Traumatic Brain Injury

Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI) is a leading cause of death and disability in the United States. The most common causes of TBI include Falls, Motor Vehicle Accidents, Assaults, and Object-to-head impacts. Alcohol (ethanol) is a contributing factor in 40-56% of cases.

Individuals 75 years of age and older have the highest rates of hospitalization and death following traumatic brain injury. Importantly, a history of traumatic brain injury increases the risk for future TBI events.
About 40% of patients who suffer TBI develop neuropsychiatric symptoms that do not correlate with the severity of the injury. That is, mild TBI without loss of consciousness or hospitalization can lead to significant neuropsychiatric problems in vulnerable individuals.

TBI can be divided into 3 categories (mild, moderate, severe) according to severity and duration of altered mental status. The severity is often based on the Glasgow Coma Scale* (Eye Opening, Verbal Response, Motor Response) with lower Glasgow Coma Scores associated with more severe injury and poorer recovery outcomes. 

Primary and Secondary Injuries

TBI can be divided into Primary and Secondary brain injuries. Primary injury refers to the “initial blow” or the immediate injuries following the event whereas the secondary injury refers to the physiological responses to the primary injury. 

Primary Injuries

Primary Injuries can be further divided into Focal and Diffuse injuries

Focal Injuries

Most focal injuries occur in the polar temporal lobes and on the inferior surface of the frontal lobes (coup-contrecoup mechanism, see image below). Examples of focal injuries include hematomas and contusions.

Epidural hematomas: Lateral Skull Fractures with tearing of middle meningeal artery and vein often leading to involvement of the temporal and temporoparietal regions. Usually a period of initial loss of consciousness followed by a lucid period and finally a period of neurological decline. SURGICAL EVACUATION is often needed.

Subdural hematomas: More common than epidural hematomas. Caused by tearing of bridging vein between cortex and venous sinus and accumulation of blood in the subdural space. The underlying brain injury usually determines outcome in 80% of cases. SURGICAL EVACUATION is often needed.

Cerebral Contusions: Initial period of loss of consciousness followed by slow recovery period with intermittent fluctuations in consciousness, seizures, and focal neurological deficits from the edema that develops. Usually NO SURGERY in these cases.

Diffuse Injuries

Diffuse injuries are more dispersed and disseminated. Diffuse Axonal Injury is a common type of diffuse injury. Diffuse injuries usually occur due to rapid acceleration, deceleration, and/or rotational events. Commonly involved regions include the Reticular formation (brainstem), basal ganglia, superior cerebellar peduncles, limbic fornices, hypothalamus, and corpus callosum. Computerized Tomography is usually not helpful in identifying diffuse injuries. Diffusion-weighted MRI is preferred because it is sensitive to axonal edema.

Problems with arousal, attention, and processing speed often result from diffuse axonal injury

Secondary Injuries

Secondary injuries result from the brain’s response to the initial injury.

Pathogenesis: Edema and/or intracranial bleeding leads to increased intracranial pressure and subsequent compression and deformation of brain tissue. Inflammatory mediators (e.g. cytokines), neurotoxic neuropeptides, and glutamate toxicity likely contribute to the damage of surrounding brain tissue. Some experts believe the secondary response is more damaging than the primary response as inflammation and edema are damaging to brain tissue.

Clinical Signs and Symptoms of Traumatic Brain Injury

Also called “Post Concussive Syndrome”

  • Cognitive disturbances
  • Fatigue
  • Disordered Sleep
  • Headache
  • Vertigo
  • Irritability/Aggression
  • Anxiety Disorders
  • Depression (common)
  • Affective Lability
  • Personality Changes
  • Apathy/lack of spontaneity
  • Psychosis (rare)
  • Mania (rare)

Management of Traumatic Brain Injury (TBI)

Medication-Based Management

Patients with TBI are more sensitive to medication side effects (e.g., extrapyramidal side effects, sedation, orthostasis, etc.). Therefore, patients are started on medications at much lower doses with slower titrations. 

Medications to avoid, if possible:

  • Typical antipsychotics (EPS risk)
  • Clozapine (seizure risk, sedation, cognitive impairment)
  • Benzodiazepines (delirium risk, falls, cognitive impairment, paradoxical disinhibition)
  • Barbiturates (delirium risk, falls, cognitive impairment, paradoxical disinhibition)
  • Anticholinergics (delirium risk)
  • Antihistamines (delirium risk)
  • Alpha-1 blockers (falls, orthostasis)

Medication Options

  • Selective Serotonin Reuptake Inhibitors (e.g., Citalopram, Fluoxetine, Sertraline)
  • Propranolol
  • Amantadine
  • Modafinil/Armodafinil
  • Psychostimulants (Methylphenidate, Amphetamines)
  • Buspirone
  • Electroconvulsive Therapy (ECT)*
  • Valproic acid, Carbamazepine
  • Atypical Antipsychotics**
  • Lithium

*Except in patients with mass occupying lesions

**Animal research suggests some antipsychotics may interfere with neural plasticity and are associated with longer post-traumatic amnesia and worse outcomes

NOTE: While not covered here, it is worth mentioning that psychosocial/behavioral/cognitive interventions are essential for long term recovery. Below is a great review article.

Traumatic Brain Injury Review Article (PDF)


  1. Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
  2. Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  3. J. Ferrando, J. L. Levenson, & J. A. Owen (Eds.), Clinical manual of psychopharmacology in the medically ill(pp. 3-38). Arlington, VA, US: American Psychiatric Publishing, Inc.
  4. Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  5. Arciniegas, Yudofsky, Hales (editors). The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences. Sixth Edition.
  6. Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  7. Mendez, M. F., Clark, D. L., Boutros, N. N. (2018). The Brain and Behavior: An Introduction to Behavioral Neuroanatomy. United States: Cambridge University Press.
  8. Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. Sixth Edition

What is Cognitive Behavioral Therapy (CBT)?

Cognitive Behavioral Therapy (CBT) 

DISCLAIMER: This module is for educational purposes only. Please always consult a physician or mental health professional for personal health concerns.

The Science of Cannabis

Marijuana (also spelled marihuana) is a word derived from maraguanquo, meaning “intoxicating plant”. Marijuana refers to a mixture of dried leaves, stems, and flowering tops of a weed-like plant, which was given the name Cannabis sativa by Linnaeus in 1753. Cannabis is a flowering hemp used for thousands of years as a fiber source for producing rope, clothing, and paper (among other uses). 

The term Cannabinoid describes the basic chemical structure shared by 70 or so unique compounds identified in the cannabis plant.

It wasn’t until the 1960s when Israeli researchers Yehiel Gaoini and Raphael Mechoulam identified one of these cannabinoid compounds, Δ-9-tetrahydrocannabinol (THC), as the major psychoactive ingredient in Cannabis. Another important phytocannabinoid (“phyto” means plant) with relatively low affinity for neuronal cannabinoid receptors is cannabidiol (CBD).

CBD is not considered psychoactive and research suggests considerable therapeutic potential for CBD in treating epilepsy, neurodegenerative disorders, anxiety, psychosis, and substance abuse. 

Marijuana can be obtained and prepared in a variety of ways for consumption. While marijuana can be consumed orally (e.g., cookies, brownies), the most common method of consumption is smoking the plant in rolled cigarettes called “joints” or in pipes and bongs. Tobacco and marijuana can be consumed together in hollowed-out cigars, or blunts, or in spliffs, which are joints/cigarettes containing a mixture of tobacco and marijuana.

Common street slang for marijuana include pot, reefer, grass, weed, dope, ganja, and mary jane. Terms used for the intoxicating experience of THC include “stoned” or “high”. 

The THC content of the cannabis plant depends on the strain, growing conditions, and pollination. The most common method of increasing marijuana’s THC potency is by preventing pollination and seed production by female plants. This is called sinsemilla (“without seeds”) and is now the most popular type of cannabis in circulation. 

The amount of THC can be increased by various methods that involve extracting the cannabinoids from the cannabis plant. Hashish is an example of a concentrated extract found in many parts of the Middle East and East Asia.

Recently, “dabbing” has become popular. Dabbing involves extraction of cannabinoids with butane. The solvent is then evaporated leaving behind a waxy sticky residue that is very high in THC. The waxy resin is smoked using a torch lighter or vaporizing device (i.e., vape pen). 

Not surprisingly, the THC content in consumed cannabis plants has risen over the past 20 years. The yearly mean THC content of marijuana seized by the drug enforcement agency (DEA) in 1995 was about 4%. In 2014 this number was as high as 12%. 

While medicinal and recreational use of marijuana dates back over 8,000 years in East Asia, the practice of marijuana smoking was introduced into the United States in the early 1900s. An anti-marijuana campaign in the 1930s led to the first federal regulations controlling cannabis and in 1937 marijuana became illegal in the United States with the passage of the Marijuana Tax Act. Recently, marijuana has been legalized in many states for medicinal use only but many are beginning to legalize the purchasing and recreational consumption of this intoxicating plant. 

Pharmacology of THC

Routes of Administration, Absorption, and Dosing

Marijuana is consumed orally (brownies, cookies, candies, tinctures) or smoked (inhaled into the lungs). An average joint contains about 0.5 grams to 1.0 grams of cannabis and approximately 40mg of THC. Smoking marijuana is the most rapid method of delivering THC to the brain as THC absorbed by the lungs bypasses the metabolizing enzymes in the liver. After inhaling marijuana smoke, about 20%-30% of the THC content in the smoke is rapidly absorbed in the lungs where it quickly enters the pulmonary circulation and travels to the brain. The amount of THC absorbed depends on the initial THC content in the plant and the pattern of smoking. The dose and time to effect are influenced by puff volume, puff frequency, inhalation depth, and the length of time the breath is held.

After smoking marijuana, THC levels peak in the blood after about 20 to 30 minutes and decline rapidly over the course of 1-2 hours. However, complete elimination from the body can take much longer as the lipophilic properties of THC means it can easily accumulate in fat tissue. The slow release of THC stored in fat is the reason THC metabolites can be detected weeks after a single use. 

Oral consumption of THC leads to prolonged but poor absorption of THC compared to inhalation. The bioavailability of THC is markedly reduced with oral consumption as a result of first-pass metabolism in the liver. This means oral consumption leads to unpredictable and variable THC levels. After consuming THC orally, THC levels peak in about 2-3 hours. 

Metabolism of THC and CBD

THC is metabolized initially in the lungs and liver. There are over 80 THC metabolites identified. Two major metabolites are 11-hydroxy-THC (11-OH-THC) and 11-nor-9-carboxy-THC (THC-COOH). Interestingly, 11-OH-THC crosses the blood-brain-barrier more readily than THC and is more effective in producing psychological effects in man. About 60%-70% of THC metabolites are excreted in feces and 20%-30% are excreted in the urine. Some metabolites may remain in the body for several weeks (metabolites may be detected in urine and feces for more than a week). As mentioned previously, THC and its metabolites accumulate in tissues (fat and brain) with repeated administration. Chronic users metabolize THC more rapidly than others. 

Cannabinoid Receptors

There are two major types of cannabinoid receptors identified to date: CB1 receptors and CB2 receptors. Generally, activation of CB receptors inhibits neurotransmission.

