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At Shorehaven, we help our clients with almost all kinds of behavioral, emotional, and psychological problems. You may want to understand some of these problems and how we help clients recover.
You may also want to understand how the different mental health professions differ from one another.
In this section, we explain a few major problems.
One major intervention that has become increasingly popular is Mindfulness. We have included a section that gives you some instruction on how to practice mindfulness.
Depression is one of the world’s leading causes of disability. So, let’s learn more about it. Depression is a subject that touches many lives, yet it is often misunderstood.
Depression is not a trait. We never refer to “my depression” as if it were part of a person. Depression is a state of thought, emotion, and behavior that is a result of reaction patterns. States are not traits; they can be changed and can improve.
Let’s begin by letting you know treatment works.
We hope you will take 10 minutes to read through and learn a lot about depression.
Understanding Clinical Depression
Distinguishing Grief, Sadness, and Depression
Major Symptoms of Depression
Types of Depressive Disorders
Theories of Depression Development
Treatments for Depression
Clinical depression is different from the typical sadness or grief we all sometimes experience. It is a pervasive (most situations, most of the time) mood disorder that significantly impacts an individual's daily life. It is not just a fleeting blue mood; it's a deep, persistent feeling of despair, irritability, and/or disinterest that affects how one feels, thinks, and manages daily activities. When we talk about clinical depression, we're referring to several diagnosable conditions where depression is severe and enduring. Clinical depression requires professional intervention.
While grief and sadness are natural, universal experiences, they differ markedly from clinical depression. Grief following a significant loss, ebbs and flows and can coexist with moments of pleasure or happy memories. After a while, usually grief naturally improves.
In contrast, clinical depression involves near constant feelings of sadness, emptiness, and despair. Understanding this distinction helps in recognizing when to seek help. Yes, in milder cases, a person may be able to work, sometimes enjoy themselves, but a weight or dark cloud seems to be there, with feelings of guilt, questioning one’s worth, a depressive heaviness. In Major Depression, those feelings happen much of the time.
The hallmark symptoms of depression include overwhelming sadness, irritability, loss of interest in pleasurable activities, and a suite of physical and cognitive changes, such as fatigue, changes in sleep or appetite, and difficulty concentrating. These symptoms are persistent and can lead to significant impairments in an individual's life. Suicidal thinking is common in depression. For example, it may be hard to get up or get going or hard to concentrate at work. People report loss of initiative and a withdrawn feeling.
Look at our article All the Depression Symptoms.
Here is a scale commonly used to measure depression, the PHQ-9
Here is an adolescent version of the PHQ-9.
Depression is now thought of as a stress-related disorder. What that means is that it usually begins with some negative life-change event. Negative events are those which cause us some distress, for example, a death, loss of a job, a financial setback, a break-up. The therapist will want to understand what events were taking place in someone’s life when the depression began. Because it’s merely having negative events, but how we look at them and reavt to them, clinicians look at how the client reacts to changes and stressors. People with depression tend to react with Negative Thoughts, Negative Beliefs, and high levels of emotional distress.
Let's delve deeper into the types of depressive disorders, illustrating each with a case example.
1. Major Depressive Disorder (MDD)
Description: MDD is characterized by intense, persistent feelings of sadness, irritability, down mood, and despair that last for at least two weeks, interfering with daily functions. The impairment from one’s normal function is serious. We usually will see four or more major symptoms of depression. Once MDD sets in, it may last months or years. See the link All the Depression and Bipolar Symptoms for a complete array of the potential depressive symptoms.
Example: John, a 45-year-old engineer, finds himself unable to muster the energy or interest to engage in any of his former hobbies and struggles to complete tasks at work. He feels worthless and contemplates suicide.
2. Persistent Depressive Disorder (Dysthymia)
Description: This chronic form of depression presents with less severe symptoms than MDD but lasts for two years or more (one year in adolescents), affecting the individual's ability to function optimally. The person can do most regular activities, but with difficulty.
Example: Maria, a 32-year-old teacher, has felt mildly depressed for over three years. She manages to work and maintain relationships, but she always feels the joy is missing from her life.
3. Bipolar Disorder
Description: Involves periods of severe depression alternating with episodes of extreme elation or mania. When we see the person, the symptoms will lean towards one pole, e.g., the depressive side, so we have to diagnose Bipolar from the history of previous mania. If we see the person is in a mania, not caused by medications, drugs, or some other external cause, we can diagnose Bipolar Disorder. There is a milder form we call Bipolar II in which the mania is mild and not impairing when compared to the more severe mania in Bipolar I. The mood swings in bipolar can be rapid, such as in a day or a week, or slow, occurring over months.
Example: Alex, a 29-year-old artist, experiences dramatic shifts from productive, energetic highs to crippling lows where he cannot leave his bed. When he is up, ht ethinks his work is the best of anyone and he barely needs any sleep. On a scale from +5 = joy and -5 = despair, in mania he rates himself 4 or 5, but in depression he rates himself -5. In mania, he loses jobs because he is unrestrained in what he says, blows up at criticism or stress, or quits without thinking of the future. In depression, he cannot help his partner or get any work done – he lacks the energy and concentration.
To measure the severity of Bipolar symptoms, we use the MDQ.
Description: This type of depression is related to changes in seasons, often worsening in winter when there is less natural sunlight. It must happen year after year to be called SAD and the seasonal lows must be low to the point of being impaired, not just feeling a lapse in energy.
Example: Every winter, Emma, a 38-year-old nurse, feels overwhelmingly depressed, losing interest in life until spring arrives. She calls in sick to work a number of times in the winter months. This happened several years in a row.
5. Postpartum Depression (PPD)
Description: A severe form of depression occurring after childbirth, characterized by profound sadness, anxiety, and exhaustion. Mother may feel inadequate to the task of mothering and may even feel harmful to the baby. Suicidal thoughts are common. In extreme forms, a postpartum psychosis is known to occur, with a loss of touch with reality. PPD tends to lift after several weeks to a few months. However, it can interfere with parenting and can be dangerous to mother, so we recommend immediate treatment.
Example: After giving birth to her son, Linda, a 27-year-old new mother, experiences intense depression, feeling detached from her baby and overwhelmed with guilt for not feeling the joy she expected.
6. Adjustment Disorder with Depressed Mood (Reactive Depression)
Description: Life presents innumerable challenges. Some of those challenges can throw us into a mildly depressed state. While the person feels down, perhaps sad, with some loss of concentration or energy, this does not become major clinical depression and the person can usually get done much of what he or she needs to do. But then, many tasks may be put off or done only with a lot of pressure. Although mostly negative events cause depressed moods – especially losses – even positive changes in life require us to adapt – a promotion at work, a new child, starting a new school – and may engage some of our lingering doubts about ourselves or may remind us of something in the past that did not go well. So, we have some negative emotion about the old event and some negative thoughts about the new situation.
Example: Bill had a mild stroke at age 54. It left no permanent physical problems. But Bill started to think his life will be shortened. He won’t get done what he wanted to. He started to think about not living to the eventual college graduation and wedding of his 15 year-old daughter. He was afraid to exercise. He lost some motivation to work and but for the need to push himself to go and earn an income, he felt a loss of motivation to excel.
7. Cyclothymia
Description: This is a milder form of bipolar. Think of waves on the ocean. If there are no waves or little ones, that’s most of our mood level most of the time. If there are bigger ones, that may be cyclothymia, with highs and lows, waves and troughs. Big frothy, wild ones might be likened to bipolar disorder. The mood swings in bipolar can be rapid, such as in a day or a week, or slow, occurring over months. In cyclothymia, they can be over a couple of weeks to months and may not be noticed, like those small waves. The up moods are hypomanic – mildly up. The down moods do not reach to despair. Because this patterns is stable over the course of two or more years, we think it is a separate form of depression.
