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Author: At Your Service Psychiatry, PLLC

Emotional Support Animals

The ESA Request

The following story is a culmination of the various requests I’ve had over the years, not one specific person, or animal, and the details are changed to protect the identity of the clients.

… He matches the soft breaths of the animal and slows down his …

He comes to me, obviously nervous.  A referral from his trauma-informed therapist. His voice is shaking, and he sweats.  He clutches a letter he’s prepared. I try to make him as comfortable as I can, but this poor young man looks terrified. I ask why he’s here, and he begins to tell me of the most horrific trauma he endured.  He sweats more, and he can barely look me in the eye, afraid to cry.  He can hardly get the words out, “I don’t want medications” he says almost apologetically, “I am doing so good with therapy, I can get through this, but the panic attacks happen almost every day.” He opens the letter, his hands trembling as he reads how having his cat has saved his life.  And it is no exaggeration.

He says that when he is reminded of the trauma, the re-living starts to happen, and then the subsequent panic comes on. His heart is racing, he cannot think, feels like he’s not in his body, and that he will faint. There are times he even thinks, “I can’t live like this anymore.” So, he lays down, he practices ‘grounding’- feeling the floor beneath him, and his sweet kitty comes and lays on his stomach. He matches the soft breaths of the animal and slows down his.  He feels the light weight of kitty on his stomach, which also stops it from spinning. He comes back to the room and spends a moment in cuddles and is then able to continue his day. His cat keeps him working, keeps him sleeping, and helps with grounding.

ESA Letters

When doing a letter for an emotional support animal (ESA), we make sure they are for people with a mental health diagnosis.  We ensure the owner understands they are responsible for picking a safe animal.  We make assess that the person knows and can clean, train, and care for their ESA, and most importantly, keep the animal safe around others.

Animals are an essential part of many people’s mental health recovery.

We include all paperwork you should need with your visit.  If your therapist is not comfortable filling out ESA paperwork, or you need additional supporting documentation, we can get that for you.  Paperwork is filled out and sent within 24 hours of your visit.

Health Anxiety

 

There are many ways anxiety, stress, trauma may manifest in our bodies. One common manifestation of this is through health anxiety, also called Illness Anxiety Disorder, where people worry about getting an illness.  People with illness anxiety disorder have often been through their own health scare or seen someone they love suffer from an illness or die.  This trauma becomes internalized, then may come out later in life during times of stress or worry.  People with health anxiety often go to the worst-case scenario, as most people with anxiety also do. They catastrophize the things that could occur should they get a disease. Many highly sensitive people may misinterpret their body sensitivities in times of stress, and it manifests into illness anxiety. With the media inundating us with news stories using pressured dramatic speech, alarming headlines, and sensationalized violence and illness, it can easily overwhelm us.

 

Anxiety is genuine and can feel a lump in the throat, sighing, heart racing, numbness, and tingling. It can exacerbate physical symptoms of headaches, migraines, and worsen tremors and other neurological conditions. It can manifest in the following syndromes in psychiatry.

 

Illness Anxiety Disorder

  • Preoccupation with having or getting a severe illness
  • No major physical symptoms
  • Worry is disproportionate to the actual risk of the disease
  • High level of anxiety about health
  • Easily alarmed about personal health status
  • Care-Seeking or Care-Avoidant Types
    • Either excessively checking through multiple visits to doctors, checking the body for signs of the illness
    • Avoids doctors and hospitals altogether

Somatic Symptom Disorder

  • Having body sensations that are bothersome and interferes in your life
  • Excessive thoughts, feelings or behaviors, related to the sensations and may be associated with the health concerns
  • Worry about the seriousness of one’s symptoms
  • High level of anxiety about health or these symptoms
  • Excessive time and energy devoted to these symptoms or health concerns
  • Can present as pain

Conversion or Functional Neurological Symptom Disorder

  • One or more motor or sensory symptoms that do not have medical explanations
  • The symptoms cause problems in social, work, or other significant parts of your life
  • Symptoms commonly present as some of these:
    • Pain
    • Swallowing
    • Tremors
    • Speech
    • Seizures
    • Loss of feeling
    • Problems with vision, smell, or hearing
    • Can have psychological stressors before it occurs
    • Can occur for no reason without stress

There are mind-body modalities for lessening health and illness anxiety.  Cognitive behavioral therapy, yoga, somatic experiencing, breathwork, exercise, and many others are available.  Some people choose medications to help with these symptoms.

