a cup of tea.

But even if we're aware that worrying and ruminating won't solve our problems, we don't know how to shut our minds off. Meditation can teach you this skill! Like any skill, it requires practice. But with dedicated practice, even five or ten minutes a day, we can learn how to let go of worries and redirect our mind to the present moment.

3. Meditation teaches you to be more aware of your thoughts and emotions

Too often we have a thought and react to it without considering why. We get angry at someone and start yelling. We hear a critical remark and get defensive. Instead of taking our thoughts and assumptions as facts and immediately reacting (possibly saying or doing something we'd regret), we can pause and consider what's really going on. 

Maybe we feel angry but are really hurt. Maybe we feel defensive because part of what the other person said is true. Meditation teaches us to be more aware of our deepest thoughts and emotions, so that we can choose to react to conflict in a wise way.

4. Meditation helps you tolerate difficult emotions

Some people have a misunderstanding that meditation somehow helps you get rid of all negative emotions - after all, isn't that what enlightenment is?

The truth is, though, that painful emotions like sadness, anger, and shame are part of being human. We make things worse when we fight against these emotions or blame ourselves for having them.

Instead of getting caught up in the narratives of our emotions, we can learn to experience them just as they are. Anger can feel like a tightness and burning of the chest. Shame can be a flushed feeling of the face and churning feeling in the stomach. Meditation teaches us to experience these emotions without getting caught up in the story.

Does Meditation really work? What are the basic elements?

According to a government survey, almost 1 in 10 adults use meditation each year to help them cope with conditions such as anxiety, depression, pain, stress, insomnia, and symptoms associated with chronic illness. It is believed that meditation can improve the ability to focus attention and improve how we handle our emotions. These improvements may have broader benefits for our daily lives including personal relationships.

Researchers have linked meditation to some beneficial changes in the human body. Some experts have suggested that meditation may dampen down our body’s sympathetic nervous system, the system responsible for our “fight or flight” response. There is also continuing interest on how meditation can alter different parts of the brain, although the answer remains unclear and research is ongoing.

The National Center for Complementary and Alternative Medicine, a federally funded research organization, suggests that there are several elements that are important when you are trying any type of meditation. These elements include finding a quiet location, a comfortable posture, being able to focus your attention, and having an open attitude to the experience.

Interested in learning more about how meditation can help you lead a happier and more relaxed life?

Check out zenpsychiatry.com where Elana Miller, M.D., blogs about integrative strategies to be happy, live well, and fulfill your greatest potential. To get tips and helpful advice sent straight to your inbox, sign up for her free newsletter.

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THE DIVIDE: Transgender Mental Health Disparities - why they exist & what we can do…

By Anthony Dobner, Medical Student
Reviewed by Claudia Reardon, M.D.

The Basics…

A transgender individual is someone with the desire to live and be accepted as a member of the opposite sex. This can be accompanied by the wish to make his or her body as congruent as possible with the preferred sex. A transsexual individual is someone who has taken measures, through surgery or hormone therapy, to achieve their desire of living and being accepted as a member of the opposite sex. In general, transgender individuals prefer to be addressed using pronouns and other culture norms that are congruent with their preferred gender identity.

Mental Health Issues Affecting Transgender Individuals…

Lesbian, gay, bisexual, and transgender individuals (LGBT) in general are 2-3 times more likely than the general population to suffer from anxiety and depression. This is probably because anyone who experiences discrimination is more likely to have anxiety or depression.

Almost half of transgender individuals report having attempted suicide. Transgender individuals are also more likely to suffer from substance abuse compared to the general population. Interestingly, transgender individuals who are accepted by their families are less likely to abuse substances. Also, transgender individuals who undertake hormone therapy are less likely to report depressed mood.

Barriers…

Many LGBT individuals experience unintentional discrimination from health care professionals. This may be because they use behavior and language that make assumptions about sexuality. Examples of this include assuming a lesbian or transgender woman does not need to receive education on condoms because she will “never have to worry about getting pregnant.” Research indicates that other barriers include:

• Homophobia
• Assumptions of heterosexuality (or homosexuality in transgender individuals)
• Real or perceived lack of confidentiality
• Lack of training
• Insurance policies and laws that create loopholes for employers that do not provide coverage to domestic partners.