CB1 Receptors

The CB1 receptor is the principal cannabinoid receptor in the brain, where it is expressed at a high density in areas such as the basal ganglia, cerebellum, hippocampus, and cerebral cortex. 

CB1 receptors are typically located on axon terminals, where they act to inhibit the release of many different neurotransmitters. THC administration to mice causes classical CB1 receptor–mediated effects. These include reduced motor activity, hypothermia (reduced body temperature), catalepsy (rigidity/freezing behavior), and decreased response to painful stimuli (hypoalgesia). CB1 agonists also impair learning and memory consolidation via inhibition of long term potentiation (LTP) in the hippocampus. CB2 receptor activation in the immune system causes cytokine release and changes in immune cell migration necessary for an appropriate inflammatory response.

CB2 Receptors

The CB2 receptor was first identified in the immune system, but it is also found in a number of other tissues, including the brain, where it is mainly localized in microglial cells, which are immune cells that help fight off foreign invaders (among other roles). 

Endocannabinoids (The cannabinoids we make ourselves)

Our brain synthesizes several substances, called endocannabinoids, that are neurotransmitter-like retrograde messengers that stimulate CB1 receptors on presynaptic neurons (and other nearby cells) and modulate the release of numerous neurotransmitters. Anandamide was the first endocannabinoid to be discovered followed by 2-arachidonylglycerol (2-AG). 

The endocannabinoid system plays a complex role in learning, memory, and extinction of already learned tasks. Enhancing endocannabinoid signaling has anxiolytic effects in both stressed and unstressed laboratory animals, and it also leads to an antidepressant profile in standard rodent tests of depressive-like behavior. In contrast, reduced endocannabinoid levels are associated with increased anxiety- and depressive-like behaviors.

How Marijuana (THC) Affects Us

Acute (short-term) Physiological effects

Conjunctival injection (red eyes)
Orthostatic hypotension
Increased appetite

The Marijuana “High”

sense of well-being
mild enhancement of senses (smell, taste, hearing)
subtle changes in thought and expression
increased appreciation of music
increased appetite
mild closed-eye visual distortions

visual distortions may become more prominent
sense of time is altered (overestimation of time)
attention span is reduced
short-term memory (seconds to minutes) is impaired (confabulation may occur)
thought processes and mental perception may be significantly altered


Lung damage (1 smoked joint = 5 cigarettes)
Memory lapses
Inability to concentrate
Possible decreased resistance to diseases (impaired immune mechanisms)
Exacerbation of psychosis
Decreased testosterone levels (plasma) with chronic high doses
Impairment of driving judgment with regard to speed; motor coordination not necessarily impaired; compensation for drug effect may occur in some subjects (behavioral tolerance); motor incoordination and ataxia at high doses; additive or synergistic effects of THC and alcohol on motor coordination
Brain damage– evidence of neuronal damage in hippocampus after repeated administration of large doses in animals; no evidence of such damage substantiated in humans


Drug tolerance describes the reduced reaction to a drug following repeated use. Increasing the dosage of drug may or may not restore the drug’s effects. Tolerance is often reversible (e.g., through a drug holiday) and can involve both physiological and psychological factors. Tolerance to the psychological effect of THC has been demonstrated but is subject-dependent. There is some tolerance to physiological effects. Pharmacodynamic and behavioral tolerance also occurs. 

Therapeutic Roles for THC

Dronabinol (Marinol®)

Dronabinol is a THC analog approved for chemotherapy-induced nausea and as an appetite stimulant in patients with AIDS or cancer. Other potential therapeutic uses include glaucoma (by reducing ocular pressure) and analgesia (neuropathic pain, allodynia, hyperalgesia, peripheral pain).

Cannabinoids and Pain

Cannabinoid involvement in pain modulation is beyond the scope of this post, but it is worth mentioning that cannabinoids modulate pain pathways.


  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
  • Arciniegas, Yudofsky, Hales (editors). The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences. Sixth Edition.
  • Bear, Mark F.,, Barry W. Connors, and Michael A. Paradiso. Neuroscience: Exploring the Brain. Fourth edition. Philadelphia: Wolters Kluwer, 2016.
  • Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. 2nd ed. Sunderland, Mass.: Sinauer Associates, 2010.
  • Cooper, J. R., Bloom, F. E., & Roth, R. H. (2003). The biochemical basis of neuropharmacology (8th ed.). New York, NY, US: Oxford University Press.
  • Higgins, E. S., & George, M. S. (2019). The neuroscience of clinical psychiatry: the pathophysiology of behavior and mental illness. Philadelphia: Wolters Kluwer.
  • Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  • Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
  • Mendez, M. F., Clark, D. L., Boutros, N. N. (2018). The Brain and Behavior: An Introduction to Behavioral Neuroanatomy. United States: Cambridge University Press.
  • Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  • Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  • Sixth Edition. Edited by Dale Purves, George J. Augustine, David Fitzpatrick, William C. Hall, Anthony-Samuel LaMantia, Richard D. Mooney, Michael L. Platt, and Leonard E. White.
  • Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  • Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  • Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincotts illustrated reviews: pharmacology. Philadelphia, PA: Wolters Kluwer.

Folate, Methylfolate, MTHFR, and Mood

Folate, Methylfolate, MTHFR, and Mood

What is Folate?

Folate, also called vitamin B-9 or folic acid, is a B vitamin found mainly in dark green leafy vegetables, beans, peas, nuts, oranges, lemons, bananas, melons and strawberries. Folate has important roles in red blood cell formation, cell growth, and cell functioning. It is also a very important vitamin during neurodevelopment. Let’s first discuss how folate is transformed in the body.

Folate is converted into L-methylfolate (L-MF)

  1. Folate, also called folic acid, is converted to dihydrofolate (DHF) and then tetrahydrofolate (THF) by the enzyme dihydrofolate reductase (DHFR).
  2. Serine hydroxymethyl-transferase (SHMT) then converts tetrahydrofolate (THF) to methylene-tetrahydrofolate (THF).
  3. Methylene tetrahydrofolate (THF) is converted by methylene tetrahydrofolate reductase (MTHFR) to L-methylfolate.

Methylenetetrahydrofolate reductase (MTHFR) is an important enzyme in the production of L-methylfolate

As we discussed above, L-methylfolate, the active form of folate, is very important in the production of brain chemicals that regulate mood such as dopamine, norepinephrine, and serotonin. The methylenetetrahydrofolate reductase (MTHFR) enzyme (the chef in the figure below) is an important enzyme involved in the conversion of folic acid (folate) into L-methylfolate.

What does any of this have to do with mood?

Some individuals carry a mutation (or change in the gene) which results in reduced activity of MTHFR.

Below are a few genetic variants of MTHFR:

Methylene tetrahydrofolate reductase: MTHFR C677T; MTHFR A1298C

If an individual’s MTHFR activity is reduced, then they are “struggle” to convert folate to L-methylfolate.

Without enough L-methylfolate, the body may not be able to produce enough serotonin, dopamine, or norepinephrine and this may explain why certain medications that rely on adequate levels of these brain/mood chemicals (such as selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors) don’t work that well in some people. That is, if there is little to no serotonin or norepinephrine available to be released, then reuptake inhibition of serotonin or norepinephrine won’t do much.

In those individuals with reduced capacity to convert folate to L-methylfolate, supplementation with L-methylfolate may increase production of those important brain/mood chemicals and hypothetically improve the responsiveness to antidepressants and other medications that rely upon the presence of those brain/mood chemicals to work properly. 

For more information on MTHFR, Click Here.


DNA Methylation, L-Methylfolate, and COMT

DNA methylation occurs when a methyl (-CH3) group is attached to DNA. When this happens, the DNA molecule becomes more tightly coiled and this, in turn, prevents gene expression.

In other words, methylation silences genes.

L-Methylfolate is considered a “methylator” as it provides a methyl group for this type of DNA methylation.

Why does this matter?

Catechol-O-methyl-transferase (COMT) is an important enzyme that breaks down monoamines like dopamine and norepinephrine.

The more COMT there is, the more dopamine is broken down and therefore less available for neurotransmission.

If L-methylfolate is low, then perhaps this means less methylation of various genes such as COMT.

Since methylation reduces genetic expression, decreased methylation of, say, COMT, would mean INCREASED genetic expression of COMT. The more COMT, the more breakdown of monoamines.

Studies have shown genetic variability in the expression of COMT in patients with disorders such as Schizophrenia. Some variants of the COMT gene result in greater expression of COMT and less dopamine availability in areas of the brain like the prefrontal cortex (PFC).

Decreased dopamine levels in a specific area of the prefrontal cortex called the dorsolateral prefrontal cortex (DLPFC) could impair information processing and cause symptoms such as cognitive dysfunction.

Therefore, L-methylfolate supplementation would, theoretically, result in higher dopamine levels in those brain areas and improve cognitive deficits in individuals with that gene variant of COMT.

Folate and Drug Interactions

Folate + Anticonvulsants

Taking folic acid with fosphenytoin (Cerebyx), phenytoin (Dilantin, Phenytek) or primidone (Mysoline) might decrease the drug’s concentration in your blood.

Folate + Barbiturates

Taking folic acid with a drug that acts as a central nervous system depressant (barbiturate) might decrease the drug’s effectiveness.

Folate + Methotrexate (Trexall)

Taking folic acid with this medication used to treat cancer could interfere with its effectiveness.

Folate + Pyrimethamine (Daraprim)

Taking folic acid with this antimalarial drug might reduce the effectiveness of the drug.

Folate Facts

  • The recommended daily amount of folate for adults is about 400 micrograms (mcg). For adult women who are planning pregnancy or could become pregnant the recommended daily amount of folate is usually 400 to 1,000 mcg per day.
  • Folate works together with other vitamins such as B-6 and B-12 to regulate high levels of something called homocysteine. Elevated homocysteine levels in the blood have been shown to increase the risk of cardiovascular diseases.
  • Increased intake of folate can mask the megaloblastic anemia associated with vitamin B-12 deficiency, which may go undiagnosed and cause irreversible nerve damage.


  1. Cooper, J. R., Bloom, F. E., & Roth, R. H. (2003). The biochemical basis of neuropharmacology (8th ed.). New York, NY, US: Oxford University Press.
  2. Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  3. Puzantian, T., & Carlat, D. J. (2016). Medication fact book: for psychiatric practice. Newburyport, MA: Carlat Publishing, LLC.
  4. J. Ferrando, J. L. Levenson, & J. A. Owen (Eds.), Clinical manual of psychopharmacology in the medically ill(pp. 3-38). Arlington, VA, US: American Psychiatric Publishing, Inc.
  5. Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  6. Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  7. Stahl, S. M. (2014). Stahl’s essential psychopharmacology: Prescriber’s guide (5th ed.). New York, NY, US: Cambridge University Press.
  8. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  9. Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincotts illustrated reviews: pharmacology. Philadelphia, PA: Wolters Kluwer.
  10. Charney and Nestler’s Neurobiology of Mental Illness. 5th Ed. Oxford University Press. 2017. 