Example: A age 16, Alex reported depressed mood and skipping school, unable to get up. Two weeks later, he reported being on time for everything and excitement at his excellent report in a class. After 3 or 4 of these cycles, the therapist noted the cyclothymic pattern. The goal then became to understand and accept it, to look for experiences that triggered shifts in mood, and to maintain routines during the down cycles.
8. Other Reasons for Depressive Symptoms
Secondary Depression. Sometimes, we find depressed mood was secondary to a medication (e.g., interferon) or an illness (e.g., stroke). It may be secondary to receiving serious diagnosis, such as a cancer. That is normal and we would only call it depression is it lingered and was impairing.
Grief can look like depression. We distinguish Acute Grief, in which sadness and crying are normal, from Prolonged Grief, in which the person has made virtually no progress in their grieving after six or more months.’
Co-Occurring Disorders. Anyone can have two or more psychiatric diagnoses! So, people with PTSD over long period of time can develop depression at well. People with OCD limit their lives to the point they too can become depressed. People with ADHD often have so many challenges that they also get depressed.
The co-occurring disorder may be alcohol abuse or excessive use of other drugs. Then we work to understand if the depressed mood is caused by the drug use or is a separate problem..
The co-occurring disorder may be a medical problem. This occurs commonly after a diagnosis of a major illness, after a stroke, or as a side effect of some medications.
Several theories attempt to explain why depression occurs.
Biological Theories suggest that depression is linked to physical changes in the brain’s neurotransmitters, the chemicals in the brain that affect mood and emotions. Although several theories have been suggested, such as a shortage of serotonin, none had been found to be a conclusive reason for depression. The idea of a chemical imbalance has no basis in fact. A recent finding is a change in a stress-response area of the brain, but that is still being researched
Psychological Theories: Propose that depression results from several patterns which interact with one another. They often occur together.
1. Loss - One of the most common reasons for depression is loss. Loss may elicit hopelessness about the future, feelings of guilt, anger either at the person who has left or at one’s self in the form of self-reproach.
2. Negative thinking patterns almost always appear with depression. By negative, we mean evoking negative feeling. For example, let’s say there is a recession and one gets laid of from a job. A positive reaction is that this is a recession; I had lower seniority; there are jobs that may not be ideal but will cover my bills until things improve and I can get a better job; this is a good time to get some retraining; I can take in a roommate to help with expenses.
A negative reaction is this is unfair because I am a better worker than x; there are no jobs and I’ll go bankrupt before I find something; I have so much to lose that I am terrified; the situation is hopeless. You can see the depressive power in a negative reaction. The thing is sometimes people don’t realize that they’re having a negative reaction, and it needs to be pointed out to them by a therapist who will help them turn things around emotionally .
A. Automatic thoughts - If you heard something negative happened, your very first reaction might be to say, “nothing ever works out. Why do bad things happen to good people? I screw everything up.” Those are automatic thoughts. They pop out rather instantly, are not necessarily accurate, and are a person’s common reaction to unpleasant events. The fact that they are inaccurate allows us to experiment with shifting those thoughts, a process therapist called cognitive restructuring.
B. Dysfunctional beliefs - Behind this automatic thoughts are broader belief systems that we all have. We develop beliefs based upon our experiences. The beliefs allow us to operate more rapidly because it makes our world seem predictable – even if the beliefs are wrong or dysfunctional. By dysfunctional, we mean they’re unhelpful to the way we live our lives. For example, ‘if something goes wrong, that’s a disaster. If something goes wrong, it must be because of me or my fault. I just don’t expect things to go very well in my life. I expect them to go badly.’ ;This is my second loss this year. Bad things come in threes. Now, what will happen?’ None of these statements are exactly accurate, and they’re all dysfunctional because they lead to depressive thinking.
C. Schemas - Schemas are more deeply held, usually unconscious or only partly conscious beliefs, beliefs that come from early in life. They shape not only how we react, but how we filter information and how we appraise and interpret everything that happens. For example, a common schema is in one’s inadequacy. Another common one is an underlying belief that a person is defective. These are deeply held, often unconscious beliefs that form very early in life, anyone of which could lead to depression.
3. Unresolved emotional conflicts - Most of the reasons that we feel depressed are unconscious to us. Let’s say that a. young person felt scolded and reprimanded by her parents and their style for getting her to perform better in school was through criticism. Some years later, she experiences criticism from an employer and does not understand why suddenly she feels depressed. She thought she was doing pretty well on the job What has happened is that she has unconscious, unresolved emotions from growing up under conditions of criticism. And something new in her life that had the same emotion for her made her feel defeated, as if things just never seemed to turn out.
In order to to adapt, we tend to find ways to repress those old experiences. We call these defense mechanisms that enabled us to move forward, to adapt. But, all-of-a-sudden, the emotions from the earlier experience spilled over into the present. Therapists can help identify them and see how they are affecting the client now.
4. Traumatic experiences - Traumas leave a trail that never seems to go away. Because of that, and because of the need to protect oneself from further injury or trauma, we perceive new situations as if they were echoes of the old ones. Most often, we are unconscious of how this is working. Because of the trauma, we have may have feelings that something terrible will happen again. Therapy can help uncover the depressing effect of the old experience and resolve both the new one and the old one.
5. Withdrawal – If you look around in your life, you’ll find that every day there are some satisfactions, some recognitions, some accomplishments, something that you found enjoyable. One theory of depression is that the withdrawal symptom causes a dearth of satisfying life experiences. So imagine day after day being more isolated and failing to experience much in the way of satisfactions. Life would feel dull and dissatisfying. And then there would be more depression with more withdrawal and less and less gratification. Therapists tried to rearrange daily life so the client feels more satisfactions and more accomplishments in daily life. That tends to help lift depression.
6. Emptiness, deflation, and depletion - If you watch parents with a toddler, you’ll see how many times the child does something for which the parents say ‘that’s great. Good job.’ It’s in the smiles. Emptiness and feelings of deflation and depletion are more common in children who did not have very many of those kind of experiences. They may have had a distant parent or experienced abuse growing up. Without all of that sense of positive reinforcement in early life, the person feels a sense of emptiness. We need that positivity in order to develop normally. Without it, we feel depleted.
7. Anger turned against the self - One common theme in depression is called introjection, which just means to turn against the self, to turn angry impulses inward. It means that we observe depressed people saying very many self-reproachful and self-critical comments, but few if any self-reinforcing, high self-worth comments. Behind the comments is anger towards the self. They may feel anger towards someone that they’ve lost, or towards the job that laid them off, or any number of things that may have been stressors and changes in their lives. But they see those as caused by failures in the self for which they are self-critical and self-reproachful.
8. Aloneness - Feeling lonely, we usually pick up the phone to text somebody or call a friend. Then, our loneliness is abated. We may have a higher level of loneliness, the kind that comes from feeling a lack of daily closeness to others. So, those measures may be insufficient to resolve it. But we don’t get depressed. We do what we can to mitigate it.
Aloneness is something on another plane. It means no matter how many people are in your life, you still feel you are disconnected from them. You are feeling alone in the world. This is often accompanied by schemas of inadequacy and worthlessness – with feelings of deflation and emptiness.
9. Social Theories - Emphasize the role of environmental stressors – such as social isolation, elderly persons being alone, or chronic adversity -- in triggering depression. You can see how such social events could interact with psychological processes to produce depressed moods.
10. Genetic Theories - suggest genes affect depression. There is no one gene for bipolar disorder, but changes in several genes may lead to it. Certain psychiatric problems including Bipolar and Borderline Personality tend to be more frequent in some families and studies show Bipolar in a parent predicts an increased likelihood (between 16 and 33%) of Bipolar in a child. The genetics are not yet known. But genes are not likely to explain most depressions.