5 Tips for Overcoming Disparities & Receiving Quality Health Care...

SEEK friends and allies who love and accept you for who you are no matter what. Research shows that having a strong support system decreases depression and suicidal ideation.

ASK friends and allies what resources are available in your community. Some communities have LGBT-specific clinics. Smaller communities may not have these services, but there may be individual clinicians who have experience working with LGBT patients.

TALK to your doctor! He or she should care about you and want you to be happy and healthy but may not know the best way to address your unique needs. Don’t be afraid to bring up the issue if they don’t. Refer them to this excellent resource for clinicians who want to improve the accessibility of their clinics for transgender individuals.

ENCOURAGE your doctor to use gender neutral language during your visit, and on surveys, signs, and intake forms.

SUPPORT efforts in your community to pass laws that change language in insurance policies that make it difficult for LGBT individuals to receive quality care.

For more information, check out this great resource for transgender individuals on a variety of health care issues.

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What You Should Know About Binge Eating Disorder: 3 Doctors Discuss

By Arshya Vahabzadeh, M.D. Follow @VahabzadehMD

Holly Peek, M.D., MPH Follow @PsychGumbo

Mona Amini, M.D., MBA Follow @MonAmiMD

What Causes Binge Eating Disorder? 

With up to 4 million Americans having binge eating disorder, it's a significant health issue for our nation.  Binge eating disorder has a wide variety of causes, and sometimes it can be caused by several different reasons, even in the same individual.

To understand why someone develops binge eating disorder, we need to recognize binging triggers. These triggers often result in binging behavior, and they are often negative feelings or thoughts toward body shape, weight, or food. Triggers to binging may also include worry, anxiety, difficult relationships with loved ones, or even boredom. Some people binge eat because it helps them numb these feelings in the short term. But later, they find the binge eating to be harmful to their own self-perception.

Sometimes dieting may be a major factor for binge eating. While dieting tends to happen after binge eating disorder has started, missing meals or not eating enough can lead to binging episodes. If left untreated, binging behaviors become more and more ingrained and harder to control.

Depression has also been linked to binge eating disorder. People who have depression or have been depressed in the past are more at risk. Binge eating is also higher in people who have bipolar disorder or anxiety disorder. Some evidence suggests that it may be more common in people who have addictions to recreational drugs.

Binge eating disorder may be more common in families where the condition is already present. Therefore it seems that our genetics are also an important factor to consider. Researchers continue to explore more scientific explanations on why binge eating disorder happens including studying the neurochemicals and pathways of the brain. 

How is Binge Eating Disorder Treated? 

The treatment goal for binge eating disorder focuses on binge eating and weight control. Treatment also addresses conditions that commonly occur with binge eating disorder, including depression, difficulty in work or relationships, and distortions in body image.

Treatment outcomes are generally good with psychological treatment often being more helpful than medication based management, although in some cases both are used. There is evidence that cognitive behavioral therapy (CBT), a type of talk therapy, is successful in treating binge eating disorder. Multiple research studies point to benefits with its use. CBT works by disrupting the “binge-diet cycle” by promoting healthy and structured eating patterns, improving body shape and weight concerns, and encouraging healthy weight-control behaviors.

Another type of talk therapy used in treatment is interpersonal psychotherapy (IPT). IPT helps people express and manage their negative feelings without turning to food to cope. Research shows that 20 sessions of CBT and IPT can provide improvements for more than 70% of people with binge eating disorder.

Reading self-help guides like Overcoming Binge Eating by Christopher Fairburn in combination with therapy sessions can also have substantial benefits.

Medications may also be used to ease binge eating disorder symptoms. Serotonin selective reuptake inhibitors (SSRIs), commonly used for anxiety and depression, have been found effective for reducing some binge eating disorder symptoms as well. SSRIs can help with depression often occurring in people with binge eating disorder. Continued research will examine how other medications, including anti-obesity medication and mood stabilizers, may also treat people suffering from binge eating disorder. 

What Should I Say to My Friend / Family Member Who is Suffering?

It is important to take the approach of talking to your loved one with serious intent. Though some people can overcome eating disorders, seeking professional help usually has more lasting positive results. In seeking the care of a professional, both the patient and his/her family benefit from the information presented by the doctor. The first step to talking to someone you care about who has an eating disorder may feel nearly impossible.