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All About ADHD

What is ADHD?

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder of attention, concentration, impulsivity, and hyperactivity. ADHD is one of the most heritable psychiatric disorders and the most common behavioral disorder in children.

ADHD was initially thought to be a disorder exclusively in children, but we now know that adults may also suffer with ADHD symptoms. In fact, approximately two-thirds of children diagnosed with ADHD experience impairing symptoms in adulthood.

In school-aged children/adolescents, the prevalence of ADHD is about 5-7%.

There are different types of ADHD. The specific type will depend on whether the predominant symptoms are inattentiveness, hyperactivity, or a combination of both. The combined type is the most common type in children and adolescents.

Males are more likely diagnosed in childhood and adolescence, likely because males display more hyperactive symptoms than females and therefore are more likely to be referred for evaluation.

Females usually experience more inattentive symptoms and aren’t diagnosed until later in life. This is supported by the more equal prevalence of ADHD in adult males and females. The inattentive type is the most prevalent type in adults (about 47% of cases). As children age, there is a decrease in the hyperactive-impulsive symptoms due to the maturation of brain circuits in the cerebral cortex.

The core symptoms of ADHD include inattention, hyperactivity, and impulsivity. These symptoms interfere with an individual’s relationships, work, schooling, or other important areas of functioning.

Inattention problems include any of the following 

-Difficulty with attention to detail
-Often makes careless mistakes
-Difficulty listening when spoken to directly (e.g., mind seems to wander elsewhere).
-Difficulty following directions
-Difficulty organizing tasks and activities
-Often avoids tasks requiring sustained mental effort
-Often loses things/personal items 
-Often is easily distracted
-Often forgetful about daily activities
-Often has difficulty sustaining attention
-Often bored or loses interest quickly

Hyperactivity includes any of the following

-Often fidgets or shifts in seat (example: meditation can be very difficult for those with ADHD)
-Often leaves seat in situations when remaining seated is required 
-In children, often runs about or climbs in situations where it is inappropriate
-Often unable to play or engage in leisure activities quietly
-Internal restlessness or feeling constantly on the go
-May talk excessively

Impulsivity includes any of the following

-Often finishes sentences or blurts out answers
-Often has difficulty waiting his or her turn
-Often interrupts others 
-Often impatient 

What is Attention?

Attention is a cognitive function. Attention describes the process of determining the importance of various stimuli and selecting the stimuli most relevant to the task at hand. Attention is an important component of our consciousness.

Which Brain Areas are Involved in Attention?

Although neural networks throughout the entire brain contribute to most cognitive functions, there are some areas of the brain which appear to play a greater role in attentiveness. These areas include the prefrontal cortex (which is part of the frontal lobe or frontal region of the brain) and the regions “underneath” or “embedded” in the frontal lobe such as the cingulate cortex and its connections with the nondominant parietal lobe.


Reward and Impulse Control

Controlling the impulse to take an immediate, smaller reward rather than waiting for the larger, delayed reward is essential for completing long term goals. People who cannot control their impulses often fall behind. In the famous Stanford Marshmallow Experiments of the 1970s, Walter Mischel, a psychologist, conducted a very interesting experiment:

Four-year-old children were given one marshmallow. These children were told that they could either eat the marshmallow now or wait and receive TWO marshmallows (oh my!) later. Some children couldn’t wait and ate the marshmallow immediately. Others waited a little but eventually ate the marshmallow. And yet others waited until they were rewarded the TWO marshmallows (what a reward!).

The children in the study were followed into adolescence and adulthood. It turned out that the children who were better at inhibiting the impulse to immediately eat the one marshmallow were more resilient, confident, and dependable as adolescents. They also scored higher on standardized tests such as the SAT. While a controversial study with some methodological problems, the results were interesting nonetheless.

Dopamine, Norepinephrine, and Impulsivity

Dopamine and norepinephrine are two very important brain chemicals involved in attention, movement, and impulse control. These two chemicals work together to filter out irrelevant stimuli while enhancing the relevant stimuli. In individuals with ADHD, these two chemicals appear to be imbalanced or “out of tune.” By enhancing these brain chemicals with medications and therapy we can improve symptoms dramatically!

Attention and impulsivity are partially controlled by dopamine (DA) located in an area of the brain called the Nucleus Accumbens (NAc)–a part of the brain responsible for pleasure, motivation, and reinforcement. This area of the brain is activated by drugs such as cocaine, amphetamines, alcohol, and opioids.

Prescription medications such as Concerta, Ritalin, Focalin, Adderall, Dexedrine, and Vyvanse are used to help with the core symptoms of ADHD. These medications increase dopamine in the NAc to improve one’s ability to control impulsive behaviors.

Brain Changes in ADHD

Changes in the prefrontal cortex (PFC) and striatum are the most common abnormal brain findings reported for ADHD. Judith Rapoport’s National Institute of Mental Health (NIMH) neuroimaging studies have revealed interesting findings in children with ADHD. Children with ADHD, on average, have smaller brain volumes by about 5% and also have smaller cerebellums (the little brain in the back of the brain). Importantly, the trajectory of brain volumes did not change as the children aged, nor was it affected by the use of stimulant medication.

When comparing brain activity in children with and without ADHD, there was significantly greater activity in the parietal and frontal lobes of children without ADHD during an attention task (see figure below). This tells us that decreased activity in the frontal and parietal lobes may be partially responsible for inattentiveness. That is, these brain areas aren’t activated enough or “online” during attention-requiring tasks.


ADHD & Gender Differences

The symptoms of ADHD present slightly differently in males and females. A list of differences is provided in the table below.

Consequences of Untreated ADHD

A World Health Organization survey estimated that 3.5% of all workers suffer from ADHD yet only a minority of these workers received treatment. Young adults diagnosed with ADHD, but not treated, are less likely to enroll in college or graduate from college, are more likely to be on academic probation, and are more likely to have a lower grade point average.

Adults with untreated ADHD experience difficulties in all aspects related to employment, are at significantly higher risk for developing substance use disorders and are more likely to engage in risky behaviors resulting in traffic tickets, motor vehicle accidents, and other injuries.

Core ADHD Symptoms in Adults

Hyperactivity in adults often manifests as inner restlessness, talkativeness, excessive fidgeting, and high-risk activities. Impulsivity in adults often manifests as general impatience, talking without thinking, problems maintaining employment, difficulty maintaining relationships, attention seeking behavior, high risk behaviors, and self-medicating with drugs and alcohol. Inattentiveness in adults often manifests as chronic boredom, indecisiveness, procrastination, disorganization, and distractibility.

Common complaints in adults with ADHD include rapid mood swings, difficulties dealing with stressful situations, frequent irritability and frustration, emotional excitability (e.g., anger over minor things), relationship problems (e.g., short-lived, divorce), and low frustration tolerance.

It is important to mention that ADHD IS NOT RELATED TO INTELLIGENCE.

ADHD vs Bipolar Disorder

Differentiating ADHD from Bipolar Disorder can be difficult because many symptoms overlap and both disorders often co-occur (that is, many patients have both ADHD and Bipolar Disorder). Below is a table that helps differentiate the two.

Treatment Options For ADHD

Psychostimulant medications such as amphetamines (Adderall, Dexedrine, Vyvanse) and methylphenidates (Ritalin, Concerta, Focalin) are first line treatments for attention deficit hyperactivity disorder. Nonstimulants such as Bupropion (Wellbutrin), Atomoxetine (Strattera), clonidine, and guanfacine are also used for ADHD. These medications primarily target inattention, hyperactivity, impulsivity, mood reactivity, restlessness, scattered thinking, boredom, procrastination, and tendency toward substance abuse.

Studies suggest that amphetamines may be more effective for adult ADHD symptoms than methylphenidates. However, amphetamines are more likely to worsen or induce tics. Therefore, amphetamines are usually tried first unless there is a history of tics in which case methylphenidates are a better option.

Educating patients about ADHD and offering behavioral tips (such as time management strategies) are very important and should be provided and incorporated in therapy.

Neuro-modulatory modalities such as biofeedback/neurofeedback should be considered if medication and behavioral strategies are not effective (or only partially effective).

A note on ADHD and Substance Use

The common belief that individuals with a history of substance abuse shouldn’t be prescribed psychostimulants is not supported by empirical or anecdotal evidence. In fact, proper treatment of ADHD symptoms has been associated with a reduction in substance use. For more information on this, please see the articles below.

ADHD Medication and Substance-Related Problems 

Stimulant ADHD medication and risk for substance abuse

What ADHD Might Look Like

As a psychiatrist who advocates for the appropriate diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Adults, I am frustrated by the many misconceptions of ADHD. If you or someone you know have suffered from this disorder, perhaps the story below will be familiar. 

At some point in your life, you came to the realization that something just wasn’t adding up. Throughout early schooling you struggled to stay organized and motivated. But on the rare occasion that you found the energy and courage to sit down on a Saturday (rather than Sunday near midnight) and attempt your weekend homework you were probably discouraged as your internal dialogue became louder and louder…

“How many times do I have to read this sentence before I understand what it means?”

“How did I just read 20 pages of this book but can’t tell you one meaningful thing about it?”

“Why is this so difficult?”

This pattern gets old, so you begin telling yourself that you’re just not smart enough, not good enough, not savvy enough to juggle life like everyone else. And of course, the most encouraging and reassuring remarks you received were statements like

“You just need to work harder”

“Stop being lazy”

“Do you even care about your future?” 

Now that your self-esteem was sinking like the Titanic, your contagious positive spirit began drowning too. If not already feeling like a failure, you sensed actual failure was imminent.

As time went on, you probably took one of the following routes: Either you said “f**k it” and started drinking, partying, and rebelling out of anger and frustration OR you continued to suffer in silence pretending you were okay only to feel more drained and guilty about not telling the truth. Or maybe you developed coping skills and compensated by being overly obsessive and overly worried about everything because you’ve been told repeatedly that in order to achieve your goals you just needed to work harder. 

Then one day you heard someone talk about attention deficit hyperactivity disorder and you immediately felt something awaken inside you. You were so relieved to hear you weren’t the only one who relied on Spark notes to pass English class–not because you were lazy but because there wasn’t enough time in the day to read the same page more than 3 times. After all, 20 pages of reading meant 60 pages for you. 

So, you debated whether to go to the doctor and be evaluated. You felt vulnerable and worried about opening up to someone you’ve never met. You started to worry that you might sound like a “drug seeker” or a “cheater.” Once you finally built the courage to share your story you were met with your worst nightmare–immediate invalidation. 

“We don’t prescribe those drugs in this clinic.” 

This is followed by urine drug testing and a referral for a $1,500 Neuropsychological test that only worsens your preexisting anxiety and obsessive thinking.

So, you go to the testing center and sit there in a quiet room clicking buttons and solving puzzles for hours as if that accurately captures the work-life of someone struggling with ADHD symptoms. 

Human beings are really complicated

There are many points to this story. Humans are complex and the brain is by far the most complicated system in our universe. Neuropsychological tests for ADHD are NOT something I routinely order, and the reasoning is simple: How does sitting at a computer in a quiet exam room solving boring puzzles for hours confirm that my patient really is experiencing distress and dysfunction? How does a neuropsychology test with inconsistent validity help my patient who can clearly articulate how they are feeling and what they are experiencing?