Cognitive-Behavioral Therapy (CBT)
Focuses on identifying and changing negative thought patterns and behaviors. For instance, a therapist might work with John to challenge his feelings of worthlessness, question hs evidence, look not only at his beliefs but also at illogical processes behind his beliefs, such as catastrophizing, personalizing, selective attention to negative events. The clinician will help him develop healthier ways to view himself and his world.
Interpersonal Therapy (IPT)
Aims to improve relationship skills, addressing issues like unresolved grief, role transitions, and relationship conflicts. Maria might benefit from IPT by learning to communicate her needs more effectively and building stronger, more supportive relationships.
Psychodynamic Therapy (Psychoanalytic, Insight-Oriented)
Explores unconscious processes and unresolved past conflicts as sources of current symptoms. This therapy is known to be equally effective as others, but to have longer-lasting results. Alex could gain insight into how past experiences influence his present mood swings through this therapy.
Behavioral Activation
Several behavioral interventions are useful in helping people overcome depression. Behavioral activation begins with the smallest steps the person could get themselves to do to re-engage with life. Simple steps such as attending to hygiene, calling a friend, or going to a park begin a process of moving out of the depressive state. The person starts to see the self as more effective. Then, positive emotions emerge. In a series of steps, the person more and more engages in a healthy lifestyle. Experiencing oneself accomplishing more and more in the world, one begins to feel more positively towards itself.
Exposure and Desensitization
EMDR (eye-movement desensitization and reprocessing), Brainspotting, and other therapies that work on overcoming the effect of painful past experiences are important to overcoming depressed mood that is associated with trauma, anxiety, and identifiable, unpleasant, life experiences. Because depression usually begins with specific stressful life events, we can use these therapies to desensitize the client to the continued influence of those events.
Medications
Antidepressants can be crucial for alleviating symptoms. An older class of anti-depressants, the tri-cyclics, were all we had in the 1960s through around 1990. They are now used less frequently except for limited symptoms, such as insomnia and OCD. More recent classes of medications target the efficiency of the brain’s use of serotonin and epinephrine. This group includes fluoxetine, paroxetine, venlafaxine, citalapram, escitalapram, sertraline, and numerous others. For someone like Emma, medication might be key to managing her SAD effectively.
Lifestyle Adjustments and Support Groups
Regular exercise, Yoga, a healthy diet, adequate sleep, and social support can complement medical treatments, offering holistic benefits. Some evidence suggests these lifestyle and social changes, particularly as part of a behavioral activation regime, can be very effective.
Thank you for joining us in this in-depth exploration of depression. Remember, seeking help is a sign of strength, not weakness. If you or someone you know is struggling, reach out – support and treatment are available.
Call 414-540-2170.
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Patient Health Questionnaire for Adolescents
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As a center of excellence for the psychotherapy and family therapy of children, Shorehaven has extensive experience working with children who have Attention Deficit/Hyperactivity Disorder. We provide:
To help you improve the care of children with ADHD, we have assembled some resources for parents and professionals. You will find many resources to your right.
Before you check those out, however, let’s give you a comprehensive introduction to attention deficit disorder in children and adults.
Children with ADHD may exhibit a range of behaviors that reflect their difficulties with attention, distractibility, and self-regulation. Understanding these behaviors is crucial for recognizing ADHD in both children and adults. It is important to note that ADHD can vary significantly from one person to another, and not all individuals will exhibit all these behaviors or to the same degree. Key behaviors include:
Inattention
About 1/3 of kids with ADHD have mainly inattention symptoms without hyperactivity.
Children with ADHD may have trouble focusing, following detailed instructions, and completing tasks. They might seem to not listen when spoken to, to be easily distracted, or to forget to complete daily activities. They do not give close attention to details and may make careless mistakes in their work. They may not sustain attention even during play.
When spoken to, the child does not seem to listen unless you specifically get the child’s attention. These kids leave a trail of incomplete tasks and forgets to come back to things that are not finished. If the tasks look difficult, the child may avoid getting started on them for lack of knowing how to approach the task. They avoid tasks that they dislike – same problem, not mustering the focus to get start.
Yet, at the same time they can hyper-focus on things that are captivate their interest.
Hyperactivity
About 1/4 of kids with ADHD are mainly hyperactive and impulsive. About 1/3 are both inattentive and hyperactive.
Hyperactivity in children with ADHD can manifest as constant movement, fidgeting, or excessive talking. These children might have difficulty sitting still during class or while doing homework. They get up out of their seat in a classroom when seating, not staying seated as expected. They may run or climb excessively in situations where sitting or being still is expected. They always seems to be on the go. They act without thinking ahead (so consequences
Impulsivity
Impulsive behaviors in children with ADHD include acting without much thought, interrupting conversations, blurting out in class without being called upon, and having difficulty waiting their turn. This can result in hasty decisions that have negative consequences.
ADHD in adults often presents differently than in children, though some core characteristics remain. Most adults retain many of the symptoms they had as children.
Inattention
Adults with ADHD may struggle with organization, prioritizing tasks, and maintaining focus on their work or conversations. They might be forgetful in daily activities and have difficulty managing time effectively. People in their lives remark that they seem not to listen when spoken to.
Hyperactivity
While physical hyperactivity may decrease, adults can still feel internally restless or seek constant activity. They might engage in a high level of activity or feel uncomfortable sitting still for extended periods.
Impulsivity
Adults with ADHD may make quick decisions without fully considering the consequences, experience difficulties in self-control, and engage in risky behaviors. This impulsivity can impact every area of life adaptation – relationships, work, driving skill, legal problems, and financial decisions.
Research suggests that about 20% of adults who have ADHD have a full and persisting group of ADHD symptoms and impairments just as they had in childhood. Only about another 20% have all of the symptoms, but maintain a good regime of medication. About 40% have symptoms, but some of those are not quite as severe as they had been. Finally, about 20% still have symptoms, but at a much lower level. So, you see ADHD does not resolve.
Studies of children growing up show that as adults they have more car accidents and more severe ones, more injuries, more driving suspensions, more moving violations. Compared to other grwon-ups, they have poorer self-image, more troubled relationships, more divorces, and more breakups. They have a much higher number of adult jobs with lower lifetime income. And a number of other problematic outcomes take place.
We also know that early management in childhood and throughout adolescence is a protection against some of these more negative outcomes. We also know that children who are well-medicated in childhood have adolescent outcomes that are not much different than other children. We also know that the level of drug abuse in the well-treated group will be lower. We also know that drug problems in adolescents are linked not to ADHD per see, but to having more severe conduct disorders.
One of the ways therapists evaluate problems is by looking at Executive Functioning. That is a set of capabilities built into the highest level of brain processes. Executive functions are underlying processes of the that are necessary in our modern world in order to function most ineffective.
Observation and Self-Report
In order to make a diagnosis of ADHD, the first thing that a therapist will do is observe the child or adult and pay attention to how they respond to questions. We will ask what they remember about their own behaviors and experiences, how they experience academic and work, any history of school or occupational situations.
Developmental History
We’ll take a thorough history of the child’s development. We will look for experiences that may explain some symptoms, the ones that may be related to PTSD, depression, anxiety. Any of those conditions may lead to a few of the symptoms. We will look for the possibility of bipolar disorder or autism spectrum disorder or some other explanation before we conclude, it must be ADHD.
Medical History
We look for explanations for their behavior that might not involve ADHD symptoms, and we will look for medical problems, such as high lead levels, high thyroid, celiac disease.
Questionnaires
We will also use screening questionnaires or scales for parents and teachers for adolescents and adults. We have self report scales as well.
Testing
Sometimes people ask for testing for ADHD. We use testing primarily when it is more difficult to determine that the person has ADHD.
You may be surprised to know that only about 31% of people with ADHD have only ADHD and no other conditions. This makes the diagnosis a little more complex. About 50% have problems with coordination or other physical behavior. Also, about 50% have some kind of learning disability, dyslexia, or nonverbal learning disability. There’s about 25 per cent overlap with autism. About 11 per cent have tics. About 40% are thought to be oppositional.
