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Psychosis is defined by symptoms such as hallucinations (seeing or hearing things that others cannot) and delusions (fixed, false beliefs). Brief periods of psychosis can be caused by medical conditions, a side effect of a medication, or other psychiatric conditions such as Depression or Bipolar Disorder. When a person is severely depressed or in a manic state, they may experience hallucinations or delusions; then when the mood is more stable, these symptoms go away. Sustained psychosis (for months to years) is more likely to be a separate diagnosis such as Schizophrenia or Schizoaffective Disorder. Other symptoms of Schizophrenia may include confusing speech, catatonic behavior (such as not moving or talking), or overall not being able to express emotion.

It should be noted that there are times where people may experience thinking they see or hear something. For example, it can be common for people with insomnia or anxiety to think they hear someone or something as they are trying to fall asleep. A person with PTSD or anxiety may think they saw a shadow out of the corner of their eyes, but when they looked nothing was there. These can be called "illusions" instead of hallucinations, because often times it is the brain mis-interpreting a signal that actually is there (maybe the house made a noise or person walked by and cast a shadow); this is opposed to hallucinations, where nothing was there and it is persistent. Sometimes it can be hard to tell the difference, and if the experiences are recurrent and/or distressing, we will treat them as if they are hallucinations.

No matter what the cause of the psychosis, the treatment is with antipsychotic medication. If you are struggling with Depression with Psychotic Features, you will most likely be recommended to be on an antidepressant and an antipsychotic; if Bipolar Disorder with Psychotic Features, you will likely be on a mood stabilizer and an antipsychotic. Once the psychosis has stopped for a period of time, we can discuss removing the antipsychotic medication and monitoring for any symptoms. If you have a diagnosis of Schizophrenia, you will most likely be on long-term antipsychotic treatment; in fact, there are long-acting injections that can be administered once every 2-4 weeks if you have trouble remembering to take your oral medication everyday. People with any longer-term diagnosis such as Schizophrenia or Bipolar Disorder also benefit from case management services, frequent check-ins to monitor your progress and help you continue to succeed in all your life goals.

Most toddlers have short attention spans and can be rambunctious. If these start to become excessive or continue into older ages, these may actually be symptoms of ADHD. ADHD has two main types of symptoms - the symptoms that relate to poor attention (what used to be called ADD), and the symptoms that relate to hyperactivity and impulsivity. Even if you are given a diagnosis of ADHD, that doesn't necessarily mean you have hyperactivity symptoms. Your diagnosis might be ADHD - inattentive type, ADHD - hyperactive/impulsive type, or ADHD - combined type.

ADHD often starts in childhood, and may become more obvious when the demands of school start to increase. Some patients will continue to have symptoms into adulthood. Treating ADHD is important; the focus is not just improving grades or behavior at school. People with ADHD have chemical and functional changes in their brain that make it easy to lose focus or to be impulsive. People with ADHD have higher rates of accidental injuries, car accidents and substance use urges; when people with ADHD are appropriately treated, these rates significantly decrease, sometimes back to the rate of a person without ADHD. If you have a child with ADHD, something that can be difficult to do as a parent is to figure out when their ADHD is causing the child to not be able to achieve a task yet, and when to push them to do tasks you think they can do. Sometimes asking a child with ADHD to do complex tasks, like "do the chores," is not possible, but breaking down the task into smaller tasks, like "put all the clothes on the floor in the hamper," makes it achievable. Over time, they may learn to break down tasks on their own, but this may be a skill they have to have modeled for them and practiced for a sustained period of time. Like any child though, there are times where they do not want to do a task or think they cannot, and giving them a little push to try and challenge them is needed.

For treatment, there are definitely benefits to parent management training, organizational training for the child, and learning accommodations from the school. The gold standard treatment for ADHD is a class of medication called stimulants. People with ADHD may seem to have a lot of energy, so adding a stimulant might seem like the opposite of what you want to do. But while these people have a lot of energy, part of the problem is not being able to channel that energy into a specific goal. Stimulant medication helps to direct that energy to the task at hand. There are also some non-stimulant medications that we use in very young children, patients who cannot be on stimulants for medical reasons, or patients who have not responded well enough to stimulant medications.

There are many misconceptions about what the symptoms of this disorder might look like. Many assume that people with bipolar disorder have very quick shifts in mood and outbursts throughout the day. In reality, during their lifetime, people with bipolar disorder will experience days-long episodes of an extremely elevated state called mania, and at other times in their life will have depression for weeks at a time. During a manic episode, people can experience symptoms of sustained euphoria or severe irritability for days, and may also have other symptoms such as not needing to sleep for days because of high energy, rapid speech, or risk-taking behavior that is out of character for them. Sometimes there may be a pattern that a person will have a manic episode, and at the end of it feel very drained of energy and start a depressive episode. However, this is not true for everyone; sometimes the episodes can be months or years apart, or a patient could present with a depressive episode first. That can make the diagnosis of Bipolar Disorder difficult, because the only thing that separates this from Major Depressive Disorder is the fact that the patient goes through a manic episode. Someone may present with depression, but it is not until years later that they have a manic episode that allows us to make a formal diagnosis of bipolar disorder.

Family history is helpful when considering the diagnosis of Bipolar Disorder; if you have a first degree relative with bipolar disorder (parents or siblings), the likelihood that you may have bipolar disorder increases from about 1% to about 10%. So if there is a family history of bipolar disorder, it is very helpful for your provider to know about that to help determine the right diagnosis as they get to know you better. 