Science Speaks

Despite numerous attempts by the uninformed to delegitimize the diagnosis of ADHD, the science speaks loud and clear: attention deficit hyperactivity disorder (ADHD) is a real disorder that can occur in children and adults. It isn’t uncommon to hear people offer opinions such as “ADHD is an excuse to medicate misbehaving children to appease parents” or “everyone has ADHD and would benefit from psychostimulants.” When I hear these things, I take a deep breath and remind myself that these opinions are just what they are…opinions.

The belief that ADHD is an excuse to medicate misbehaving children, or the notion that adults seek an ADHD diagnosis to obtain stimulants to “cheat the system”, are not supported by any legitimate scientific evidence.

Do people abuse prescription stimulants? Yes, they do.

Are some children misdiagnosed with ADHD? Yes, some are.

Do some adults “fake” the diagnosis to obtain stimulants? Yes, some do.

But let’s leave the blanket statements and unsubstantiated beliefs in the box labeled “99% of political arguments” (the label included). If anything, ADHD is not recognized nearly enough in adults. The possible reasons for this are beyond the scope of this post.


If you’re the one spreading rumors that street methamphetamine is just like Adderall, then you’re also the one who believes that illicit methamphetamine purchased on the street has the same pharmacokinetic and pharmacodynamic effects as prescription stimulants simply because both are amphetamines. In which case I’ll go ahead and whip up some methanol martinis for you. Don’t worry, ethanol and methanol are both alcohols. If you go blind, you’ll understand my point.


  1. Young, Joel. ADHD Grown Up: A Guide to Adolescent and Adult ADHD .(2007)
  2. Gil Zalsman & Tal Shilton (2016) Adult ADHD: A new disease?, International Journal of Psychiatry in Clinical Practice, 20:2, 70-76, DOI: 10.3109/13651501.2016.1149197
  3. Stewart, T. D., & Reed, M. B. (2015). Lifetime nonmedical use of prescription medications and socioeconomic status among young adults in the United States. The American journal of drug and alcohol abuse, 41(5), 458–464. doi:10.3109/00952990.2015.1060242
  4. Psychiatric Times. 7 Evidence-Based Insights About ADHD.
  5. Higgins, E.S. & George, M.S. The Neuroscience of Clinical Psychiatry: The Pathophysiology of Behavior and Mental Illness. 3rd Edition. 2018.
  6. Blumenfeld, Hal., MD, PhD. Neuroanatomy Through Clinical Cases. 2nd Edition. 2010.
  7. Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  8. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.
  9. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013
  10. Schatzberg & Nemeroff. The American Psychiatric Association Publishing Textbook of Psychopharmacology. 5th Edition. 2017.


Obsessive Compulsive Disorder is more than being a germaphobe

Obsessive-Compulsive and Related Disorders

Being a “neat freak” has little to do with obsessive compulsive disorder

Obsessive Compulsive Disorder (OCD) is a type of anxiety disorder where individuals experience intrusive and unwanted thoughts (or images). That is, the thoughts or images pop up at inconvenient times and stay there. These awful thoughts can cause a lot of anxiety and distress. This is because those suffering with OCD attach greater meaning and significance to every thought, feeling, or experience they have.

The figure below illustrates this point. The marbles represent all the thoughts, feelings, and sensations we have, and the spotlight represents the focus of our attention. Normally, we filter the thoughts, feelings, and sensations we experience and only direct our attention to those that are truly meaningful and important. However, those with obsessive compulsive disorder (and other anxiety disorders) place significance on nearly every thought, emotion, and sensation they experience. This is because the “alarm system” is constantly signaling that “something is wrong.”

It’s difficult to be mentally present when our attention is constantly being hijacked and directed to the thoughts, feelings, and sensations that we believe are significant. It’s also an exhausting existence.

What is an obsession?

An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. Obsessions are mental events. This can include worries about contamination (germs), health problems (e.g., worrying about having cancer or some other devastating disease without any clinical evidence that it exists), sexual thoughts (e.g., worrying about being a pedophile, sex offender, or fear of molesting others when there is no evidence or history to support it), perfectionism or “just right” obsessions, moral OCD (e.g., worrying about being an immoral or horrible person), among others. 

What is a compulsion?

In an attempt to reduce distress and anxiety, individuals with OCD may perform compulsive rituals such as counting, checking, or repeating words in a very specific way. These repetitive acts are called compulsions. By definition, a compulsion is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding. Compulsions may be mental or behavioral events. Compulsive acts are carried out in an attempt to relieve the anxiety associated with the obsession. Resisting a compulsive act increases anxiety. 

A few examples of compulsions include

  • Counting
  • Checking repeatedly 
  • Washing hands or body repeatedly
  • “Fixing” items that seem out of place, so they are “just right”
  • Repeating a word or words aloud or internally
  • Attempting to “undo” a thought
  • Researching online
  • Visiting healthcare providers repeatedly
  • Difficulty letting items go (hoarding)
  • Cutting, burning, banging, hitting, picking
  • Seeking reassurance from others, asking others if certain thoughts, feelings, sensations are “normal,” or comparing oneself to others as a barometer for “living the right way.” 

These compulsive behaviors can be time-consuming, unproductive, and even harmful. To the person experiencing them, they are torturous and stressful. Because these behaviors are irrational and stressful to the individual experiencing them, they are called ego dystonic. This is in contrast to individuals with Obsessive Compulsive Personality who are perfectionists not distressed by their thoughts and behaviors because they align with their values and beliefs (ego syntonic).

A Disorder of Pathological Doubt

OCD can be thought of as a disorder of doubt. A persistent feeling of doubt and the need for reassurance are the prominent features of OCD. One of the most debilitating aspects of OCD is the insatiable nature of the compulsive behavior (i.e., seeking reassurance) that never quite reaches an acceptable level. This leads to tortuous repetition of the compulsive acts/reassurance-seeking behaviors despite the individual recognizing their irrational nature (ego dystonic). 

There are numerous symptom “themes” or “types” of OCD, and many have more than one “theme” of OCD. Click on each theme to read more about them.




OCD is the 4th most common outpatient psychiatric diagnosis with approximately 10% of people having the diagnosis in psychiatric clinics. Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries. Females are slightly more affected than males in adulthood whereas boys are 2-3 times more affected than girls in childhood. Mean age of onset is approximately 19.5 years old. Males typically have an earlier age of onset than females. It is important to note that OCD rarely develops after age 35. 

Risk Factors

Risk factors for developing OCD include genetic factors and environmental factors (e.g., psychosocial stressors, developmental problems, trauma, abuse, perinatal complications, infections). There is ongoing controversy around the purported association of childhood streptococcal infections and risk of developing obsessive compulsive disorder. Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) is a controversial autoimmune disorder believed to develop in children after group A beta hemolytic streptococcal infections. Antibodies to GABHS also attack health brain regions causing acute and rapid onset of tics and other OCD symptoms. 

Associated Conditions

About 90% of patients with OCD suffer from other disorders such as anxiety disorders, depression, bipolar disorder, impulse control disorders, substance use disorders, and Tourette’s disorder (i.e., tic disorders). Up to 50% of children suffering with OCD also suffer from attention deficit hyperactivity disorder, separation anxiety disorder, specific phobias, generalized anxiety disorder, and Tourette’s disorder (i.e., tic disorders). 

Other Disorders related to OCD

Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder is a type of OCD-related disorder whereby individuals are preoccupied with an imagined defect in appearance which causes clinically significant distress. If a slight physical anomaly is actually present, the individual’s concern with the anomaly is excessive and bothersome. BDD is often accompanied by compulsions such as Mirror checking, Excessive grooming, and Comparing appearance to others. Women are more commonly affected than men and the age of onset is typically between 15 years old and 30 years old. Individuals with BDD often suffer with mood disorders, anxiety disorders, and psychotic disorders. Individuals with BDD are more commonly seen in Plastic Surgery Clinics, Dermatology Clinics, and/or Primary Care Clinics.

Hoarding Disorder 

Hoarding Disorder is another type of OCD-related disorder whereby individuals acquire and “hoard” unimportant possessions with little or no value due to an obsessive fear that may be needed in the future. This is a disorder of distorted beliefs about the importance of possessions. There is often excessive emotional attachment to possessions. The hoarding behavior leads to Cluttering, Unsanitary living conditions, Health risks (falls, animal born diseases), and Fire risks. Hoarding Disorder is commonly diagnosed in single persons with social anxiety or dependent personality traits. However, Hoarding Disorder can occur as a manifestation of other disorders/diseases such as dementia, Cerebrovascular disease, and schizophrenia. Unfortunately, most individuals with Hoarding Disorder not present to mental health clinics because most lack insight into their illness (ego-syntonic).

Hair-Pulling Disorder (Trichotillomania)

Trichotillomania was coined by a French dermatologist Francois Hallopeau in 1889 and is a chronic disorder characterized by repetitive hair pulling which results in hair loss. There is increased tension prior to hair pulling and relief of tension or gratification after the hair pulling. Women are affected more than men (10:1). Roughly 35%-40%  of individuals with Trichotillomania chew or swallow their hair. Swallowing hair increases the risk of Bezoars (hairballs in the GI tract) which can cause obstruction.

Excoriation (Skin-Picking) Disorder

Compulsive and repetitive picking of the skin. 1-5% lifetime prevalence. Women are affected more than Men. It is important to rule out stimulant-induced excoriation. Skin picking is most often seen on the Face but also Legs, Arms, Torso, Hands, Cuticles, Fingers, Scalp. Embarrassment leads to avoidance and social withdrawal. 12% of skin-picking patients have attempted suicide.

Olfactory Reference Syndrome

A false belief by the patient that he or she has a foul body odor. The odor is not perceived by others. Leads to excessive showering, changing clothes. May rise to level of somatic delusion (Delusional Disorder). It is important to rule out “organic” illnesses such as Temporal lobe epilepsy, Pituitary tumors, and Sinusitis. Currently there is little evidence for treatment. 

Medication or Drug-Induced Obsessive-Compulsive Symptoms

The following medications/drugs have been associated with worsening or causing obsessive compulsive symptoms:

Methylphenidate (rare)
MDMA (Ecstasy)
Synthetic Cathinones (“Bath Salts”)
Dopamine agonists
Aripiprazole (Abilify)
Medical Problems associate with OCD Symptoms
The following medical problems/neurological disorders have been associated with obsessive compulsive symptoms as part of the natural course of the illness:
Huntington’s Disease
Wilson’s Disease
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS)

Treatment Options

Current evidence suggests the combination of medication and mindfulness-based cognitive behavioral therapy/exposure response prevention therapy is the most effective approach to managing symptoms of OCD. By becoming consciously aware of the doubt cycle and its chain of events, one learns how to respond differently–starting with regaining cognitive and emotional balance through the application of acceptance strategies and mindfulness-based practices.