Defiance
So, let us explain something about defiance. Parents sometimes say that the ADHD child is defiant. Actually, the ADHD child has difficulty switching their attention just because you want them to. You want them to focus on the things you want them to focus on. They sometimes don’t remember what you told them to do, so they may look oppositional. The difference is the oppositional defiant disorder child has an unremitting level of hostility. They’re angry a lot. They don’t recover quickly once they are frustrated and angry. The ADHD child, however, switches moods very rapidly just. About 35% also have phobias. A percentage also of depression o bipolar disorder. Depression and anxiety problems are common in ADHD. Substance abuse is commonly associated with ADHD in children with Conduct Disorder.
Self-Esteem
We also see self-esteem problems. Imagine if you are the child who was told “Joey, sit down. Amy, pay attention. Amy, shop bothering the kids next to you. Joey, get back in your seat.” And this takes place throughout your childhood. Or, your friends may know that you are taking medication for ADHD and might tease you. The child accumulates negative self-experiences that affect their self-esteem. They may not do as well as their friends on exams They may have trouble staying organized and getting their work done. So, they get called out more in class or their grades are weaker than some of their friends. Their play behavior is impulsive and sometimes that interferes with their friendships. Add that all together and you get a lower level of self esteem that may lead to depression.
Let’s talk about treatment. ADHD is managed, not cured. Its management is a lifelong process. And in all of the person’s environments. Medication is the main intervention. So, we want to understand these medications and exactly what they’re intended to do, as well as any side effects.
Family Therapy, Parent Training and Supervision. We help the family have the best interaction and strategies for managing ADHD. Parent training is essential. These children need supervision to a far greater extent and a far longer time than other children. A parent might be doing homework with the child with ADHD well into their early teens, whereas their other children did not need that much supervision. They might need a higher level of involvement when they are 16, 18 even 22 or 24 than another child who does not have ADHD.
Punishment is rarely useful with ADHD children. They do not learn from it very well. A crucial part of parent training is teaching parents to only give instructions that the child will be able to remember – considering their working memory deficits. We also use extensive positive reinforcement. We help parents understand that a child needs 5 or 10 more repetitions than other children in order to remember a new behavior. We also teach parents to oversee much of what their child is doing in order to make sure they’re doing it in the first place and doing it effectively. We want them to check the backpack every day to check for homework assignments and to really stay on top of their child’s performance. We want parents to coach the child the night before for anything that has to be done the next morning and then remind them again in the morning. Remember, we need to keep things in working memory.
Behavioral Analysis is another essential part of treatment. The goal is to help these children to get control over their symptoms and control over their environments. Positive reinforcement in family therapy is essential. These children do not learn much from punishment. It only makes them more emotional, but does not usually improve their behavior. We must use positive reinforcement of skills and abilities. So, family therapy and family management skill training is a crucial part of the therapy.
Some people may not understand the importance of medication. Few studies of children have shown consistent improvement in ADHD symptoms and behaviors in the absence of medications. As these children get older and go into adulthood, medication may still be a crucial part of what they need.
Coaching is used to help adults with ADHD to be accountable for getting essential tasks done. Coaching helps them to focus on what is most important. A coach will help them break down tasks so that they actually begin to work on them when they need to. The coach will also keep them to a schedule.
Medication forms of foundation that allows a person with ADHD to pay better attention and to have more freedom from distractability. Once we have that, we can work on the parent training and behavioral contracting, which is helping the child make an agreement to very specific behavioral changes and for which there will be positive reinforcement. We can work on compensatory strategies to help the child better understand material that proves to be difficult. For example, reading complex essays. Arithmetic is difficult for most kids with ADHD, although some are good readers and some are good in math. So we have to find other ways to make sure that they get the main ideas out of what they read. Behavioral analysis of difficulties with executive functions, coaching, and behavioral family therapy skills training are all essential.
Diet. Does diet make a difference? Usually not too much. Sugar, caffeine and food dyes do not make a difference for most kids. However, we do have to rule out celiac disease, which is a gluten allergy, which does cause some symptoms that it look similar to ADHD. We note sugar makes a difference in some kids, but very briefly.
Organized environment. In order to manage symptoms well, we want to get control over situations.These kids tend to misplace things. They can’t remember where things are. So, they need a highly organized environment, with very simple rules to follow. They could benefit from an organized schedule that is written out and repeatedly prompted (reminded in the evening and morning). They need a sleep schedule. In the classroom, a preferred seating arrangement os one where the child is going to hear everything the teacher says and the teacher can keep a close eye on this student. It helps to vary tasks in their difficulty and their level of interests to keep the child from getting to distracted. At home the child may need a very quiet place to study or actually need a radio going in order to maintain their concentration. That is idiosyncratic with different children. If a child begins to space out and become distracted, a parent can to bring them back to their work to focusing on their work.
Some of the medications that we use are stimulants, but the dosages are small and very targeted. The medications help with focus. Most of these medications should be taken a little bit before it is necessary for the child to get themselves together and get to school. Sometimes, a second dose later in the day is necessary. One group of medications is based on methylphenidate, which is often known as Ritalin, and that comes in other forms like Daytrana, Concerta, and focalin. Another group is dextroamphetamine, which comes as dexamphetamine, Adderall, and Vyvanse. Some psychiatrists use guanfacine, also known as Tenex. A non-stimulant drug that is used is called atomoxetine, also known as Stratera. For depression, anxiety, or hostile behavior, other medications can be added, such as fluoxetine, also known as Prozac, Risperidone or Clonidine, also known as catapres. But many other medications have been tried and can be used depending on the range of symptoms the child may have.
In sum, ADHD is a persistent disorder. Most of the symptoms and impairments are lifelong. It’s associated with a range of poorer life outcomes in academics, in employment, in income in the outcomes for children of the ADHD person, for their driving record, for their sense of self, for their view of the future and their emotional controls, and even for the ability to succeed in relationships and to know how to listen to others. It can be managed with a comprehensive program of medications and behavioral therapy, family therapy, and other therapies.
You may want to look into an organization called CHADD, which has a magazine and resources for people with ADHD.
Our senior staff has many years of experience working with families of ADHD children and with ADHD adults.
Reach us at 414-540-2170.
If you want a pdf of this page, please click on: A Comprehensive Introduction to ADHD
The Twelve most common Behavioral and Psychiatric Problems in Youth
Adult ADHD Self Report Scale Symptom Checklist
Vanderbilt ADHD Diagnostic Parent Rating Scale
Vanderbilt ADHD Diagnostic Teacher Rating Scale
Adverse Childhood Experinces Questionaire
Mood Disorder Questionnaire (MDQ)
Kutcher Adolescent Depression Scale
Generalized Anxiety Disorder Screening Tool (GAD-7)
We have so much to tell you about anxiety and how we treat it in therapy that we will give you an explanation of anxiety and then links for different anxiety problems and how we treat them.
Of course, anxiety is the most common problem. It is a normal, essential emotion! Without anxiety, our ancient ancestors would not have been wary of predators and would have died out. We would not be here.
Everyone can benefit from knowing all about anxiety. Here is an outline of what to know about anxiety and anxiety disorders.
This document may take 10 minutes to read, but it is well worth knowing this data. If you have anxiety or have a family member with anxiety, you will surely want all the information on this page.
Anxiety can stimulate vigilance and heightened awareness. Anxiety can be motivating.
When It Is Too Much. However, excessive anxiety can be de-motivating and narrow awareness down to the source of the fear. In anxiety, fear is not about a real, actual stimulus. There is no bear, tiger, fire, or imminent collision. In anxiety, the source of fear is within us! It is in our negative expectations, our frightening predictions, our appraisal of situations, our projections of what might happen, our worries. Anxiety can create a state of paralysis, helpless capitulation, or panic.