It's also important to know whether a person has bipolar disorder or a depressive disorder, because the medication treatments are very different. For instance, if a person with bipolar disorder took a regular antidepressant, it has the possibility to trigger a manic episode. Instead, people with bipolar disorder will need medication management with mood stabilizers. These are medications that are trying to treat or prevent mania or depression. When you have been stable for awhile, the goal is to be on as few medications as possible (maybe only one) to control or prevent mood episodes. If you are going through a period of mania or depression, medications may need to be increased or you may need to be on two medications to help re-stabilize your mood.

We all go through stressful or even traumatic situations in our life, but sometimes these events trigger a trauma response. When it comes to diagnosing PTSD, it does not matter whether the event was "large" (like a serious car accident with severe injuries) or "small" (like a fender bender). It does not matter whether it was one event or multiple events. The event could have involved you, it may have been witnessed by you, you may have learned that this experience happened to a very close loved one, or you might be a first responder or medical provider who hears about or sees trauma frequently. What matters for diagnosis is how your brain and body respond to the incident and if you have psychological symptoms afterward. 

People experiencing PTSD can have:
- Nightmares, flashbacks, recurring memories
- Avoidance of memories or external reminders that bring about memories
- Negative beliefs about themselves or detachment from other people or decreased interest in things
- Increased reactivity, which might look like increased startle response, anger outbursts or in a state of constantly assessing for potential threats

A lot of these symptoms we just described can look like other diagnoses - depression, panic attacks, social anxiety, etc. The symptoms are happening largely in reaction to a traumatic situation that happened. That is why we often ask questions about trauma; we are not wanting you to re-live your trauma or focus on only bad things that have happened, but the treatments for PTSD can be very different from depression and anxiety, so it is important to know if you have experienced trauma.

Luckily, there are various therapy options for PTSD. Examples include Trauma-Focused CBT (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Processing Therapy, and more. There are also medications that can help with nightmares, or medications to help if the PTSD also leads to a diagnosis of a Depression.

"Isn't OCD about needing to keep things neat or having to wash your hands a lot?"

The answer is maybe. Those might be some of the most common compulsions. But the best way to describe OCD is by saying that patients will often have intense unwanted thoughts or images that pop up in their mind (obsessions) and behaviors that they feel the need to repeat (compulsions). Sometimes they feel doing the compulsions will help make the anxiety or obsessions go away, when actually doing the compulsions just reinforces the pattern in the brain. The thoughts are unwanted and upsetting, and can range from excessive concern with germs or illness, to excessive thoughts that they may hurt or kill someone, or to repeated unwanted sexual thoughts or images. Even though the person would never do these things or they are not realistic (probably unlikely to get sick from not hand washing, etc), the fact that these scary thoughts come over and over again make the person feel like the thoughts are realistic.
 
Sometimes it can be difficult for others to notice the symptoms of OCD, or the person feels uncomfortable sharing the unwanted thoughts, which can lead to a delay in diagnosis. Also, there are so many different types of obsessions and compulsions, but people only tend to hear about excessive cleaning or hand washing. For a good review of examples of obsessions and compulsions, you can always search for the Yale-Brown Obsessive Compulsive Scale Symptom Checklist, which we can review in the office as well.

OCD is treated by Exposure-Response Prevention therapy, a specific type of Cognitive-Behavioral Therapy (CBT).  For many people, treatment may include both therapy and medication. Early diagnosis and early treatment make it more likely that your symptoms will be under control.

It is normal and healthy for everyone to experience some amount of anxiety or worries. If you didn't experience some level of fear when you see an angry bear running toward you, you might not be able to have a quick enough response to keep yourself safe. Seeing angry bears might not be a frequent real life scenario. If you don't get worried about that big test or presentation coming up, you might not have motivation to prepare. There are many examples of having healthy worries.

People who have an anxiety disorder experience worries and fear that are outside of the normal range, or that interfere with parts of their lives. Sometimes anxiety disorders can be sneaky by starting later in adolescence or adulthood, so things that you used to be able to tolerate now lead to intense worries or fears. Anxiety can be so draining that it can sometimes lead to depression, as well. There are many different types of anxiety; some examples include:

The number one treatment for most anxiety disorders is therapy. Usually this therapy will involve some sort of techniques of cognitive behavioral therapy (CBT), and may include relaxation techniques, emotion and thought identification, recognizing the underlying reasons behind some of these thoughts, and/or slowly increasing exposure to the trigger that leads to anxiety. There are other forms of therapy that help with anxiety as well, and having healthy, relaxing routines built into your day can make a difference (exercise, meditation, music, self-care, etc). Your doctor may recommend labwork to make sure there are no medical conditions that are causing or worsening your anxiety. If therapy alone is not providing full treatment of symptoms, or with certain types of anxiety, your doctor may recommend medication treatment. Our goal is to help you decrease anxiety so that you can get back to doing your usual activities and feel a better sense of controlling or managing your symptoms. 

If you are struggling with any of these symptoms, please discuss them with your doctor. If you are experiencing suicidal thoughts, please reach out for help by calling 911 or seeking help at an emergency room. Some people still experience a lot of shame or stigma around their depression symptoms, but we take the approach that depression is another medical condition that needs treatment, like asthma or diabetes. It can take hard work to find the best regimen to control the depressive symptoms; sometimes these symptoms go into remission and never come back, and sometimes there can be a flare up of symptoms and we need to adjust your treatment plan. But we have hope that by working together as a team, we can find a plan that works best for you and that gets you back to feeling like yourself again.

If the depression is new-onset or seems more mild, our first recommendation will usually be starting a course of weekly therapy sessions. There are some lifestyle changes that could help, such as sleep routine, exercise, socialization, or healthier diet. We may also recommend labwork to see if there are any medical problems that are causing or worsening the depression. If the depression continues, or if the depression is more severe, we will likely recommend medication and therapy, as we know that the two work better together.