# Bullying

Being Bullied

Researchers found that being bullied often leads to not trusting other people. In turn, that can lead to poorer mental health.

A study of 10,000 youth in the United Kingdom revealed that those who were bullied had more “mental health problems in late adolescence, and this effect was partially mediated by interpersonal distrust during middle adolescence.”

Those adolescents with high levels of distrust “were approximately 3.5 times more likely to subsequently experience clinically significant mental health problems than those who developed less distrust.”

The researchers concluded that bullied kids would likely have fewer mental health problems if they received counseling that included strengthening their trust in others.

[All quotes are from a research article by Tsomokos DI and Slavich GM in Nature Mental Health (2024): https://doi.org/10.1038/s44220-024-00203-7%5D.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

My Hobby in the Clouds

What’s something most people don’t know about you?

Getting Ready to Fly

Of course, my family and close friends know that I was a family doctor and psychiatrist (now retired) and that I am a licensed sport pilot. However, most people don’t know that I have a pilot’s license and was co-owner of an airplane.

I no longer fly sport airplanes for several reasons. They include the fact that I am at an age when piloting may not be safe. Sometimes, I miss it, but I recognize that it is for the best.

I think having a hobby interest that gives you a chance to learn something new, that is exhilarating, and that keeps your mind off of your job is great for your mental health. We all need regular mental breaks.

I hope that anyone who reads this either has or will find a joyous hobby as I was fortunate enough to do.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Happiness

List 30 things that make you happy.

Enjoyment

I felt sorry for those who wrote that they couldn’t think of very many things that made them happy. So, I sat down and started to make a list.

Afterwards, I realized that most of them were experiences rather than things. That is consistent with research that shows that relationships, experiences (vs things), and “buying time” are the ways money can enhance happiness.

Buying time means paying someone else to do things that need to be done, but you don’t like to do them, e.g., paying to have your lawn mowed or your driveway shoveled after it snows.

Here is my list in no particular order:

1. Spending time with my wife. 2. Eating a tasty and nutritious meal. 3. Drinking cold water when the weather is very hot. 4. Laying on an inflatable floater in a swimming pool. 5. Travel to an interesting place. 6. Time with close family and friends. 7. Learning something new. 8. Having a great workout at the gym (when it’s over 😅). 9. Helping a homeless person at my church. 10. Getting sound, restful sleep at night for at least 7 hours. 11. Watching a sunset over the Gulf of Mexico. 12. Going on a cruise to somewhere new. 13. Eating ice cream or frozen yogurt. 14. Trying a new restaurant with really good food. 15. Having a therapeutic massage. 16. Hugging my grandchildren. 17. Feeling healthy. 18. Getting a heartfelt compliment. 19. Buying a fun, new car. 20. Giving a lecture appreciated by attendees. 21. Watching a patient recover from an illness. 22. Writing a blog. 23. Being able to pay my bills. 24. Watching a good movie (especially with popcorn to eat). 25. Coming home after being away for awhile. 26. Recalling good memories, e.g., getting my sport pilot license. 27. Having my checkbook balance. 28. Having an article or book I wrote get published. 29. Realizing most of my problems are first world problems. 30. Being able to quickly come up with these 30 items!

#Non-Suicidal #Self-Injury

Depressed Teen

Some adolescents deal with negative emotions by causing injury to their body without intending to kill themselves. An example would be delicate, superficial self-cutting of a forearm or a leg.

This behavior is called Non-Suicidal Self-Injury (NSSI). About 3-7% of teens do this in an attempt to manage emotions that seem overpowering. Unfortunately, it is risky and does not provide long-term relief.

Therapists have developed a form of treatment that teaches these teens a safer and more adaptive way to deal with overwhelming emotions. It is called Emotion Regulation Therapy (ERT), which can be used in group therapy or for an individual.

Researchers in Sweden wanted to find out if a version of this therapy could be provided on the internet with oversight by a trained therapist. This therapy was added to standard care that the adolescents were also receiving.