The Yerkes-Dodson law tells us the absence of any anxiety is associated with low motivation, but an excess can be overwhelming. The sweet spot for motivation and accomplishment is in the middle ground.
1. Definition
Anxiety is a natural and often necessary emotion characterized by feelings of tension, worried thoughts, and physical changes -- a rush of adrenalin, rapid heart rate, increased blood pressure, stomach upset, rapid breathing, and dizziness, among other signs. It is the body's response to stress or “perceived” danger. So, it serves as an alerting system to prepare an individual to face or escape potential threats. However, when anxiety becomes overwhelming or persistent beyond appropriate contexts, or when it is stimulated by imagined events in the future, it can lead to dysfunction and distress. Further, when it becomes persistent and distressing, it can be a psychological disorder.
We categorize anxiety in two ways.
1) External. The type of anxiety based upon the type of external situation that evokes the anxiety. The section below on Anxiety Disorders in DSM-5 explains.
2) Internal. The type of anxiety based upon our internal experience. The section below on Types of Anxiety explains.
Anxiety leads to significant distress or impairment when it becomes overwhelming or persistent.
Anxiety leads to impairment when we predict or imagine a catastrophic outcome, a disaster, or worry excessively. Seldom do these outcomes occur.
Anxiety manifests through a variety of signs and symptoms – physiological, emotional, cognitive, behavioral, and interpersonal.
Physiological/The Body: These include increased heart rate, sweating, trembling, shaky inside, dizziness, fatigue, shortness of breath, and gastrointestinal problems. Such symptoms are the result of the body's fight-or-flight response, preparing an individual to face or flee from perceived threats, with a secretion of adrenalin. See the treatment section for an explanation of how the brain and body react when in an anxious state.
Emotional: Feelings of apprehension, tension, nervousness, or fear. People may also experience irritability or a sense of impending doom or danger.
Cognitive: This involves constant worries, dread, racing thoughts, difficulty concentrating, or obsessing over perceived threats. Individuals may also experience unrealistic fears or beliefs about the potential consequences of situations. In panic attacks, we also see thoughts such as “I’m going to die” or “I’m going crazy.”0
Behavioral: Avoidance of feared situations, objects, or activities is common. Other behaviors include restlessness, difficulty relaxing, or engaging in repetitive behaviors or rituals to alleviate anxiety. People tend to escape the situation in which they feel anxious and then avoid that situation in the future.
Interpersonal: Anxiety can affect relationships, causing individuals to become withdrawn, overly dependent, or excessively worried about the well-being of loved ones. Communication may also be affected, with individuals finding it hard to express their feelings or needs.
3. Types of Anxiety
Sigmund Freud is the first to write extensively about anxiety. As a result, we see anxiety as a signal that something is troubling, worrisome, or potentially threatening. The signal means we should attend to the situation and evaluate what to do next.
Actual or Reality Anxiety is a response to a real threat or danger. Then we can take some action to reduce the danger.
Neurotic Anxiety is a response to our emotional conflicts, our perceived threats (that is, we believe we will be criticized), or our worries.
Separation Anxiety is the fear of being parted from figures to whom the individual is attached.
Moral Anxiety is a feeling that comes from threats of punishment from the outside world or from the conscience because of not following moral standards or thinking we have violated our rules.
Shame is the feeling that arises from the consciousness of something dishonorable or improper done by oneself or another, or feeling one IS defective or does not measure up.
Guilt is the emotional state that occurs when a person believes or realizes—accurately or not—that they have compromised their own standards of conduct or have violated a moral standard, they have done something wrong.
Annihilation Anxiety is the fundamental fear of obliteration, of ceasing to exist. This is more primal than the fear of death and is believed to underlie some phobias and anxiety disorders. It is more common in early childhood.
ANXIETY IN THE NERVOUS SYSTEM
You are probably familiar with the central nervous system (CNS), which is composed of the cerebellum, the medulla, and the cortex. You may be less familiar with the autonomic nervous system (ANS). The ANS is responsible for extremely rapid reactions. For example, we catch something out of the corner of our eye; we react to it with a jolt Adrenaline is secreted from our adrenal cortex, the glands on top of our kidneys. Our heart races. All this happens before we even realize what the source of our fear was. In other words, we have a nervous system, the ANS, that reacts faster than our cortex can recognize the threat and identify whether it is or it is not a threat.
Another example is when you narrowly escape a car accident. You reacted to the situation to avoid the collision before you’re even able to recognize at the cortical level what the threat was and how lucky you may have been to avoid it.
So, the autonomic nervous system is a rapid survival system. It has two branches, the sympathetic branch and parasympathetic branch. They are like toggles. One is on, the other is off, and vice versa. When the sympathetic is on, it prepares us for fight or flight. Therefore, it is the nervous system implicated in anxiety.
When the parasympathetic is on, we feel calm or relaxed, in a state of calm awareness. But we are not in a state of reactivity. Relaxation therapy and mindfulness techniques, which we use with anxiety treatment, aim to turn on the parasympathetic nervous system, That turns off the sympathetic meaning it turns off the anxiety-producing nervous system. If we stay in a parasympathetic state, we are countering and preventing anxiety.
However, if we’re in a sympathetic state, various stimuli, especially reminders of trauma and our fears, turn it on. So, in anxiety treatment, we want to desensitize any stimuli that tend to turn on the sympathetic and we work to increase the power of our parasympathetic. We are often completely unconscious of how various stimuli trigger the sympathetic. In therapy, we unravel those associations and connections.
Types of Anxiety Problems - With Examples
Call us with your questions at 414-540-2170
About Anxiety Audio Transcription
This is Don Rosenberg, a Psychologist at Shorehaven Behavioral Health. I want to give you an brief overview of anxiety and anxiety problems. Anxiety. Anxiety is a natural a feeling of fear or apprehension about what’s to come.
Anxiety:
Anxiety is a signal to the mind that something feels wrong, there is a perceived threat, orwe anticipate and worry some negative outcome may happen. We say a “perceived threat” because anxiety is about something we think or predict may happen and may be damaging.
To explain, if the event is real, such as anticipating speaking to an audience or going in an elevator when you are afraid of small spaces, or any number of such real situations, you can see:
a. often, the situation is not inherently fearful;
b. any “fear” response to those situations would be stimulated by what you imagined might be threatening or might go wrong in that situation;
c. imagined fears feel entirely real and elicit a wish to escape or avoid the situation;
d. exposure to the actual situation is likely to evoke those an anxious response and the closer you get to the situation, the higher the anxiety is likely to be;
e. avoiding the situation or escaping from it once you are in it can lead to relief;
f. often, the is a secondary reaction of shame, embarrassment, or lowered self-esteem as a result of seeing yourself avoiding, as if it meant a lack of courage or strength. Actually, that is an unfair self-reproach (or reproach from others) – the anxiety reaction can be extreme and frightening.
Fear.:
Fear, on the other hand, has similar changes in the body to anxiety, but the object of our fear is real. For example, it’s one thing to fear snakes when you see them a few feet away; they may be dangerous. It’s another thing to be anxious about snakes when they are not present, but only thought about, or the snake in question is being handled by a zoologist and is one of the harmless kind.
It could be that we create an anxious prediction, such as that we may not do well on an exam, we will flub a speech, we have to go somewhere where we had a severe attack of anxiety in the past, or any number of situations that we predict may not go well. You can see how it is the prediction or expectation that makes for anxiety.
But, once again, to the anxious person, the fear feels real! They don’t test out the reality or push themselves to see that it is not a necessary fear.
To go over it again, for example, we work with people who have been driving when their vehicle was struck. Then, they become anxious near that location and even avoid it. That could be an example of a phobia or it could be a form of PTSD. Either way, the odds arethey have driven through it before the collision many times without incident and the “fear” now is only a perceived fear, that is, anxiety. The danger is imagined. The odds of a second collusion there is small. Plus, the person can be ultra cautious. There is not reason for avoidance besides anxiety.