• Patience is key. Being patient and learning facts about eating disorders will guide you (and your loved one). Due to the complexity of binge-eating disorders, communicating your concerns regarding their eating habits and other behaviors will initiate a cumulative effect.
• Be prepared for a range of responses. Rejection, denial, anger, and shame are just some of the emotions that your loved one may express when you approach her/him for the first time.
• Avoid judgment, criticism, and simple solutions to disorder. Instead, you should provide encouragement and compassion regarding their feelings and relationships. Your concern and support may be enough for them to seek professional help but know that this is not guaranteed.
• Recognize binge eating may be just tip of the iceberg. Understanding that binge eating disorder, or any eating disorder, involves food and weight issues as mere symptoms of a deeper and more complex behavioral problem will help your loved one realize they need to acquire healthier coping tools.
• Know when to ask for assistance. Don't forget that health professionals can alleviate some of the imminent issues that may need to be treated before full recovery is possible. 

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Talking to Men about Mental Health

By Sarah Johnson, M.D.

While visiting with my dad for Father’s Day last month, I was inspired to write about the importance of talking to the male species about mental health. When I was a medical student coming home over Christmas (hyper-vigilant about all potential medical issues as most med students are), I noticed a mole on my father’s forehead that looked cancerous to my post-dermatology rotation eyes. After nearly a year of “reminders” to go to the doctor and have it checked, he finally agreed and luckily it was benign.

Now that I’m a psychiatrist, I often get calls from patients and friends who are worried about the mental health of men in their lives (fathers, husbands, boyfriends, brothers, friends) but have met resistance when trying to talk about their concerns with these men.

Reflecting on my personal challenge of getting one of the important men in my life to have something as minor and non-stigmatized as a mole checked out, I would like to offer some suggestions to help start the mental health conversation with a man or anyone you believe may be suffering from a mental illness.

• Use “I” statements. People are less likely to feel attacked and be open to suggestions when approached with “I” statements. For example, “I am concerned that you seem down, and I would like for you to consider seeing a counselor because I care about you,” instead of “You seem depressed and need to see someone.”

• Present mental health conditions such as anxiety and depression as medical conditions - which they are (your brain is part of your body). Unfortunately, many individuals stigmatize mental illness and do not like to see themselves as suffering from one. One of my favorite questions to ask those who resist getting care for their mental health is, “Would you seek help for high blood pressure or diabetes?” Of course you would!

• Offer factual evidence regarding mental health conditions. Many patient resources are available at www.psychiatry.org/mentalhealth (check out the Let’s Talk Facts brochures you can print). It is helpful to realize that psychiatric conditions are common. Remind him that he’s not alone.

• Be encouraging and reassure him that he won't be seen as “less of a man” if he seeks help. Seeking help is a sign of strength.

• Ask him to consider seeking help rather than telling him. Most people are more likely to follow through with a task they view as unpleasant when they are asked rather than told.

• Be mindful and also take care of your own mental health needs. It can be very stressful and tiring to be close to someone suffering from an untreated mental illness. Use your family and friends for support and don’t be afraid to seek help yourself if you find you’re struggling with excessive worry.

We are lucky to live in a time when there are effective treatments readily available for mental health disorders. Try these tips the next time you start the mental health conversation with the important men in your life. Your support and care can make a big difference in his recovery. 

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Is It Time For A Timeout? 4 Tips For Managing Your Anger

By Uyen-Khanh Quang-Dang, M.D., M.S., Resident Psychiatrist, UCSF School of Medicine &

Arshya Vahabzadeh, M.D., Resident Psychiatrist, Emory University School of Medicine Follow @VahabzadehMD

When does anger become a problem?

Anger is an emotion that everyone experiences at some point in their life. Anger in and of itself is not a bad thing. Anger becomes a problem when the anger itself, or how we express the anger, causes problems in our lives. For example, anger can be felt too intensely, too frequently, or it can be expressed inappropriately, leading to harm to oneself or to others. Poorly managed anger can result in damage to our mental health, physical well-being, social relationships, and employment.