Problems with Treatment

20-30% of patients have significant improvement in symptoms with medication alone (this is increased when combined with therapy). 40-50% of patients have moderate improvement. Higher doses of SSRIs may be required to alleviate symptoms in OCD compared to depression. Higher doses of SSRIs means greater likelihood for developing side effects from these medications. 


The algorithm above is from the Psychopharmacology Algorithms Project at the Harvard South Shore Psychiatry Residency Training Program led by David Osser, MD.

Exposure Response Prevention Therapy remains the most effective therapeutic modality for OCD

Exposure Response Prevention (ERP) Therapy is a type of exposure therapy that uses the same principles as Cognitive Behavioral Therapy. In ERP, individuals are exposed to distressing situations and then prevented from immediately responding with a compulsive act. Over time, the individual learns to tolerate anxiety-provoking thoughts and situations in a more productive way.

ERP is about facing your fears and learning that it isn’t that bad (even though it feels bad in the moment).

As an example, a patient might expose themselves by placing their hands in dirt and then refrain from washing their hands for increasing lengths of time.

Over time, the individual would become more tolerant of the discomfort as they learn they are okay despite not washing their hands immediately and repeatedly. Obviously, this is much easier said than done.


  • Afshar, Hamid et al. “N-Acetylcysteine Add-On Treatment in Refractory Obsessive-Compulsive Disorder.” Journal of Clinical Psychopharmacology (2012): 797-803. Print.
  • Pauls, David L., Amitai Abramovitch, Scott L. Rauch, and Daniel A. Geller. “Obsessive–compulsive Disorder: An Integrative Genetic and Neurobiological Perspective.” Nature Reviews Neuroscience Nat Rev Neurosci (2014): 410-24. Print.
  • Oliver, Georgina, Olivia Dean, David Camfield, Scott Blair-West, Chee Ng, Michael Berk, and Jerome Sarris. “N-Acetyl Cysteine in the Treatment of Obsessive Compulsive and Related Disorders: A Systematic Review.” Clin Psychopharmacol Neurosci Clinical Psychopharmacology and Neuroscience (2015): 12-24. Print.
  • “Obsessive Compulsive Disorder.” Dynamed.
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Which path are you going to choose?

Does this sound familiar?

Thoughts racing, heart pounding, and that feeling in our chest that something just isn’t right. The “what ifs,” the “should haves,” and the doubt that holds us hostage to a future we can’t control.

“Just be in the moment” is the advice we can’t hear because our minds are too busy ruminating on a past we can’t change or a future we can’t control.

Paralyzing. Stuck. Lost. That’s what being in this moment feels like for us. Running on a treadmill to nowhere, we wonder why fatigue is our everyday norm. And those short-lived moments of peace and joy scare us because we don’t want the fall to hurt us more.

“It will be okay” is a confidence we don’t trust.

“Just relax” confirms that no one understands us.

“You’re so strong” is a compliment we don’t believe because we are too stuck on “Am I good enough?” or “What if people find out who I really am?”

If this resonates with you then you aren’t alone. So, when life gets tough–and it will get tough–you will have to choose which path you are going to take…

Which path are you going to choose?

Imagine life as a path through a very dense, mysterious, and frightening forest where the end of the path is the end of life. There are two paths you can take to reach the end.

The first path is a straight line to the end.

The first path is safe, comfortable, and predictable. There is little to see on this path and there is little to experience. On the straight path, you can avoid your fears, blame others for your problems, and feel comfortable every step of the way.

On the straight path there are no hardships, no problems to solve, and no struggles to overcome. You can hide behind social media and show the world only those parts of yourself that you want the world to see lest others reject the most vulnerable yet authentic parts you hide. Or you can take the second path.

The second path is a winding maze.

The second path is full of mountains, dirt roads, slippery mudslides, quicksand, waterfalls, and who knows what else. The second path is uncomfortable, frightening, and confusing at times. But this path is full of life lessons and obstacles to overcome. It’s the path that humbles you, brings you to your knees, and hurts sometimes. This path leads you to beautiful sights, smells, and sounds. It is full of meaning, purpose, and beauty–but only if you give yourself permission to stop and enjoy it along the way. 

Now imagine that one of you takes the first path (i.e., the straight path) and the other takes the second path (i.e., the scary maze).

Can you imagine the conversation between you two at the end? Can you imagine which of you would tell the best stories, share the most wisdom, and feel the most fulfilled? Just imagine how that conversation would go…

So which path are you going to choose?

Related Post...

How do stimulants (like Adderall) work?

How do stimulants (like Adderall) work?

The terms stimulant and psychostimulant aren’t well defined. Cocaine, amphetamine, methylphenidate, modafinil, armodafinil, caffeine, and nicotine belong to a class of drugs called psychostimulants for the marked sensorimotor (sensory and motor) activation that occurs in response to drug administration. Stimulants are characterized by their ability to increase alertness, heighten arousal, and cause behavioral excitement.

Stimulants have a rich history which is beyond the scope of this post. 

Today, psychostimulants are prescribed for the treatment of attention-deficit hyperactivity disorder (ADHD), narcolepsy, chronic fatigue, depression, and cancer-related fatigue to name a few. Stimulants are also drugs of abuse (such as cocaine, illicit methamphetamine, nicotine, and caffeine).

Let’s take a closer look at psychostimulants and how they work. 

Table of Psychostimulants

Dopamine and Norepinephrine

Dopamine (DA) and norepinephrine (NE) are monoamine neurotransmitters in the central nervous system that play very important roles in altering (or modulating) the communication between neurons. DA and NE are released from vesicles (called synaptic vesicles) into the synaptic cleft (i.e., area between neurons). DA and NE are recycled via reuptake into the neuron by transporter proteins called dopamine and norepinephrine transporters (see diagram below).

After being pumped back into the neuron by the transporters, dopamine (DA) and norepinephrine (NE) are taken up into small vesicles (little bubbles) called synaptic vesicles. They get pumped in by more transporter proteins called vesicular monoamine transporter 2 (VMAT2). Now they are ready to be released again!

After being released from the neuron, DA and NE bind to their receptors on the postsynaptic neuron (the next neuron).

See the figure below.

Both amphetamine (AMPH) and methylphenidate (MPH) target the dopamine and norepinephrine systems by increasing the concentration of these neurotransmitters in the synapse. AMPH has additional properties of promoting release by reversing the dopamine and norepinephrine transporters.

Amphetamine, AMPH (Vyvanse, Dexedrine, Adderall)

Amphetamine (AMPH) has numerous mechanisms.

First, it can be taken up into neurons via the dopamine transporter or norepinephrine transporter and then cause the transporters to reverse their actions, which means dopamine is pumped OUT instead of IN to the neuron.

Second, AMPH enters vesicles through VMAT2 and displaces dopamine by “forcing” dopamine out of the vesicle and into the cytoplasm which increases the dopamine concentration in the neuron and creates a gradient so that dopamine can “leak” out of the neuron through the dopamine reuptake pumps. This increases the dopamine concentration in the synaptic cleft.

Methylphenidate, MPH (Ritalin, Concerta, Focalin)

Methylphenidate (MPH) acts by inhibiting the dopamine and norepinephrine transporters only which increases the concentrations of dopamine and norepinephrine in the synapse. In this way, methylphenidate acts similar to cocaine. See the figure below.


Confused yet? Just keep reading…

Psychostimulants Reduce Noise and Enhance Signals

In individuals with attention and/or concentration problems, there may be a problem with how the brain is processing sensory input. Our brains spend an enormous amount of energy (up to 20-30% of all energy used by your body) processing information below our level of awareness. In fact, only a very small percentage of brain activity contributes to our conscious awareness (roughly 15%). The rest of the activity is all the unconscious processing, integrating, and analyzing of information that ultimately results in complex behavior. Much of the brain’s energy is spent “deciding” which signals are relevant and need to be brought to conscious awareness.

Think of all the activities we do that we aren’t even aware of.

While walking down the street talking with someone, do you actively feel your left big toe? Well, no, not unless you have pain or stub your toe. We aren’t aware of our left big toe because it’s irrelevant to what we are doing. But this doesn’t mean those signals are physiologically absent.

Dopamine and norepinephrine are neurotransmitters in the brain that act like the tuners of a piano. The strings of the piano that create the sounds represent the glutamate and GABA neurons that are the primary excitatory and inhibitory neurotransmitters in the mammalian brain, respectively. Dopamine and norepinephrine are there to tighten the strings so the music sounds good. No one likes a song that’s out of tune. That is, dopamine and norepinephrine are those “tuners” of the brain–they modulate communication between neurons. They help our brain decide what to ignore and what to focus on.

In fact, norepinephrine in the prefrontal cortex (PFC) plays a role in enhancing relevant and important signals so that we focus on relevant and important things.

Low-to-moderate concentrations of norepinephrine (NE) mediate these actions by acting preferentially on postsynaptic 𝛼2A-adrenoceptors.

However, as the concentration of norepinephrine increases, norepinephrine begins stimulating 𝛼1 and 𝛽-adrenoceptors.

Stimulation of 𝛼1-adrenoceptors and 𝛽-adrenoceptors (which occurs in high stress states) impairs our ability to focus.

This makes sense as there is no reason to focus on minutiae when a lion is chasing you…

So…when the NE concentration is too low, the signal strength (i.e., our ability to focus on things) is low. But as the NE concentration increases so does the signal strength (i.e., our ability to focus on things) until it reaches a peak. After that, any additional increase in NE impairs our ability to focus.

This explains the inverted U shaped curves depicted below.

Dopamine in the prefrontal cortex (PFC) plays a role in filtering out the irrelevant stimuli. That is, dopamine D1 receptors in the prefrontal cortex reduce the “noise” or irrelevant stimuli so that we can focus on relevant and important things without being distracted.

When DA levels are too low, all incoming signals, whether they are relevant or not, are treated in the same way. Therefore, it becomes difficult to focus on a single task as there are too many distracting stimuli. However, as the concentration of DA increases to moderate levels, it will decrease ‘noise’ by stimulating D1 receptors. This results in decreased firing of neurons to irrelevant inputs in PFC networks.

When DA levels are too high, D1 receptors in the prefrontal cortex are overstimulated and the brain’s ability to filter out the noise declines. Stressful situations and illicit drug use can cause dopamine levels to be too high.

Therefore, medications like amphetamines (Vyvanse, Adderall), methylphenidates (Ritalin, Concerta, Focalin), bupropion (Wellbutrin), and atomoxetine (Strattera) alter norepinephrine and/or dopamine levels to “enhance the signal” while “reducing the noise,” respectively. 

Medications (or illicit drugs) that enhance dopamine too much in certain regions of the brain may cause us to “hyper focus” or “fixate” our attention on unproductive tasks. In addition, the euphoria and motivational reinforcement that results from overstimulation of dopamine receptors in the nucleus accumbens increases the risk for addiction and drug abuse.

In summary, we don’t want too much stimulation of dopamine (D1) receptors because this is associated with euphoria, hyper focus (like scrubbing the floor with a toothbrush), impaired attention, and drug addiction. We don’t want too little stimulation of dopamine (D1) receptors because this is associated with anhedonia, depression, lack of motivation, and apathy.