We never dismiss the anxiety. Once it is conditioned in the Unconscious, it feels severe and real.
Anxiety Disorders:
When these feelings become overwhelming, or persistent, and interfere with daily life, causing avoidance of situations, they may mark an anxiety disorder. Let's explore what anxiety disorders are and how effective treatment can help manage them. Anxiety disorders are the most common form of emotional disorder. They can affect anyone at any age. The common ones are:
The common theme in anxiety disorders is anxiety at some specific kind of stimulus or situation and avoidance of those situations. The avoidance can become disabling. For example, the person with panic disorder can develop agoraphobia, the fear of going to places were escape maybe difficult, such as malls and big stores, or even the fear of leaving the neighborhood – all due to the fear of having a panic attack in one of those places.
Treatment:
The good news is, anxiety disorders are highly treatable. Yet only about one-third of those suffering access and receive treatment. Effective treatment often involves a combination of different psychotherapies, medication, or both, always tailored to the individual's needs.
First, we have Psychotherapy, or talk therapy, is a way to address the anxious emotional response. Psychodynamic Therapy, Acceptance and Commitment Therapy, and Cognitive-behavioral therapy (CBT) are among the methods we use to uncover the roots of the anxiety and what is producing it. Other therapies, such as Mindfulness, work to increase the functioning of the parasympathetic branch of the nervous system, that is the part that keeps us calm and relaxed. Other therapies, such as EMDR and Systematic Desensitization work to desensitize the stimuli that arouse the anxiety. In order to overcome anxiety, Behavioral Activation helps you re-engage with situations, but without avoidance, in small, manageable steps. A therapist who is trained to work with these problems can determine from session-to-session which are the best methods to use.
Second, Medication, such as antidepressants, beta-blockers, and anti-anxiety drugs, can help manage symptoms. It's important to note that medication can offer relief, but not cure, soit is often most effective when combined with psychotherapy.
Third, Lifestyle changes and self-care practices, including regular exercise, a healthy diet, reduced caffeine intake, mindfulness meditation, and adequate sleep, can also significantly impact anxiety.
Finally, remember, seeking help is a sign of strength and the courage to overcome your fears and challenges. With the right treatment plan, individuals with anxiety disorders can lead fulfilling lives, free from the grips of anxiety.
If you or someone you know is struggling with anxiety, reaching out for help is the first step towards recovery. Together, you can explore the best treatment options and take the journey towards well-being.
Thank you for listening. Remember, it's okay to ask for help. Anxiety is manageable, and treatment is effective.
We are here to help. Call 414-540-2170.
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PTSD is another psychiatric problem we frequently work with in the clinic. Treatments for recovery from PTSD have advanced recently. If you suspect you or a loved one may have PTSD, this article will prove most helpful.
Post Traumatic Stress Disorder (PTSD) is a complex and often severe mental health condition triggered by witnessing or experiencing a traumatic event. PTSD affects individuals differently. Some 2/3 of people experience who an serious event do not develop PTSD, while 20-33% do.
When PTSD does occur, it causes significant distress and impairment. PTSD effects include changes in in personal, social, and professional areas of life. A person may be triggered at work or by loud noises or have troubled sleep or be on edge all the time.
PTSD can be triggered by a wide range of traumatic events. Some of the more common events include:
Most of these events are about being the victim or witness to some severe threat of harm or a directly harmful experience.
The development of PTSD is believed to involve a combination of neurobiological, psychological, and environmental factors. The theory of "fear conditioning" suggests that PTSD develops when the fear response is permanently wired into the brain during a traumatic event, leading to an abnormal response to fear in the future. This is supported by neuroimaging studies showing alterations in the amygdala, prefrontal cortex, and hippocampus—areas involved in fear response and memory (Pitman et al., 2012).
When a traumatic event happens, the nervous system becomes over-aroused and produces a fear reaction. After this occurs, anything connected with that situation, including the memory itself, can evoke the same high level of arousal. Because the brain wants to protect us from danger, it will keep the experience in a vivid state, as if they just happened. The brain will keep the indvidual who experinced the traumatic event on high alert, called hyperviglance, just in case a threatening event should recur. This can lead people avoid anything or any place connected with that situation causing the anxiety reduces and reinforcing more and more avoidance. It also reinforces the PTSD. Future events that unconsciously remind us of the event also elicit anxiety – however, we may not perceive that connection.
In some cases, instead of noticing ones high anxiety, what may occur instead is the a numbing, dissociative reaction. This occurs due to one's nervous system disconnecting from the present reality in order to cope. This can be in the form of dissociation (disconnection from emotion or out-and-out flashbacks), de-realization (the world feels unfamiliar and odd), or de-personalization (the body feels odd or feeling outside the body).
We have several memory systems. Let’s look at how PTSD can affect these symptoms.
Long-term Memory
Explicit Memory is conscious memory, things we can bring to mind.
Implicit memory is more unconscious. It is information that we do not store purposely and is unintentionally memorized.
Short-term memory (Working Memory)
We can recall a small amount of incoming information for a short period of time. That is how we track a conversation and follow a movie. The brain will move many short term memories to long-term memories.
PTSD symptoms are categorized into four types:
PTSD often co-exists with other conditions. These co-morbidities complicate the treatment and management of PTSD, necessitating a comprehensive treatment plan so we can treat the PTSD and the additional set of problems.
After years of debate, the World Health Organization adopted a diagnosis of Complex Trauma. This term describes what happens when trauma in early life, from early childhood through around early adolescence, and the trauma is repeated and inescapable. For example, a child may experience repeated sexual abuse or repeated emotional abuse or was a witness to repeated domestic violence. As a result, the child forms a much more complicated type of PTSD.
In addition to all the PTSD symptoms, the person develops some much more challenging symptoms like:
Trauma can pass through generations! In his book, It Didn’t Start With You, Mark Wolynn (Penguin Life, 2017) shows how a person may have quite disturbed reactions and relationships due to traumatic events from one or two generations before.
Caregivers can pass their own trauma experience in a few ways. One is in utero. Mother’s cortisol (stress hormone) affects the child’s nervous system and make it more reactive. As a parent, the caregiver may be more irritable and get upset more easily, leading the child’s sense of self to be more oriented to self-doubt and self-criticism. The child may subsequently be more prone to PTSD in the face of troubling events. Treatment can sometime work on the them that “Generational trauma ends here and now.”
Not all PTSD leads to long term, unremitting symptoms. Sometimes, post-traumatic growth also occurs. An example is the founder of MADD, Mothers Against Drunk Driving, whose daughter was killed by an intoxicated motorist. We sometimes see positive psychological changes and/or positive social actions that come from atrauma. We often see a shift in one’s life philosophy, self-awareness, social consciousness, and appreciation of life. PSG and PTSD can be found in the same person. Sometimes, the resolution of the latter leads to the former.
Fortunately, we have effective treatments for PTSD! Some treatments can eliminate the symptoms. Others can help manage the symptoms so they are less disturbing. In the case of Complex PTSD, it may take several years to understand repair the damage done to the person’s development.
The major treatments for PTSD include psychotherapy, medication, or a combination of both. As for the psychotherapies, they are often used in combination.
✓ Cognitive Behavioral Therapy (CBT) helps reframe (change our perspective) negative thoughts about the trauma. It involves exposure therapy to desensitize trauma reminders, and cognitive restructuring to change negative thought patterns.
✓ Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a well-researched method for trauma in youth.
✓ Prolonged Exposure Therapy is a form of CBT that involves reliving the traumatic event in a safe environment to help reduce the power it holds over the patient.
✓ Eye Movement Desensitization and Reprocessing (EMDR) involves focusing on traumatic memories while receiving bilateral sensory input (e.g., eye movements) to help process and integrate traumatic memories rapidly and effectively.