Half of the teens had on-line Emotion Regulation Therapy plus standard care, and the other half only had standard care. Treatment was provided for 12 weeks.

The group who received ERT along with standard treatment had fewer episodes of NSSI than the group who only received standard treatment. These results suggest that an internet-based ERT treatment overseen by a trained therapist could be a cost-effective treatment for NSSI in teens with depression and/or anxiety.

Regardless, a teenager with NSSI would benefit from the addition of ERT therapy approaches designed to teach them less risky and more adaptive ways to manage strong negative emotions.

This blog was based on a research article by Bjureberg and colleagues in JAMA Network 2023; 6(7). To access the article use this doi:10.1001/jamanetworkopen.2023.22069

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Brain Fog from COVID-19

COVID-19 has been shown to cause “brain fog” in people who have long-COVID (see my prior blog on this topic) after the acute infection has resolved. An article in AMA Morning News in February 2023 noted that patients with this condition describe it by using words such as “sluggishness, difficulty thinking or concentrating, ‘not as sharp,’ and having word finding problems.”

The authors of the article point out that these patients are often stigmatized because others cannot see anything wrong with them and believe that it is “not real.” Such unhelpful responses to someone struggling with this common complication of long-COVID just makes the situation worse.

The authors, who have treated many patients with brain fog, point out that brain fog is more likely in patients who had a more severe infection. Usually, these physicians order neuro-cognitive testing to document the type and degree of cognitive dysfunction. This can provide guidance for treatment approaches.

On a more positive note, the authors point out that vaccination against COVID reduces the risk of developing brain fog in a patient who gets COVID after vaccination. Vaccination does not totally prevent COVID illness, but it significantly reduces the severity of infection. In turn, this reduces the risk of brain fog.

Another helpful preventive measure is to take paxlovid shortly after acquiring COVID. Physicians and some pharmacists can determine if the medication is indicated and provide a prescription if it is appropriate.

It is also valuable to prevent future COVID infections as that can make brain fog worse. So, it is important to obtain COVID vaccination boosters when recommended. Wearing a mask and limiting exposure indoors with lots of people is helpful.

Once a patient has brain fog from COVID and has had a careful evaluation, there are treatment strategies that can help. One approach is to find ways to compensate for symptoms. For example, a patient with difficulty maintaining focus or attention, can schedule shorter times for activities that require maintaining attention.

The authors recommend that patients write down an action plan so they don’t have to remember each item. Also, taking notes is beneficial when meeting with someone, such as a doctor, accountant, or others, when recall of what was said is important.

They also suggest asking a spouse or close friend to let you know if they observe “something different about you.”

Engaging in good health habits is extra important for these patients. This includes getting adequate sleep, eating a healthy diet, and remaining hydrated. Avoid drinking alcohol and taking medications that can slow cognitive function (check with your doctor).

Develop a good physical exercise program with an emphasis on aerobics (work up to 30 minutes 5 days a week). Mental exercise is also helpful; examples include read books, do puzzles, learn a new skill, etc.

Anxiety is common in these patients. Learning how to use mindfulness to manage the anxiety is often helpful. The authors also recommend minimizing stress as much as possible.

Some patients also struggle with other psychiatric conditions such as PTSD or depression. The authors recommend prioritizing mental health.

Some people with brain fog have a severe case and/or have other problems from long-COVID. In that event, your doctor may recommend that you be seen in a specialized treatment center for the management of long COVID.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Pathological #Lying

Lying Can be Obvious

Congressmen George Santos is in the news for what he calls “embellishments” of his resume. Others refer to them as lies. As a psychiatrist, I cannot render an opinion about whether Santos has a diagnosis since I have not personally examined him. However, the news has raised interest in the topic of lying.

Drew Curtis, PhD is a psychology professor at Angelo State University; he has a longstanding interest in deception and pathological lying in particular. He has defined pathological lying as “the category of people who tell excessive amounts of lies that impairs their functioning, causes distress, and poses some risk to themselves or others.”