The same goes for norepinephrine. We don’t want too much norepinephrine because then we will feel symptoms associated with the fight or flight response such as anxiety, hypervigilance, racing heart, sweating, and shortness of breath. We don’t want too little norepinephrine because then we will feel symptoms like fatigue, depression, drowsiness, and weakness.

Therefore, we want our DA and NE to be not too hot and not too cold, but just right (yes, like Goldilocks). This is why controlled doses of stimulants can be very beneficial for some people. 



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  • Higgins, E. S., & George, M. S. (2019). The neuroscience of clinical psychiatry: the pathophysiology of behavior and mental illness. Philadelphia: Wolters Kluwer.
  • Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  • Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  • Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  • Dale Purves, George J. Augustine, David Fitzpatrick, William C. Hall, Anthony-Samuel LaMantia, Richard D. Mooney, Michael L. Platt, and Leonard E. White. Neuroscience, Sixth Edition. Oxford University Press. 2018. 
  • Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  • Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). New York, NY, US: Cambridge University Press.
  • Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincotts illustrated reviews: pharmacology. Philadelphia, PA: Wolters Kluwer.
  • Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th Ed.
  • Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott Williams & Wilkins, 2000.
  • Ebenezer, Ivor. Neuropsychopharmacology and Therapeutics. John Wiley & Sons, Ltd. 2015.
  • Meyer, Jerrold, and Quenzer, Linda. Psychopharmacology: Drugs, the Brain, and Behavior. Sinauer Associates. 2018. 

How to support someone during a difficult time

How to support someone during a difficult time

Supporting someone through a difficult time can stir up many emotions. We can feel sad, worried, helpless, frustrated, awkward or even angry. This is normal.

As compassionate and caring humans, our natural tendency is to jump in and try to “fix” the problem. We will do everything we can to relieve the suffering of those we care about. But sometimes the way we offer support has more to do with relieving our own discomfort and distress and this is where things get tricky.

It becomes even more difficult if the one you’re supporting lacks insight into the problem or refuses to accept that a problem exists.

So, what is the best way to support someone? Is there a best way?  The answer is no. One size does not fit all. But here are a few tips.

Don’t Make Assumptions

When we know someone really well, it is tempting to assume we know what they need at all times. But we don’t. Each of us responds differently to different situations even if the situation is similar to previous ones. Just because someone needed “X” in the past does not mean we should assume “X” is still relevant.

Put Your Mask on First

If you’ve ever traveled by airplane, you are probably familiar with the oxygen masks. Flight attendants tell us to put on our oxygen masks first before helping others. If you’re feeling exhausted, angry, sad, overwhelmed or frustrated, take a moment or two for yourself. Close your eyes and take a few deep breaths focusing on your breathing. We can’t help others if we aren’t taking care of ourselves. 

Silence Is Not a Bad Thing

Many of us might feel an urge to offer reassurance or advice if silence sets in. Resist this urge. Sitting with someone in silence can send the powerful message that you are there to listen whenever they are ready. Offering advice or quick reassurance can be perceived as dismissive. Have you ever cried in front of someone else? What would feel more reassuring, response number 1 or response number 2?

1) “Oh no, don’t cry, it will be okay.”

2) A silent hug or gentle back rub.

Body Language

Nonverbal communication is very important. Position yourself so your entire body is facing toward the person you are consoling. Lean forward slightly without violating personal space and make eye contact. But don’t stare if they aren’t looking at you.

When in Doubt, Ask

Sometimes we need a hug, other times we need space. Or maybe we don’t know what we need. Regardless, if you aren’t sure what someone needs, simply ask in a compassionate, supportive, and curious way. Example:

“What can I do to support you during this really difficult time?”

Validation over Reassurance

Reassurance is okay, but validation is better. Being honest and genuine is of upmost importance. Making promises we can’t keep or offering a false sense of hope can be more hurtful than helpful. You will never go wrong with validating someone’s feelings, even if you disagree or believe they are overreacting. “It’s going to be okay” isn’t as supportive and nurturing as “I can tell this is really upsetting you.”


Using a technique called reflection can help you become a better listener. When reflecting, you will repeat back what someone has just said to you, but in your own words. This shows that you didn’t just hear the other person, but you are trying to understand them.

When used correctly, reflections receive a positive reaction and drive a conversation forward. The tone of voice you use for reflections is important. Use a tone that comes across as a statement, with a bit of uncertainty. Your goal should be to express: “I think this is what you’re telling me but correct me if I’m wrong.”

Your reflections don’t have to be perfect. If the other person corrects you, that’s a good thing! Now you have a better understanding of what they are trying to say. Try to reflect emotions, even if the person you’re listening to didn’t clearly describe them. You may be able to pick up on how they feel by their tone of voice or body language.

Focus on reflecting the main point. Don’t worry too much about all the little details, especially if the person has a lot to say.

What is the best way to support someone in a heightened state of arousal (agitated, impulsive, manic, psychotic, etc.)?

Supporting someone who is acutely agitated, manic (i.e., impulsive, irritable, grandiose, distracted) and/or psychotic (e.g., delusional, responding to internal stimuli) can invoke a number of emotions and reactions in both parties. It becomes even more difficult if the individual you’re supporting lacks insight into the problem or refuses to accept that a problem exists. Supporting someone in a heightened state can be a bit trickier and requires a slightly different approach. Again, one size doesn’t fit all but here are a few tips.

Give Space

When supporting someone in an excited state (i.e., impulsive, irritable, agitated, psychotic) remember that they are in a state of heightened arousal and are easily triggered. Surrounding them or crowding them both physically and emotionally can induce panic and a sense of being trapped. Always maintain your distance and give them both physical and emotional space. Demanding or commanding someone to seek help is not helpful. Allow them to vent but place a limit on it. For example, allow the person to vent for two minutes uninterrupted before intervening. 

Assess safety

When assessing safety, share your concerns in a genuine and heartfelt way. 

“John, I am feeling worried and concerned about the way you’re behaving and the things you’re saying. I really care about you and I’m wondering whether you might be thinking of hurting yourself or hurting someone else. What do you think about these concerns?”

Show Your Hands

Although this sounds trivial, it is actually important. You don’t know what an agitated person is really thinking. Perhaps they are paranoid and think you are trying to hurt them. Placing your hands in your pocket or behind your back is not good practice. Always show your hands. This way the individual doesn’t mistake your hands in your pockets for your hands reaching for something hurtful.

Defeated Wolf

While some would not agree with this, using the defeated wolf approach by slouching your shoulders and looking down can clearly convey you aren’t a threat. Puffing your chest out, raising your voice, assuming a threatening stance, or staring the person down signals dominance and aggression which may worsen the situation for all involved.

Tone of Voice

Use an empathetic tone at a normal volume and show genuine concern. Letting the individual know how their behavior is affecting others is a very useful tool. For example:

“Mr. Thomas, I can see you are speaking quite rapidly and seem very irritable and impulsive. This really concerns me and is making me uncomfortable.”

Give Back Some Control

One of the most useful strategies in de-escalating an acutely heightened individual is to offer safe choices. A major reason people become agitated or aggressive is because they feel a loss of control. By offering choices it can provide comfort in knowing that autonomy is being respected. In these situations, asking someone what he or she needs is rarely helpful as they often don’t know what they need. By offering choices, you maintain some control over the situation while also giving some control to the person you’re supporting.

Decrease external stimuli

Loud voices, noisy surroundings, yelling, and crowded spaces are not helpful in de-escalating an agitated person. The intensity of external stimuli can make or break a situation. Try to remain calm, speak in a normal tone and volume, and keep external noise to a minimum. Providing a quiet space can be soothing for an agitated person. 

Avoid being defensive or authoritative

Remember not to take anything personally. People can be heightened for many reasons, but it is unlikely that you are the primary reason. Being authoritative is not helpful. Make an effort to establish a collaborative relationship. Let the individual know you are on their team and there to help.

Avoid Blaming

Blaming doesn’t work. In fact, it is hurtful and could escalate agitation and aggression. Be sure to share how the individual’s heightened state isn’t necessarily their fault. 

Gently Suggest Seeking Professional Help

This is very important for someone in an acute manic or psychotic state. If the person sees a psychiatrist or mental health professional, suggest they reach out to them. Offer to sit with them while they do so. If they don’t see a mental health professional, encourage them to seek help and/or offer to reach out on their behalf. But don’t do this in a threatening manner. Do not say, “if you don’t do X, then I’m going to do Y.”  Consider this alternative:

“I’m so worried about you and I care about you so much. What do you think about us calling a professional who can better help you? What do you think about us going to the hospital together to see if there is medication or other professional help that might make your situation a little easier? It hurts me to see you this way.”

Goldilocks Empathy

This discussion wouldn’t be complete without mentioning empathy. Empathy is the capacity to share and understand others (i.e., the ability to place oneself in another’s shoes). Empathy can be divided into two types, cognitive empathy and emotional empathy.

Cognitive Empathy: Understanding another’s position from an intellectual perspective. 

Emotional Empathy: Understanding another’s position by sharing similar emotions. 

We can appreciate the difference with the following example:

Your best friend Sally recently found out her spouse, Dave, has been texting another woman. Sally comes over to your place in tears. 

“I am so mad! I can’t believe he would do this to me! I hate him!”

While you might understand why Sally would be angry and upset, you might not actually feel angry and upset as well. Sally reveals that she doesn’t actually know if Dave is texting someone else but suspects he is based on his recent behaviors. Sally also reveals that she didn’t receive a promotion at work recently. 

Cognitive empathy is your understanding of Sally’s reaction. It makes sense. But there are still many unanswered questions. Perhaps Sally is feeling unwanted and rejected because she didn’t receive the promotion and is now feeling insecure about her relationship with Dave. The best support for Sally is a healthy balance of both cognitive and emotional empathy, what I call Goldilocks Empathy.

Too much cognitive empathy and you might come across as “too cold” and dismissive. Too much emotional empathy and you might come across as “too hot” and potentially reinforce a negative pattern of behavior. The goal is to share understanding on both emotional and cognitive levels as we strive for Goldilocks Empathy.

Many of us are more prone to one type of empathy over another (i.e., some of us tend to be more emotionally empathetic and some of us tend to be more cognitively empathetic). Achieving Goldilocks Empathy takes practice and doesn’t come naturally for most people so don’t get discouraged!

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What are Boundaries? Why are they important?

What are Boundaries? Why are they important?

Have you ever felt like your kindness and generosity were taken for granted? Do you struggle to say what’s really on your mind?

This could be a sign that your personal boundaries need some attention.

Personal boundaries are the rules we set for ourselves within relationships. Healthy boundaries mean preventing others from projecting their beliefs and judgements onto you.

A person with healthy boundaries can say “no” to others and not feel guilty for doing so. This is not as easy as it sounds.

Many of us have “all or none thinking.” That is, we make irrational rules and conditions such as “if I don’t buy my friend a birthday gift then it must mean I am a bad friend who doesn’t care.”

The “all or none” distortion in this case is the irrational belief that we can’t be a caring, loving, and supportive friend while also recognizing that sometimes we forget birthdays or don’t have time to purchase a gift. 