When we feel angry, the most important consideration is how we manage this emotion. In many cases, we may manage anger in a similar way to people around us. Many children learn how to deal with anger from observing their parents and other family members. The way that we respond to anger may also be as a result of what happens when we become angry; it may help us to get things that we want, thereby reinforcing our behavior. There are many practical strategies which may be adopted to help overcome problems with anger management. Here are four tips on how to deal with anger:

#1 Make a list of events or situations that trigger your anger. It can be a helpful perspective to notice that each of us get triggered by different things – while some of us may get outraged by an inconsiderate roommate who leaves dishes in the sink, others may instead fume while driving in congested traffic. Having a better awareness of triggering events will help you to better manage and possibly prevent your anger.

#2 Take a timeout. Timeouts aren’t just for kids – they are an essential anger management strategy that should be in everyone’s anger management “toolbox”. Basically, timeouts help us think instead of impulsively reacting in the heat of the moment. Timeout strategies can range from taking a few deep breaths and taking note of how your anger is experienced in your body, to leaving the situation that is causing the anger. You can have a pre-arranged agreement where any of the parties involved can call a timeout during an upsetting interaction and return to the conversation at a later point.

#3 Engage in Exercise! We all know that exercise is good for your physical health, but it’s also great for your mental and emotional health as well. Regular exercise can be an effective preventative anger management strategy. In addition to cardiovascular exercise, try yoga – either in live classes or through videos available on iPad apps and YouTube videos if live classes are too expensive.

#4 Use the A-B-C-D Model. The A-B-C-D Model (developed by Albert Ellis) helps us to change our underlying irrational beliefs that perpetuate our anger.

“A” stands for an activating event that triggers our anger.

“B” stands for our beliefs about the activating event. What do you tell yourself in reaction to the triggering event? What are your beliefs and expectations of others? For example, when a friend arrives late, you may tell yourself, “This friend is a bad friend. If he respected me, he wouldn’t be late. I can’t be friends with this person.”

“C” stands for consequences – emotional responses about the triggering event based on your self talk. For example, you may feel sadness or contempt.

“D” stands for dispute, where you examine your beliefs related to the event, identify any irrational beliefs, and dispute them with more rational or realistic ways of reacting to the activating event. The point of this model is to replace maladaptive self-statements that exacerbate anger with adaptive self-statements that reduce anger and help you have a more realistic reaction to the event.

While these tips may be helpful, you may need support from a counselor or mental health professional. Keep in mind that you don’t have to deal with anger all on your own. There are effective anger management therapies available in individual and group settings that can help you learn healthy ways of managing anger. 

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Boston Marathon Runner & Psychiatrist Shares Personal Story of Patriots' Day 2013

Special guest post by psychiatrist Brent Forester, M.D.

"People here need to talk about what they have been through,” says Dr. Forester. “I spoke with my medical students after the race, and they all wanted to do something to help. I told them that the injured, their families, and first responders all need a lot of emotional support.”

Monday, April 15, 2013 began as a sunny, chilly early spring day...a perfect respite to our long, dark, cold winter that brought challenges to the months of training required to run a marathon. My wife, Kim, was giving me a hard time for the training schedule I was keeping, perhaps secretly knowing what I did not yet realize: I was destined to run Boston in 2013.

What began as a challenge from Kim to run a half marathon in 1999 had morphed into a full blown passion and time consuming avocation: running long distance races to fundraise for the Alzheimer’s Association and this year, a mentoring program for future geriatric psychiatry clinicians. But after a personal best in the Chicago Marathon in October 2012, I had decided to spend 2013 focusing on a more “normal” distance of 13.1 miles, setting a goal of running 50 half marathons by my 50^th birthday (35 down with three years to go!).

Perhaps by fate, one of my running buddies was felled by a foot injury and offered me his number for Boston in late February, with only six weeks to go until race day. Luckily, I had been training with this most incredible group of friends, all neighbors and fellow runners, meeting five days a week at 5:40 a.m. (or earlier!) at the corner of Ledge and Mossman in Sudbury. Sadly, a year of brainstorming had yet to generate a team name.

On Saturday before the marathon, our families and friends gathered for a festive night of pasta to celebrate all the hours and miles of running, lack of sleep, painful legs, and cross-training efforts that included early morning TRX and spin classes and a Tuesday night yoga group for runners (minus the see-through Lululemon wear). Anticipation and excitement for Monday, Patriots’ Day, was at a peak.