Another description of pathological lying is “telling numerous lies each day for longer than 3 months.” Dr. Curtis notes that some research subjects, that he has studied, describe themselves as meeting criteria for pathological lying. They report “greater distress, impaired functioning, and more danger than people not considered pathological liars.”

Based on his research, Dr. Curtis believes that “pathological lying seems to be compulsive, with lies growing from an initial lie, and done for no apparent reason.” When behaviors are compulsive, the person has restraints on their ability to stop their compulsive behaviors.

What about people who lie but don’t have pathological lying? The “ordinary, everyday” lies that most people tell are referred to as “common lies.” They may be told to avoid embarrassment, to avoid hurting someone’s feelings, or to avoid a negative event such as getting fired. There is a clear reason for lying.

However, there are people with a personality disorder who frequently tell lies. Those disorders are primarily three related ones. The first is the person with an antisocial personality disorder who frequently lies, usually for some personal gain. They do not have a normal conscience so they may not experience guilt when they lie.

The next two diagnoses are borderline and narcissistic personality disorders. They have a tendency to lie more than the average person, and they typically lie to “alter reality” to match their emotional state. They may also lie for personal gain just like most people.

Pathological lying is accepted by mental health professionals as a real thing, but, by itself, it is not an official diagnosis. Dr. Curtis is trying to change that.

So, telling “small lies” is very common; frequent lying is much less common and may result from a personality disorder; and pathological lying is uncommon and may be due to a compulsion.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Sextortion and #Suicide

Sextortion is a serious crime described by the FBI as “threatening to distribute your private and sensitive material if you don’t provide them images of a sexual nature, sexual favors, or money.” They may “threaten to harm your friends or relatives” by using information from your computer or other electronic device.

Usually, the criminal is an adult who preys on young children, teens, or young adults. The adult pretends to be about the same age as the victim. If the victim is a boy, the adult may pretend to be a young girl who is interested in him. For example, “she” may ask him to send “her” sexually explicit pictures or videos. A number of teenage boys ages 14-17 have been targeted.

The adult criminal demands money or gift cards be sent to him, or he will publish the pictures or videos online. Victims are usually reached by going onto chat rooms or other online sites. They may also hack into a victims computer and access files or control the victims web camera and microphone without the victim realizing it.

Victims of sextortion are usually ashamed and frightened, especially if they are threatened. They may do what the criminal is demanding of them.

Sometimes the criminal pretends to already have sexually explicit material and blackmail victims. The Department of Justice reports that they are aware of more than 3,000 victims during this past year. Victims can be from any socioeconomic group.

Unfortunately, a number of victims have become so ashamed that they commit suicide. It is a tragic situation, and the FBI has agents working on these crimes. They have made arrests when the perpetrator is in the U.S.

The FBI recommends that young people take precautions to avoid becoming a victim. They recommend that you never send “compromising images to anyone.” Do not open a request when you are not certain who it is. Turn off your electronic devices and the web-camera when not using them.

If you have been victimized by sexstortion, let an adult know and call the FBI. Their number is 1-800-CALL-FBI.

Sextortion is a tragic cause of suicide. Parents and other caregivers should educate their children and let them know you will support them if they let you know they have been victimized.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

New Medicine for Depression

Major Depressive Disorder (MDD) is one of the more common psychiatric illnesses. Treatments can include psychotherapy, oral antidepressant medications, transcranial magnetic stimulation, ECT, and ketamine (IV or nasal spray). Although these treatments can be effective for some patients with MDD, not all patients respond, some are very expensive, and the current oral antidepressants usually take weeks before being effective, if at all.

There is a new oral antidepressant that shows great promise in providing significant relief beginning in about one week. It is a combination of dextromethorphan and bupropion. The name is Auvelity. It has been approved by the FDA and is expected to be available sometime during the fourth quarter of 2022.