✓ Psychodynamic Therapy helps uncover deeper beliefs and behaviors that may not have been understood previously to be trauma-related, and helps understand adult behaviors that have roots in earlier trauma.
✓ A number of other approaches have been promising for PTSD, such as Acceptance and Commitment Therapy, some approaches using mental imagery, hypnosis, and Mindfulness, Brainspotting, and Seeking Safety, a program for those who experienced sexual abuse.
A wealth of research supports the efficacy of these treatments. For example, a meta-analysis by Cusack et al. (2016) found that CBT, EMDR, and stress management techniques are effective in treating PTSD, with CBT and EMDR showing the most promise. Medications, particularly SSRIs, have been endorsed by the American Psychiatric Association for PTSD treatment, based on extensive clinical trials demonstrating their efficacy in reducing PTSD symptoms (American Psychiatric Association, 2017).
PTSD is often a debilitating condition that requires a nuanced understanding of its triggers, symptoms, and treatments. The combination of evidence-based psychotherapies and, sometimes pharmacotherapy, remains the cornerstone of PTSD management. As research advances, our understanding of PTSD and its treatment will continue to evolve, offering hope and healing to those affected.
References
American Psychiatric Association. (2017). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141.
Pitman, R. K., Rasmusson, A. M., Koenen, K. C., Shin, L. M., Orr, S. P., Gilbertson, M. W., ... & Liberzon, I. (2012). Biological studies of post-traumatic stress disorder. Nature Reviews Neuroscience, 13(11), 769-787.
Mark Wolynn (2017). It Didn’t Start With You, Penguin Life.
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Human beings are hard wired for social attachment. Our earliest attachment figures are our immediate caregivers. Children need those caregivers to provide safety and emotional security. The essence of the process we call attachment is a feeling of being in proximity to someone who makes you feel safe. The attachment process in infancy culminates in the second half of the first year when the child becomes more attached to the main caregiver(s) who takes care of that child and provides for their safety.
That is the beginning of a process that is lifelong. Even adults create attachment relationships. However, those adult attachment relationships are based upon the quality of the earliest attachment relationships. As we will explain, breaches or wounds in early attachment affect the ability of people to attach throughout the rest of their lifetimes. And yet, at the same time, repair of the attachment system issometimes still possible through a healthy positive, safe later relationship.
Attachment is the closely-connected emotional relationship between a child and his or her primary caregiver(s). Effective attachment comes from consistent care of the child’s basic and emotional needs for safety and security from earliest infancy through around age five. Attachment is critically important -- it involves some of our most basic emotional capabilities that ordinarily develop in a securely attached child:
• basic trust in others
• the sense of living in a dependable and predictable world
• sense of self-worth, identity, and being special and worthwhile
• capacity to regulate the sense-of-self
• capacity for effective autonomy
• capacity to regulate emotions, emotional arousal, and calming or soothing after a disturbance in emotions.
Attachment is a core element in our basic schemas (deeply held ideas) for understanding the world and our place and value in it. We refer to that as the child’s Internal Working Model of the World.
The articles below explain in more detail attachment styles, coregulation and attachment in the brain in more detail.
Breakup of a love relationship in adolescence leads to heartbreak. The way a broken heart feels is a type of attachment wound. Attachment Wounds are deep emotional injuries when attachment needs are not met during critical developmental periods, particularly in childhood. The consequences of such wounds can profoundly affect a child's emotional, cognitive, and social development. Wounded attachment begins with extended separation from caregivers, traumatic loss of caregiver, perhaps loss of a family member leading caregiver to be withdrawn from the child, caregiver mental or physical illness resulting in lack of caretaking, abuse, neglect, or other disruption in the attachmentrelationship. Wounds are more common than RAD, which comes from extreme attachment wounds and occurs in one or two in 100 children.
Attachment and Reactive Attachment Disorder
This article is a primer that explains attachment, attachment styles, attachment wounds, and explains how we treat attachment wounds and attachment problems.
Contact us at 414-540-2170 to learn more about our psychotherapy services and how we can help you.
February 2024: Mastering the point of view needed for parents and clinicians to develop the empathic attunement necessary to re-awaken a child's inhibited attachment system.
Among the most frequently seen problems in the clinic are problems of adjusting to life events or life changes. Back in 1967, Holmes and Rahe discovered that most of us view changes in life such as marriage, divorce, death of a loved one, buying a house, taking out a loan, losing a job, or even a promotion as stressful to about the same degree, regardless of our culture or locale. If that was not striking enough, they also discovered that people who had more than a certain amount of life change in a two-year period had a significantly higher risk of medical disorders or life changing illness in the following months!
So, our adjustment to what happens in our lives can be a major factor in whether we need help.
Research throughout the 1970s and 80s also found that we have predictable reactions to many kinds of crises and life event. Given any major life change, roughly a third would then benefit from having mental health therapy as a result of the depression, anxiety, or behavioral changes they experience after a series of those life changes. We also know from the famous ACES study that certain events in childhood leave a lasting impression on the quality of our adjustment to life and our overall mental wellness. Events and life changes affect mental health.
Adjustment disorders are stress-related conditions that arise when an individual struggles to cope with a significant life change or stressor. Recognized within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), these disorders manifest through emotional and behavioral symptoms. They significantly impact one's daily functioning.
1. Adjustment Disorder with Depressed Mood
Description: Individuals experiencing this type of adjustment disorder primarily exhibit symptoms of depression, such as persistent feelings of sadness, hopelessness, and a lack of enjoyment in activities once found pleasurable. These symptoms occur in response to an identifiable stressor. This may last from a few weeks to a few months.
Adult Example: A 45-year-old man loses his job of 20 years due to company downsizing. Within a few weeks, he begins to show signs of depression, expressing feelings of worthlessness and disinterest in searching for new employment or engaging in activities he once enjoyed. He seems apathetic.
Child Example: A 12-year-old girl moves to a new city with her family, leaving behind her friends and school. She becomes increasingly withdrawn and sad, refusing to engage with peers at her new school or participate in her favorite sports.
2. Adjustment Disorder with Anxiety
Description: This category is characterized by symptoms of anxiety, such as excessive worry, nervousness, or fear about everyday situations. The anxiety is more intense than what might be typically expected.
Adult Example: Following a minor car accident, a 30-year-old woman develops an intense fear of driving or being a passenger in a car, leading to avoidance of situations requiring travel and significant distress in her daily life as she tries to compensate for being afraid and becomes more withdrawn.
Child Example: A child who has recently started kindergarten exhibits extreme worry about being separated from parents, leading to stomach aches and tears every morning before school, which is not typical for their age. She never had these symptoms before even when going to pre-school.
3. Adjustment Disorder with Mixed Anxiety and Depressed Mood
Description: Individuals with this disorder experience both depressive and anxiety symptoms, neither of which predominates. This mixed presentation can complicate diagnosis and treatment.
Adult Example: After a significant relationship breakup, a 28-year-old experiences bouts of crying, feelings of hopelessness, alongside constant worry about their future romantic prospects and loneliness. He predicts no one will want to be with him.
Adult Example: A 50-year-old woman, after relocating to a new country for a job, experiences general malaise, sleep disturbances, and difficulty concentrating, without a clear predominance of depression or anxiety.
Child Example: A 6-year-old, facing the serious illness of a sibling, begins to have nightmares, refuses to attend school, and cannot articulate his feelings of fear or sadness, showing a general disturbance in emotional regulation.
Child Example: Following the divorce of his parents, a 10-year-old boy shows signs of sadness, loss of interest in playing with friends, coupled with worries about being left alone or his parents not returning home when they leave.
4. Adjustment Disorder with Disturbance of Conduct
Description: This form of adjustment disorder is marked by behavioral changes, usually disagreeable behavior, such as violating social norms or rights of others. Actions may include truancy, vandalism, or reckless driving, significantly diverging from the individual's usual behavior.