The Boston Marathon is known for Heartbreak Hill, the cheering Wellesley women, the rowdy and inebriated Boston College students, the biker bar patrons on the Hopkinton/Ashland line yelling in their black leather outfits drinking beers on a Monday Morning. Where else does this happen? The Boston Marathon is all about the crowds. They are loud, deep, diverse, and hysterically funny with signs and outrageous costumes. The same fans cheering on the world’s elite, yell even louder for the “normal” charity and barely qualified runners, distributing beer, oranges, pretzels, and even Vaseline on a stick to reduce the inevitable burning and blistering skin.

Monday, April 15^th was a tough run for me. It was warmer in the sun than expected, and a pacing problem during the first half of the race left me weary climbing Heartbreak Hill. But a running buddy neighbor of mine ran a mile with me through the Newton Hills, and then I took off, determined to complete this race in less than four hours. It would be very close. The Red Sox crowd had just spilled into Kenmore Square when I arrived, and they were loud…but I stayed focused, down and up Commonwealth Ave. crossing beneath Massachusetts Ave., then a right on Hereford, a surprisingly tough hill up to Boylston, and a left hand turn down the long, endless 800 meters to the finish line near Dartmouth.

3:58:46. I did it! Exhausted. About to break out into tears reflecting my emotional sense of accomplishment and relief, when I heard behind me a massive explosion. I ducked. We shook. And then I looked behind me at a cloud of smoke and debris. “Oh my God,” I thought immediately of the many lives that had instantaneously ended or changed forever. But it was all very confusing: Where were my wife and daughter? I’ve got to get out of here. Where were the water and the silver warming cape? Was that a terrible accident or… And then the second bomb, panic; we were under attack.

Where was the next bomb going to strike? I borrowed a cell phone, “Kim, there was a bomb at the finish line; I am fine. Where are you?” She was driving on Huntington and Dartmouth, a block away…oh no. “Stay away from the Westin, do not park; drive to the corner of Boylston and the Commons.” How come everyone was so calm? The volunteers handed out our water, the silver cape, food, and the precious finisher’s medal, and then I left on Berkeley to the buses for my yellow bag and the port-o-potties, but were they even safe?

I do not recall well the four block walk to that meeting spot; it seemed endless, and there was no Kim when I arrived. And no cell phone service. Then, three of our psychiatry residents came walking across the street, calmly and not sure of what was happening. They are a godsend of emotional support with cell phones. I am shivering. I have not eaten or even sipped any water. An hour passes; finally Kim and my daughter arrive, unscathed. We were safe.

And then the “what ifs” race through your mind: What if I had taken my usual port-o-potty break or not pushed through those last few miles to break the four hour mark? I cannot really think about these realities.

Will the marathon, Patriots’ Day, Boston, Fenway Park, and all the stadiums hosting our beloved local sports teams ever be the same again?

The timing of the bombs was such that the charity runners were crossing the finish line, the four hour gang, not the elites or the sub-three hour athletes, but the everyday guy and gal who train though ice and snow for this moment, to cross the finish line in Boston cheered on by hundreds of thousands of loud supporters, strangers who seem to care about you and want to see you reach your goals whatever they may be. They were the targets of the Boston bombers.

Boston strong, the theme that has risen from the ashes of this tragedy, carries us forward and brings us closer together as a community of runners, spectators, first responders, healthcare professionals, firefighters, and police. We are all together now as one, culminating in the heroic 24 hour siege and Boston area lockdown, another surreal event capturing the intensity, exhaustion, and ultimately relief of a region.

Finally, at 8:42 p.m. on April 19^th, it is over. In a boat on Franklin Street, five blocks from my old Watertown apartment. The local hero is a regular guy who spies the blood and then the suspect.

It’s now time to go to sleep. I'll be up in five hours to meet my running crew for a slow six miles around our neighborhood, running for the first time since Hopkinton and sharing our stories, our grief, our anger, and our triumphs. This is the way we process our emotions and move forward. We still need a name for our crew; Sudbury Strong may work.

The American Psychiatric Association's website has resources for coping with traumatic events and how to help children.

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