Boundaries should be based on your beliefs and values (i.e., the things that are important to you). These may not align with the beliefs and values of others–but that is okay. After all, they are YOUR boundaries.

When a client, patient, loved one, stranger, close friend, or family member begins attacking you with hurtful comments, it is only natural to become defensive, frustrated, and insecure.

We might even begin questioning our own abilities and intentions.

Our personal boundaries become violated when we allow the opinions of others to negatively influence our beliefs about ourselves. This is when we become vulnerable to manipulation, resentment, and frustration.

It is essential to set limits and personal boundaries for yourself. Your needs are just as important as anyone else’s. By giving others the power to hurt us, we lose our sense of self and become resentful, angry, and lost. 

When you find yourself asking, “who am I?” it usually means your personal boundaries have faded. 

Don’t fall into the trap of believing we can’t be compassionate and supportive unless we allow others to walk all over us. This way of thinking is very unhealthy for everyone involved. 


Boundary Styles

Boundaries can be either porous, healthy, or rigid. Ideally, we want to practice healthy boundaries. Below are the different boundary styles and examples of what each might look like.

How do we set personal boundaries?

Be Prepared

Before entering a situation where boundaries might be violated, set boundaries for yourself explicitly. For example, if you have to interact with someone who is very critical or condescending, tell yourself “if I feel disrespected or judged then I will concisely state my feelings without having to explain and then respectfully remove myself from the conversation.”

Plan Ahead

Think about what you are going to say and how you are going to say it prior to a difficult encounter. This will help boost confidence in yourself.

Be Clear

You always have the right to express yourself. When you do, make sure it is clear and without ambiguity. YOU DO NOT HAVE TO EXPLAIN YOURSELF.

The Power of “I”

When expressing how you feel, be sure to use “I” rather than “you.” When we keep it about our feelings, it comes across much less threatening. Consider how the two statements below may be received.

(1) “You are being mean and hurtful. You don’t listen to me.”

(2) “I feel hurt by your words. I’m not feeling heard.”

Both statements are expressing the same feeling but in very different ways. It’s often not what we say but how we say it that matters most.

Here are some examples of how to express yourself clearly:

  • “Please don’t speak to me that way.”
  • “I’ve decided not to ___”
  • “I’ve decided to ___”
  • “I feel belittled by you and that will not work for me.”
  • “I appreciate your opinion, but I disagree with you.”

Use Confident Body Language and a Respectful Tone

Face the other person, make eye contact, and use an appropriate volume of speech (not too loud or too soft). Be respectful but don’t shy away from stating how you feel. Many people don’t like confrontation and they will avoid stating their beliefs lest others will get upset, angry, or defensive. Quieting your own voice is another way of saying

“I don’t respect myself. My feelings don’t matter. I don’t matter.”

Compromise when appropriate

You don’t have to compromise. But consider listening to the others’ points of view and appreciate their needs as much as possible. Healthy relationships require “give and take.” But when you find yourself giving more than taking, make note of it as this probably means personal boundaries need strengthening. 

How to Effectively Communicate Your Needs

Communicating effectively isn’t natural for many people. One of the most, if not the most, important contributors to a healthy relationship is effective communication. Whether it’s a loved one, a coworker, or your financial advisor, communicating effectively creates trust and respect between two people. Here we review different types of communication and provide a few tips for communicating your needs assertively and respectfully.

Passive, Aggressive, and Assertive Communication

Passive Communication

In passive communication, a person prioritizes the needs, wants, and feelings of others instead of their own. The person does not express their own needs or does not stand up for them. This can lead to being taken advantage of, even by well-meaning people who are unaware of the passive communicator’s needs and wants.

Aggressive Communication

In aggressive communication, a person expresses that only their needs, wants, and feelings matter. The other person is bullied, and their needs are ignored.

Assertive Communication

In assertive communication, the needs of both parties are emphasized as equally important. During assertive communication, a person stands up for their own needs, wants, and feelings, but also listens to and respects the needs of others. Assertive communication is defined by confidence, and a willingness to compromise.

Using “I” Statements

When a person feels that they are being blamed, it’s common that they respond with defensiveness. “I” statements are a simple way of speaking that will help you share your feelings in a productive and blame-less way. When using “I” statements, be sure to use a soft and even tone to describe how the other person’s actions affect you.

Example Structure

“I feel (EMOTION WORD) when _________”


“I feel concerned when you go so long without texting me back. I am afraid something bad happened to you.”

“I feel worried when you come home late. I find it hard to sleep.”

5 Tips for Soft Startups

When bringing up a problem to someone else (like your partner, coworker, loved one, friend), the first three minutes are crucial. A soft startup sets a positive tone and helps resolve conflict. By starting a conversation calmly and respectfully, you and your partner are more likely to focus on the problem, rather than who’s to blame.

  • Save the conversation for a calm moment

    Wait for a time when you and your partner are alone without distractions or interruptions. Make sure you both are relaxed and not tired, hungry, or stressed.

  • Use gentle body language and tone of voice

    Take an attitude of teamwork and problem-solving. Speak calmly. Don't raise your voice. Avoid hurtful body language such as eye rolling, scowling, or mocking.

  • Use "I" statements to express how you feel

    Focus on how a problem is affecting you, rather than assigning blame.

  • Describe the problem clearly

    Discuss only one problem at a time. Be specific. Vague complaints are easily misunderstood.

  • Be respectful

    Make a polite request rather than a demand. Tell your partner thank you for listening. Be appreciative.

Fighting Fairly

When not in the heat of the moment, review these “Fair Fighting Rules” with a friend, family member, or loved one, and agree to follow them whenever a fight ensues…

Don’t Let Shannon Trap You

Who is Shannon?

You’ve recently met a new co-worker named Shannon who is very kind, caring, and compassionate. You find yourself drawn to her charismatic, charming, and energetic personality. And although you don’t agree with many of her opinions, you find her humor controversial yet hilarious. Shannon always seems to be in the know–the new fashion trends, the latest gossip, and the trendiest places to socialize. She hosts the best parties at her enormous home which is nothing shy of gorgeous. From the couches to the wine glasses to the small antique pieces arranged around her home, everything seems so intentional and thoughtful. You haven’t met her close friends. But, every day, Shannon has stories about how “awful” her close friends are and how mean they can be.

One day, Shannon comes into work, and you immediately notice something is off. She is quiet, withdrawn, and doesn’t even acknowledge your existence. You grow concerned so you approach her to say hello. She gives you a forced smile and appears to be on the verge of tears. You ask her if everything is okay. At this point she begins crying. You can feel her pain, so you sit down and ask her what’s going on.

“No one gives a shit about anyone but themselves. I can’t believe I thought I had friends.”

You recognize her statements as being a bit extreme but you can tell she is suffering emotionally. You really want to be there for her. Shannon goes into a long story about her friends and how they treat her. 

“I feel so used.”

She tells you how her friends only contact her or reach out to her when they need something or want something from her. 

“If I didn’t know the bouncers at the best nightclubs or I didn’t have my beautiful home, they wouldn’t have anything to do with me.”

You sit down next to Shannon and offer her a supportive ear. She tells you all the things her friends have done to hurt her and reject her. You try to build up her self-esteem because you don’t want to see her hurting. You offer reassuring statements. Shannon immediately cheers up and tells you how amazing you are–how you’re the only person who truly understands her and listens to her. 
She then offers to have you over for a cocktail next weekend. 
For the next few weeks, you are excited about your friendship with Shannon. She buys you incredible gifts, takes you on fun experiences, and seems to idolize you. Shannon constantly tells you how much you have changed her life and how special you are–how you were meant to meet and how you are the one person she needed in her life during this difficult time. 
You feel good about how you’ve changed her life in a positive way–but there is also a feeling of discomfort that is hard to describe. Something is off. You start to wonder how you became the most important person in Shannon’s life. Despite your growing suspicions, you go with it.

Soon you find yourself spending more and more time with Shannon. Your family and other close friends take notice. While you want to make the time for your family and close friends, Shannon makes you feel so special and important that saying no to her becomes increasingly more difficult. The last thing you want to do is let her down or disappoint her. She has idolized you to the point where you feel trapped on a pedestal so tall that the thought of falling off scares the shit out of you. It doesn’t help that Shannon has a way of asking for things. You recall a recent text message exchange:

It doesn’t take long before you begin to feel responsible for Shannon’s feelings. When you can’t be there 24/7 or whenever she needs you, you feel guilty. You start questioning your own loyalty as a friend and you feel really mad at yourself for not being a good enough friend to her. 

Resentment starts to build as you try endlessly to be the friend you think Shannon needs. But it never seems to be enough. You begin feeling helpless, frustrated, and inadequate. But those feelings are nothing compared to the guilt that infects your soul.

Shannon’s birthday is approaching, which happens to be on the same day as the music festival you look forward to all year because you get to reunite with your closest childhood friends who you rarely get to see. You plan on inviting Shannon once you have the details because you know she will want to know all the logistics. You panic when you receive a voicemail from Shannon:

“My life is falling apart, but at least I have you. I am so grateful I get to spend my birthday with you. What do you think about having a spa day at that place you’ve always wanted to go to? I know the owner and she is giving us the deal of a lifetime!”

You begin obsessing about how you should respond. You love spa days and you have wanted to go to this place for years and you finally have the opportunity to go. You can’t believe she is picking the place YOU love. 

You feel stuck, but you think maybe she will enjoy the music festival. A few minutes pass and you see your phone light up. Shannon is calling you. You don’t pick up.

An hour later you receive a text message:

You bite. You respond with a long message about how grateful you are for the invitation and then you tell Shannon about the music festival and how you were waiting for the details before officially inviting her.

She responds:

You feel terrible. Shannon did go out of her way for you. She has given you so much over the past month and you feel embarrassed and stupid that you didn’t know she doesn’t like crowds (even though she loves nightclubs and other events she plans).  Either way, you feel like you should have known better. The pit in your stomach grows as your favorite concert approaches. You decide to go, but all you can think about is Shannon and how she is alone on her birthday. You can’t stop thinking about it. 
The guilt you feel prevents you from having a good time. You try not to take photos because you don’t want Shannon to see you having a good time on social media. But really, you feel like you don’t deserve to have fun unless Shannon is having fun too.

While at the concert you get messages from Shannon:

That hits deep. So many emotions begin to surface. You love Shannon and wish she was having fun with you, but you are angry and frustrated because you feel responsible for her pain. You vacillate between anger and guilt to the point where you start questioning things. 

Maybe Shannon is right. Maybe I am selfish. Maybe I’m not good enough. 

And you start to feel depressed and lost. Shannon blames you for all her problems and you feel terrible. You do everything to console her and gain her trust back and finally Shannon accepts your apology. But the cycle continues…
Soon, you learn that being happy without Shannon creates conflict. And doing or feeling anything that isn’t acceptable to Shannon also creates conflict. Before you know it, you don’t even know who you are anymore because you have worked so hard at becoming someone you aren’t just to avoid conflict with Shannon. 
Now you know how people with prominent borderline personality traits can affect those around them.
To learn more about Borderline Personality Disorder see the links at the bottom of this post.