 

ILLINOIS ONLINE ADHD

Welcome Back, College Students!

You only have a limited time when you’re back in town. With your Vyvanse, you can keep on task, concentrate, and get through the coursework, but you keep running out of your medications at school.

How am I supposed to get to an office when I’m in class all day, plus clubs, sorority, work, and sports?

Do I really have to come in for an office visit when my dose doesn’t ever change?

AN EASIER WAY FOR ADHD TREATMENT

You take Adderall, Vyvanse, Ritalin, or another stimulant for ADHD or ADD, but find it challenging to keep taking time out of your busy life to get to an office every month. You take off work or class, sit in traffic, wait in a crowded waiting room, just for a brief visit to refill the same medication. That ten-minute appointment now turned into an hour or longer chunk of your day, wasting your already limited time.  Now, after one in-person visit, the follow up visits are done using an app similar to Skype or FaceTime for that visit.

Picture, you’re down to your last few tabs, you pop online and make an appointment that week, on your lunch break, that evening, or weekend. Prescriptions are sent right to your pharmacy, no handing in papers, just show up to the pharmacy when it’s ready.

Welcome to the convenience of TelePsychiatry. In this innovative psychiatry practice, after one in-person visit in Illinois, we can do your monthly visits from your phone in your dorm, car (not driving, of course), office, anywhere you are located.

On your Thanksgiving or Christmas break, you can take a trip out to our Bloomingdale, IL office, where we do a full psychiatric evaluation. After that, you can conveniently self-schedule in advance or even at the last minute. You may text me in between visits for any concerns or questions about your medications.

After the initial visit, the ADHD visits are $99 monthly.

Schedule Here

Care for the Highly Sensitive Person

Dr. Elaine Aron, PhD first described the highly sensitive person (HSP) as a personality trait in her book, The Highly Sensitive Person: How to Thrive When the World Overwhelms You. One part of this trait includes symptoms of being easily overwhelmed with strong sensory input, such as sounds, smells, and sensations. HSPs are more aware of subtleties around them; they pick up quickly on other people’s feelings and what is needed to soothe others who may be struggling. They also have a greater need to recuperate after upsetting and overwhelming tasks and must protect their energy levels.

Many of the traits of highly sensitive, empathic, and introversion overlap. HSPs may come in for help due to feeling anxious or overwhelmed when others do not seem so bothered by life, work, or family events. They judge themselves or feel judged for needing more alone time, more quiet time, and more self-soothing than others.

In the field of psychiatry, many clinicians look towards the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to label mental health conditions and illnesses. HSP, empath, and introversion traits are not in there due to not being pathological; it is just a way of being. HSPs have different wiring than others.

It is important for psychiatry clinicians to understand the HSP trait.

Things to know about HSP’s in Psychiatry:

  • Maybe prone to depression, anxiety
  • May look like social anxiety or avoidance when really it is recharging from overload
  • May exhibit more tearfulness without that being a symptom of a depressive episode
  • May react stronger to medications or have more side effects of drugs
  • Typically need sub-therapeutic (lower than standard) dosing of medications if they take them
  • More sensitive to the effects of stimulants
  • Benefit from mind-body modalities such as yoga, salt floats, meditation, time in nature, alone time

Having a highly sensitive personality is both a blessing and a challenge. HSPs feel a great depth of love and compassion for others. They also need to balance this with self-care and create good personal boundaries for protecting their energy.