Some of you may recognize dextromethorphan as an ingredient in cough medicine. It attaches to certain chemical receptors in the brain (NMDA and sigma-1 receptors). It has been tested on over 1,000 research subjects with MDD in two different studies.

The dextromethorphan is combined with bupropion, a well-established oral antidepressant. In this case, a low dose of the bupropion is used to increase the blood level of dextromethorphan by blocking the enzyme that breaks down dextromethorphan.

As you would expect, there are possible side-effects. The more common ones are dizziness, headache, diarrhea, sleepiness, dry mouth, sexual dysfunction, and excessive sweating. They occur in a minority of patients and can be mild.

The availability of this new oral treatment is a helpful advance in treatment options for MDD.

Peter M. Hartmann, MD

Family Medicine and Psychiatry

What is Digital Self-harm?

Digital self-harm means to anonymously put “hurtful content” about yourself on social media. Because it is anonymous, readers don’t know that the bad things said about you are what you think about yourself.

About 9% of teens do this. This likely represents an attempt to self-harm by trashing your reputation. Doing it anonymously makes it appear that someone else thinks badly of you.

A “survey of 4,972 American middle and high school students” showed that kids who anonymously publish bad things about themselves are up to 7 times more likely to have suicidal thoughts and up to 15 times the rate of suicide attempts compared to kids who don’t engage in digital self-harm.

Yesterday, I published a blog about shame. One response to shame is called “attack self.” I think that digital self-harm is an example of that. When you feel shame, you believe that you are a bad person.

Kids who engage in digital self-harm because of shame demonstrate the problem with the 4 responses to shame discussed in my blog. Anyone who engages in digital self-harm should talk about it with a trusted adult.

The survey results were published in the psychiatry journal, Child and Adolescent Mental Health on July 10, 2022.

Shame: How to Respond

Shame is one of the 9 primary emotions (technically, they are called, affects, which are the innate biological part of emotions). When we experience shame, we say to ourselves, “I am bad.” In contrast, when we feel guilty, we say, “I did a bad thing.”

Donald Nathanson, MD is a psychiatrist who is an expert on shame. He discovered that people react to feeling shame in 4 possible ways. They can be plotted out as if they were points on a compass, representing the 4 cardinal positions (North, South, East, West).

Response 1: Attack Self. In this case you believe that your shame is valid, and you are angry at yourself as a result. You criticize yourself and may even feel contempt. You may deal with your shame by subordinating yourself to others. As a result, you may do what others want you to do even if it is not in your best interests. You can lose your sense of autonomy.

Response 2: Attack Other. You project your sense of being bad by blaming others. You may put others down to make you feel better about yourself. In the worst case you may physically abuse someone else. Obviously, attacking others to reduce your shame is damaging to your relationships and does not directly address the shame.

Response 3: Avoidance. You think and act in ways that allow you to avoid feeling the shame. You may do this by distracting yourself by engaging in more sex, eating just for pleasure, or using alcohol or drugs (especially stimulants) to mask shame. Using substances in this way prevents you from dealing with your underlying shame. Alternatively, you may do things that increase pride in yourself such as being more charitable, learning a challenging new skill, etc.

Response 4: Withdrawl. As is the case with Attack Self, you accept that your shame is valid so you withdraw from situations to avoid shame. You may turn down invitations from others, turn to solitary activities, and cut off friendships. Although withdrawal may lesson a sense of shame (“People can tell that I am bad so I will stay away”), cutting yourself off from support is an unhealthy response to shame.

If you struggle with shame, you may find it helpful to figure out which of the four responses you are using to deal with it. It may be that you use more than one of these defenses. None of them are optimal responses, and they may make your life worse.

Seeing a therapist is a good idea if you are unsure if you are dealing with shame, depression or other psychological states. Therapy is also useful to figure out which defenses you are using and how to modify your responses in a healthier way.

Peter M. Hartmann, MD

Family Medicine & Psychiatry