Adult Example: A previously law-abiding 22-year-old begins engaging in shoplifting and aggressive confrontations following a significant financial loss, behaviors that are uncharacteristic and directly traceable to their recent stressor. He is irritable and easily angered.
Child Example: A 7-year-old starts showing aggressive behavior at school, hitting peers and defying teachers, shortly after the arrival of a new sibling, reflecting difficulty adjusting to the change in family dynamics.
5. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
Description: This disorder encompasses both emotional symptoms (depression, anxiety) and behavioral issues (disturbance of conduct), presenting a complex challenge for diagnosis and management.
Adult Example: Following a life-threatening health diagnosis, a 35-year-old exhibits severe anxiety, frequent emotional outbursts of crying and anger, alongside impulsive behaviors like reckless driving and substance use.
Child Example: A 9-year-old, struggling with his parents' contentious divorce, shows signs of sadness and anxiety, as well as bullying at school and lying.
Adjustment is our reaction after a life change event. Even positive events requires us to adjust. Negative events, such as a death of a close friend or pet, loss of a job, or illness, may lead to a broad spectrum of emotional and behavioral stress responses. These conditions underscore the importance of recognizing the impact of life changes on mental health, for both adults and children. Through understanding the various types of adjustment disorders and their manifestations, we can foster empathy, provide appropriate support, and pursue effective treatments for those affected. Mental health professionals play a crucial role in identifying and managing these disorders, ensuring individuals receive the care and intervention needed to navigate life's challenges and transitions.
References:
V J Felitti 1, R F Anda, D Nordenberg, D F Williamson, A M Spitz, V Edwards, M P Koss, J S Marks. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med, May;14(4), 245-58.
Holmes, T. H., & Rahe, R. H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research, 11(2), 213–218.
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This is a primer to help you understand the different professionals you may meet when you come for psychotherapy or substance abuse counseling.
We hope this can help reduce confusion about the profession. You can be assured that the amount of clinical training for all these professions is about the same and all are trained in the same basic methods and ethics for helping our clients.
Shorehaven Behavioral Health, Inc., has high standards for its licensed staff, higher than is required under state law.
1. The Mental Health Professionals – Shorehaven employs the special, advanced skills of several kinds of mental health professionals.
Psychiatrist – an MD with a residency in psychiatry, whose role is often primarily to prescribe medications to help with psychiatric symptoms
Psychologist – usually a doctorate level professional with PhD or PsyD whose expertise is in assessment and behavioral therapies, but who may be trained in a variety of methods of treatment
Clinical Social Workers – Licensed CSWs are licensed masters-level professionals who may use a variety of methods of treatment, and who often have expertise in linking clients to various services and programs in the community
Professional Counselors – Licensed PCs are licensed masters-level professionals who are trained in the techniques of counseling to help clients probe feelings and emotions, thoughts and ideas, in order to achieve greater understanding
Art Therapists – Registered Art Therapists are licensed masters-level professionals who help clients use art to express emotions and inner experiences and trauma
Marriage and Family Therapists – Licensed MFTs are licensed masters-level professionals trained to understand how the interactions and roles in our relationships shape our feelings, thoughts, self-image, and behavior, and how to make changes in our patterns of interaction in order to bring about change
Substance Abuse Counselors – Certified SACs can be at any level of the educational spectrum, and they have spent at least 3-5 years working extensively with the clients who suffer the problems of substance abuse and dependence and other compulsive, addictive behaviors, and SACs have techniques to help achieve recovery
Below, we detail the nature of Licensing and Certification in the mental health professions.
2. Licenses — In Wisconsin, all of the professions place the public trust as a number one priority. Protection of the public is the main reason for licensing of professions. Licensing establishes the minimum requirements for being a mental health professional. All of these professionals completed a 4-year bachelor's degree and a 2-year master's degree. Some have completed additional studies and research for a PhD degree. All have had the experience of "clinical supervision,"" which includes BOTH a 5-10 month course of study during graduate school and a 2-year course of training under the eye of a highly experienced professional.
In addition, all of our professionals continue to meet on a regular basis for their entire careers to become more skilled and achieve better OUTCOMES for our clients.
The licenses for Mental Health in Wisconsin include:
Licensed Clinical Social Workers (LCSW) – completion of a Masters of Social Work (MSW), an internship during the masters, plus two full years of post-masters clinical supervision, completion of a challenging national examination and a Wisconsin examination. Some LCSW holders also completed a course of research to become a PhD. UWM also has a course of study so that an MSW could study an extra 6 months to take coursework in marriage and family therapy.
Licensed Marriage and Family Therapists (LMFT) – completion of a Masters in Marriage and Family Therapy (MMFT) or one of the other degrees plus a year or two of extra coursework just in marriage and family therapy. The LMFT also completed an internship during the master's degree, two full years of post-masters clinical supervision, completion of a difficult national examination and a Wisconsin examination. Some LMFT holders have also completed a course of research to become a PhD. The LMFT has the same learning in mental health studies as the other professionals, and in addition has completed an additional course of study in couples and family therapy.
Licensed Professional Counselors (LPC) – completion of a Master of Arts (MA), Master of Science (MS), or Master of Education (M.Ed.), an internship during the maters, plus two full years of post-masters clinical supervision, completion of a difficult national examination and a Wisconsin examination. Some have also completed a course of study and research to become a PhD.
Licensed Psychologists (LP) – completion of a doctorate (PhD), a year-long internship, a year of clinical supervision after the PhD, a very challenging national examination, and a Wisconsin examination. Psychologists all have a "Scope of Practice," meaning a range of clientele for whom they are licensed to help. So, some psychologists only work with children, some only with adults. Therefore, some may not work with couples or substance abuse, while others may have those specializations within their scope of practice.
There are other professionals who work with mental health patients, among them being Occupational Therapists, Rehabilitation Therapists, Psychiatric Nurses (RN), and Advanced Practice Nurse Practitioners (APNP).
3. TRAINING LICENSES
For three of these licenses, LCSW, LMFT, and LPC, there are also levels called TRAINING LICENSES. These are for professionals who have completed the Master's degree, but have not completed the other requirements. In Wisconsion, people with these training liscenes may also be refered being Qualified Treatment Trainee (QTT). You may see professionals who have these training level credentials:
Shorehaven Behavioral Health, Inc., has high standards for its licensed staff. We require and provide an additional year of clinical supervision over and above the requirements of the state. Shorehaven's professionals who work under a training license also receive more supervision than the state requires.
4. Certifications — Certification signifies advanced study in a specialized field. There are two types of certification.
A) These are specialized fields for which the state has not yet decided to create a level of licensure, but the state has created legislation which protects the title for that profession. So no one can use the title unless they have attained all the training needed for that field. Substance abuse counseling is such a field. Only a person with rather extensive classroom training (360 hours, the equivalent of 8 or 9 college courses) and clinical supervision (2-4 years) may use the title Substance Abuse Counselor or may tell patients he or she specializes in substance abuse.
B) Sometimes the study of the field requires basic licensure and some additional studies and supervision, but there is no special protection for the title. Certified Sex Therapist is such a title; the practitioner has had a course of advanced study and clinical supervision. The title is governed by rules of the American Association of Sex Educators, Counselors, and Therapists. But it is not regulated by the state.
A. State Regulated Mental Health and Substance Abuse Certifications
B. These certifications are granted by professional associations, in essence, by professional colleagues, after a Licensed professional completes an additional course of study and supervision. We will just detail a handful of such certifications.
We hope this overview helps you to understand the different professionals you may meet in the mental health and substance abuse field.
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3900 W. Brown Deer Rd, Ste 200
Brown Deer WI 53209
414-540-2170
4370 S. 76th St.
Greenfield, WI 53228
6233 Durand Avenue, Ste F
Racine, WI 53406
262-554-8165