The Dr. Denise Way

My approach is to meet my clients where they are at – to understand their world view and their perspective on medicine and wellness. I want people to embrace their mental health. Your strengths can be your weaknesses. My golden rule is to be loving and be kind and be the best version of yourself. What does your best look like for you to thrive, not just exist? Create your own golden rule – something that keeps you grounded and mindful throughout the day.

Depression

If you’re not having the true joy each day that you are familiar with in the past, there could be a good chance that you’re suffering from low grade depression. Most people who come to see me have just had a traumatic event and they are pre-disposed to having a larger depression and now they are having hopelessness and the inability to get out of bed. You don’t have to wait until a traumatic event happens and you start feeling hopeless and not be able to get out of bed. Go see someone before your low grade depression turns into a major depression. You can have a lot more joy in your life. If you don’t have enough energy or enough joy, even if you are successful you might want to get assessed or let your doctor know you are feeling this way. You can experience a much more joyful life. 

Obsessive Compulsive Disorder and Anxiety

Did you know that Obsessive Compulsive Disorder  (OCD) affects 2-4% of adolescents and that 80% of people who have OCD experience symptoms before age 18?

It is important to point out that most mental health challenges start in childhood.

I value science and the need for a uniform way of discussing mental health, yet feel the term “disorder” (when discussing mental health) really puts a distance to someone embracing their “neurostyle”. We need to identify children who need extra mental health support and integrate wellness thinking and acceptance of neurodiversity in our society. Let’s discuss OCD now.

Did you know that the World Health Organization (WHO) ranks OCD as one of the ten most disabling diseases?

The OCD cycle usually starts with an environmental trigger that leads to an obsession described as intrusive, repetitive, negative images, thoughts or impulses. This causes distress as manifested by anxiety, fear, disgust or shame, followed by compulsive behavior as represented by repetitive thoughts, images, or actions.

The OCD cycle

(Trigger >>Obsession >>Distress>>Compulsions >>Negative Reinforcement)

It is a myth that OCD is an Adult disorder.

The two common onset peaks for OCD include earlier for boys that have the triad of OCD, ADHD and Tic disorder, and early puberty for girls.

In child psychiatry it is common for children to present with more than one behavioral disorder. OCD exists in combination with one other behavioral problem ¾ of the time and with multiple problems 1/3 of the time.

How do we identify and begin to treat OCD?

A diagnostic interview is done which includes parent and child interviews, a review of rating scales, report cards and if OCD is present a clinician scores the severity of OCD with the Yale-Brown Obsessive Compulsive Scale (YBOCS). The 10-item (each item rated from 0 (no symptoms) to 4 (extreme symptoms) Y-BOCS scale evaluates the severity of obsessions and compulsions separately and is the standard scale used in treatment outcome studies of obsessive compulsive disorder (OCD).  The severity of OCD is based on total core: 0-7,is subclinical; 8-15 is mild; 16-23 is moderate;24-31 is severe; 32-40 is extreme.

Do you want to know the good news? Pediatric OCD is usually responsive to treatment with the goal of a score of <8 on YBOCS .

“Exposure therapy is the secret sauce in treating OCD,” UCLA Scientist and Professor James McCracken M.D. would say during our child psychiatry clinic. Exposure therapy is a behavior therapy that involves the exposure of the patient to the feared object or context without any danger in order to overcome their anxiety. An example would be an individual with fear of contamination. The exposure would be putting their hands in dirt and not allowing them to wash their hands for a period of time.  The patient ranks their fear level before and after the exposure and realizes that the fear reduces over time after exposure.

The first line treatment for OCD is Cognitive Behavioral Therapy with  Exposure and Response Prevention (ERP).Children who lack insight, have ADHD or depression, have a family history of OCD, or high family conflict tend to have challenges with response to behavioral therapy alone. From a medication standpoint the Selective Serotonin Reuptake Inhibitors are the first line of treatment, the four FDA approved SSRI”s are Clomipramine, Fluoxetine, Sertraline and Fluvoxomine.

The well known POTS study (Pediatric OCD TREATMENT STUDY JAMA 2004:292(16) reveals that  combination treatment was consistent with a 53.6% remission rate and CBT alone 39.3%, Zoloft alone 21.4%. It was also noted that those with family history of OCD had more than a 6 fold decrease in response to CBT alone.