Don’t Let Brent Blur Your Boundaries

Who is Brent?

Brent is a 36 year old husband and father of two who presented to my office for initial psychiatric consultation. He presents at the request of his wife, Jennifer, who recently moved out of their family home because she “just couldn’t take it anymore.” My first meeting with Brent went something like this:

Therapist: Hi Brent, what brings you in today?

Brent: Didn’t you read over my file before this? You should know the answer to that already. I’ve seen enough therapists to know how this is supposed to go.

Therapist: Can you help me understand what you mean by that?

Brent: What do you need help understanding? It’s pretty simple. I’m supposed to come here, tell you my problems, and you’re supposed to listen and say things that make me feel better. Aren’t you a therapist?
Therapist: Hmm, has this been your experience with therapy in the past?

 Yep. I mean let’s be real, therapists don’t actually care. They just pretend to care so they can take my money. It’s such a scam.

 Wow, I am sorry this has been your experience. It sounds like you haven’t had very positive experiences with therapy in the past. It makes sense that you would be skeptical about our time together. How can I be most supportive?

 I don’t even know. My life is falling apart. I am not sure there is anything you can do at this point.

 Sounds like life has been really difficult. I am wondering what you mean when you say your life is falling apart. 
Brent: Well, my wife left me, my kids don’t want to see me, and I might lose my job. I just don’t understand what I’m doing wrong. [Brent becomes tearful]
Therapist: [I remain silent but attentive to encourage Brent to continue]

 I’m sure you’re rolling your eyes inside, ‘here we go, another drama queen.’

 What makes you say that?
Brent: I can just tell. You must get so tired of listening to people like me.

 [I make note of Brent’s assumption because it could provide insight into how he feels about sharing his emotions with important people in his life. However, I don’t immediately reply with an overly validating remark that might stymie the therapeutic dialog]. Sharing our emotions can be really scary sometimes. Can you tell me a little more what you mean by ‘people like me?’

 I can’t tell you how many times I’ve been told I’m too sensitive or overly dramatic or that I read into things too much.

 How does it feel when others say those things?
Brent: [Brent becomes tearful again]. It hurts so much. No one gets it. I care so much but that just ends up biting me in the ass. It would be so much easier if I just didn’t give a shit about anyone.

 [I remain silent and refrain from offering an automatic reassuring remark but I use body language to show Brent that I am attentive and concerned].

 When I love someone, I love them with all my heart. I go out of my way to make sure people feel special. That’s just who I am. But what about me? What about my needs?
Therapist: [I nod]
[Brent’s body language communicates to me that he is angry and unsatisfied.]

Brent: This is stupid, you just sit there and nod like you know what I’m going through. How dare you pretend to care! I came here because I needed help. Just sitting there staring at me and nodding isn’t helping, it is making things worse! I knew I should have stayed home!

Therapist: [I begin to feel frustrated by my inability to meet Brent’s expectations and I feel insulted and disrespected by his comments. At the same time I begin to feel anxious, ashamed, and insecure as I start to believe Brent is right.] I am sorry you feel that way. Nodding is my way of showing attentiveness and interest in what you’re sharing with me. 

Brent: [Looks away and shakes his head]

 [I begin to question by abilities. Maybe I’m not good enough to be a therapist. Maybe Brent is right. I decide to share my feelings with Brent.] I’m frustrated with my inability to help you. It hurts me when I see others suffering. [I share with Brent how this situation is affecting me and I validate his emotions by letting him know I can see he is in pain. I show compassion by remaining calm and concerned so Brent doesn’t feel I am abandoning him]. 

Brent: [Brent becomes tearful.] I am in so much pain. I get so angry because I feel like no one cares about me. [Brent begins to shift his anger away from me. His defenses begin to lift now that he feels validated and unabandoned. He opens up a little more as the session continues].

How To Support Someone Like Brent

Validation, Validation, Validation.

If you’re a compassionate human being, it is normal to feel uncomfortable when someone you care about is suffering emotionally. Imagine a close relative expressing the following sentiment: 

“I am such a loser. No one will ever understand me.” 

Our gut reaction might be to offer reassurance by saying something like:

“That’s not true!” 

While this might be well intentioned, it is rarely effective. Reassurance is usually not the way to go because it isn’t as supportive as validating the emotion. It is easy to get caught up in the content and forget about the underlying emotion. Has a close friend or relative ever said something like:

“You don’t even care about me!” 

We might become defensive and push back with “yes I do!” And then give a speech justifying why we care. But again, this is probably not helpful. Instead, try validating the underlying emotion while also stating how the statement impacted you. Consider the following alternative response: 

“It hurts me to hear that. I can’t imagine how painful it must be to feel that way.” 

We all know our thoughts can be irrational and untrue sometimes, but our emotions are ALWAYS real regardless of whether we believe they are justified. By validating the emotion, we avoid getting caught up trying to “convince” someone like Brent that his thoughts are irrational (which is not validating at all and will ultimately lead to frustration and anger for everyone involved). 

Be Concise, Direct, and Matter of Fact

This can be challenging as many of us feel the need to explain ourselves when others challenge our views, opinions, or beliefs. Unfortunately, when we do this, we become susceptible to manipulation. That is, the more words we use and the longer we take to explain or share something, the greater the likelihood those words and explanations will be distorted or misinterpreted. In fact, this is often the unconscious strategy employed by those with Cluster B traits. Consider the following example where someone like Brent is interacting with a friend who did not return his phone calls (i.e., did not do what Brent demanded):

Someone like Brent: Where the hell are you? I called you 14 times and you never picked up. I was in a crisis, and you weren’t there for me! How could you do this to me? Do you even give a shit about me? Or anyone else for that matter? You are so selfish!

Supportive Friend: I am so sorry I didn’t get back to you. I was at the office and had to take care of some important work and then my son called because he needed a ride home from school. By the time I got home I was exhausted, and it completed escaped my mind. I am trying to be as supportive as I can. I am not selfish at all!

Someone like Brent: What work could have been more important than helping a friend who was in so much pain. Feeling exhausted is my normal. If you really cared, you would have called me back. It only takes 2 minutes. Am I not worth two extra minutes of your time??

You can see the pickle of a situation this is becoming. It is important to set limits and remind yourself that your needs matter as well. Don’t fall into the trap of believing we can’t be compassionate and supportive unless we explain ourselves entirely and/or allow others to walk all over us. Being concise and direct does not mean being unsupportive. Consider the following alternative response:

Someone like Brent: Where the hell are you? I called you 14 times and you never picked up. I was in a crisis, and you weren’t there for me! How could you do this to me? Do you even give a shit about me? Or anyone else for that matter? You are so selfish!

Supportive Friend: I am so sorry to hear you were in crisis. Unfortunately, something personal had come up that required my immediate attention. I hope you are okay.

In the alternative approach, the supportive friend did not “bite the bait” (i.e., become offended and feel the need to explain). The supportive friend also did not acknowledge or address the irrational and hurtful accusations/comments. When in doubt, try to respond as concisely and matter of fact as possible.

Set Strict Boundaries

This cannot be overstated. It is vital to set boundaries for yourself. When a difficult patient, loved one, close friend, or colleague begins attacking with hurtful comments, it is easy to become immediately defensive and then insecure later on. We might begin questioning our abilities and our intentions. It is easy to mistakenly internalize emotions that aren’t ours and this is when we become vulnerable to manipulation. It is important to set limits and boundaries for yourself. Your needs matter as well. It’s when we begin losing our sense of self that we become resentful, angry, and lost. 

Don’t fall into the trap of believing we can’t be compassionate and supportive unless we allow others to walk all over us. This way of thinking is very unhealthy for everyone involved. 

It is important to let Brent’s problems remain his problems. 

Stay Consistent

If you say 11:30am, be sure you are ready at 11:30am. Try to be consistent in how you respond. If one day you respond one way and then another day you respond differently, someone like Brent will never learn from the responses. It is the consistency in response that promotes learning. Someone like Brent will begin to learn that his behavior must change if he seeks a particular outcome. 

Don’t Be Afraid to Share Your Feelings

If we hide our feelings, it is impossible for others to know how we feel. This is particularly important for supporting someone like Brent. When Brent says something hurtful, make it known. Tell him. Allowing yourself to be emotionally vulnerable and share exactly how you feel does two things–it validates your own feelings, so you don’t neglect yourself and it provides important feedback to someone like Brent. Sometimes it can even de-escalate the situation. 

Seek Reassurance from a Colleague or Friend When Needed

It is normal to question yourself. But when you begin believing the irrational accusations others make, it is important to keep yourself grounded in reality and run things by people you trust and respect. This is ESSENTIAL. Learn all about Projective Identification and borderline personality disorder by visiting the links at the bottom of this post.

Dialectical Behavioral Therapy, The Wise Mind, and How It Can Help Those With Extreme Emotional Sensitivity

Dialectical Behavioral Therapy

DBT is a cognitive-behavioral treatment developed by Marsha Linehan, Ph.D., in the 1980s to help people with cluster B personality traits (e.g., borderline personality disorder), who often experience extremely intense negative emotions that are nearly impossible to manage. These intense and uncontrollable negative emotions are often experienced when the individual is interacting with others—friends, romantic partners, family members. Not surprisingly, individuals with cluster B personality traits often experience a great deal of conflict in their relationships.

The “D” means “dialectical.” A dialectic is a synthesis or integration of opposites. A DBT-oriented therapist consistently works with an individual to find ways to hold two seemingly opposite perspectives at once, promoting balance and avoiding black and white—the all-or-nothing styles of thinking. In service of this balance, DBT promotes a both-and rather than an either-or outlook. The dialectic at the heart of DBT is acceptance and change.

Dialectical strategies help us get unstuck from extreme positions. They help us stay “in-balance” so we can reach our ultimate goals as quickly as possible. The Wise Mind is a classic example.

Dialectical behavior therapy (DBT) provides us with new skills to manage painful emotions and decrease conflict in our relationships. DBT specifically focuses on providing skills in four key areas.

  1. Mindfulness: Mindfulness focuses on improving our ability to accept and be present in the current moment.
  2. Distress Tolerance: Distress tolerance is geared toward increasing our tolerance of negative emotion, rather than trying to escape from it.
  3. Emotion regulation: Emotion regulation covers strategies to manage and change intense emotions that are causing problems in our lives.
  4. Interpersonal effectiveness: Interpersonal effectiveness consists of techniques that allow us to communicate with others in a way that is assertive, maintains self-respect, and strengthens relationships.

Using a DBT approach, a therapist uses acceptance strategies and behavioral change strategies by validating the client and accepting him or her as he or she is.  A DBT therapist appreciates that too much focus on change results in clients feeling misunderstood and invalidated. Working with people with extreme emotional sensitivity requires careful attention to the balance between acceptance and change.

DBT was originally developed to treat borderline personality disorder. However, research shows that DBT has also been used successfully to help people suffering from depression, bulimia, binge-eating, bipolar disorder, post-traumatic-stress disorder, and substance abuse. 


  • What was your internal dialogue like?
  • What were the voices in your head saying?
  • Were they mean? Were they positive or negative?
  • Describe what you noticed.