Combination therapy yields the best results for moderate to severe OCD.

Let me give you a clinical example of a sixteen-year-old girl, Christina (pseudonym) who I worked with whose trigger to her obsessions was watching television and witnessing motor vehicle accidents, or driving over speed bumps. Her obsession was that she had fatally harmed someone as her obsessive image and thought. Her compulsive behavior was getting in the car and retracing her route to make sure she had not actually injured someone.  She would call hospitals to make sure no one had been hurt.  She came to see me for help with her OCD.

Her YBOCS score was in the extreme range (>32). She did not respond initially to CBT-ERP alone. A combination of Prozac and exposure therapy yielded great success for Christina! Her YBOCS was less than 8 within a year of treatment. She and I drove in her car and we would ride over bumps and not go back to the site to see if anyone was ok or call hospitals to make sure no one was in the emergency room. Christina is now in her mid twenties successfully working and is not on any medication for OCD! She utilizes her tools from therapy, exercises regularly, eats healthy and meditates routinely. This is a great thrive story-right? This is why I love what I do.

Dr. Denise

 

Childhood Anxiety Disorders

As a Child Psychiatrist I see a lot of children struggling with different types of anxiety: Separation Anxiety, Generalized Anxiety, Social Anxiety.  The symptoms of each above often “travel together” and are persistent into the adult years which can lead to other more serious challenges such as substance abuse and other mood disorders.

Here’s the good news:

We have great treatment options and can provide early intervention so that your child can thrive!

Here is the data to back this up:

The Child/Adolescent Anxiety MultiModel Study (CAMS) (Dr. JT Walkup in 2008) revealed greater than 2/3 of the children with anxiety had two or more types of anxiety listed above. *This is the largest existing anxiety study to date.

The data revealed combination therapy (Cognitive Behavioral Therapy [CBT] and sertraline combined) which showed an 81% response! Therapy alone revealed a 60% response and medication alone a 55% response rate.

Source:Walkup JT,et al, NEJM 359:2753-2766,2008

This is amazing, right?

The bottom line is that you should always start with cognitive behavioral therapy as the first line of treatment for childhood anxiety symptoms. For complex and severe situations medication and cognitive behavior therapy together capture a great response.

What is CBT?

Cognitive behavior therapy is one of the few forms of psychotherapy that has been scientifically tested and found to be effective in hundreds of clinical trials for many different disorders. In contrast to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem solving oriented. In addition, patients learn specific skills that they can use for the rest of their lives. These skills involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.

How can we as a society have less suffering and more “mental wellness”?

I believe parents, teachers, and pediatricians are on the “front line” to be able to recognize anxiety. If you are a parent reading this ask yourself: “Is there anyone in my family who was a “worrier”? Any relatives with difficulty in social situations?”  “Did I have troubles separating from my Mom as a kid?” Many families have a history of anxiety.  Usually you see a child psychologist, or a child psychiatrist if there is moderate to severe impairment at school, home, or socially.

If you are a teacher you can give information to the parents at parent-teacher conferences with examples of the ways a student might be shy, socially challenged or perfectionistic.  I know that a lot of teachers share their observations, which can prompt a parent to be aware of any need for further help.

I have been very impressed with the pediatricians I work with that are providing early screening for anxiety. I am so happy to see routine questionnaires being given to detect any outlier anxiety or other behavioral issues.

When treating these disorders, I include the importance of nutrition, daily exercise, and daily meditation. It is common sense to limit sugar and teach kids to listen to their bodies to know when they are full or hungry. Kids thrive when they move! A sport, PE, or good old fashioned hide and seek can burn calories and reduce stress.

I am a strong believer in teaching our kids meditation.

I recommend starting with ten minutes a day with the goal of twenty minutes as a lifetime daily habit.  I like simple solutions. What if every school in the World included a ten-minute “quiet time” for meditation right after lunch?  This is possible and I am committed to implementing these types of important programs into our schools, not only because of the proven research but also the results I’ve seen are life changing.

In summary, childhood anxiety is common and can be treated effectively. Cognitive behavioral therapy is first line treatment.  Combined treatment yields 81% response. Prevention of substance abuse and mood disorders can happen if early intervention happens!

Dr. Denise