High Functioning Depression

The alarm goes off, and you sigh. Everything feels so heavy. You hit snooze, and again, and are still tired. Wearily you sigh again and get up. It feels like too much today to wash your hair. “I’m so lazy,” but you keep going. Driving to work, you can’t remember how you got there, every day seems like a monotonous blur. Friends text you, and you pretend you forgot to hit send. But really it’s too hard to say, I’m depressed. You don’t cry all the time, but just don’t find joy. You don’t want to hang out with friends, or it takes a huge push to do it.

We think of depression as crying all the time, spending all the days in bed, and wanting to die. While this is the picture of severe major depression, there are variances in the severity of depression. Many people with moderate depression can still push through life. High functioning depression may look like taking a lot more effort, there is less enjoyment, you get enough sleep, even more than usual, but always feel tired.

The typical depression screener that we do to look at these symptoms is called the Patient Health Questionnaire or PHQ-9 (Pfizer, 1999). It asks, in the last two weeks, how often have you been bothered by any of the following problems:

• Little interest or pleasure in doing things
• Felling down, depressed, or hopeless
• Trouble falling or staying asleep, or sleeping too much
• Feeling tired or having low energy
• Poor appetite or overeating
• Feeling bad about yourself- or that you are a failure or have let yourself or your family down
• Trouble concentrating on things, such as reading the newspaper or watching television
• Moving or speaking so slowly that other people could have noticed. Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual
• Thoughts that you would be better or dead or hurting yourself

Major depression, dysthymia, and “high functioning depression” have similar medication treatments, but vary on dosing and aggressiveness of treatment based on the severity of symptoms. Some treatment options may include therapy, exercise, supplementation, and medications. Medications are chosen based on your presentation, family history, length of symptoms, concerns for particular side effects, and co-morbidities. Your clinician should work with your preferences. If you choose to take medication, the goal is not to feel numbed out or unlike yourself.

People with high-functioning depression still struggle with motivation, making phone calls, and attending appointments. It is hard enough getting to work and caring for the family. Telepsychiatry offers another alternative to get care. This practice allows for scheduling within a few days and taking visits from the comfort of your couch in jammies for when motivation is a struggle.

Depression Screener

Agoraphobia & Phone Call Anxiety

We often think of Agoraphobia only as of the inability to leave one’s house. But it may present in more subtle ways and still be very debilitating.

The DSM-5 gives Agoraphobia examples of marked fear or anxiety about:

·      Using public transportation (cars, buses, trains, ships, planes)

·      Being in open spaces (parking lots, marketplaces, bridges)

·      Being in enclosed places (shops, theaters, cinemas)

·      Standing in line or being in a crowd, and also maybe being outside of the home.

A person with agoraphobia fears or avoids these situations where escape may be difficult.

They are afraid of having attacks of panic or embarrassment (like fearing falling, fainting, or incontinence). Often, the person needs someone to go with them to get through these.

Agoraphobia responds well to psychotherapy and medications for anxiety.

Some old-school beliefs in the field about the care of someone with agoraphobia would purport that teletherapy or telepsychiatry further enables a person to stay in their comfort zone.  They believe it prevents the therapeutic exposure process.  While there is some truth to that, what about the people not there yet?  The ones who need a few more steps before walking into an office.  The ones who cannot even make a phone call because of profound anxiety.  I believe telehealth is a way to reach these struggling people.  Exposure therapy is gradual.  I have worked with people who delayed therapy and psychiatry for because even making a phone call is anxiety-provoking.

Phone Call Anxiety      

Phone Call Anxiety is one reason I created the ability in my practice to directly text me and any of our clinicians before scheduling a visit.

For some people with anxiety, the act of making a phone call or downloading a mental health app is too big or high of a step.  I intentionally left out the patient portal experience with the passwords and the stuff that makes reaching out even scarier.  I feel like this small detail of texting me, like texting a friend, was the stepping stone for someone with high anxiety to get support.  When I searched for systems that allowed me to maintain HIPAA-compliance, they all said the doctors and providers don’t want patients to be able to directly contact them.  So, I devised my own HIPAA-compliant texting system because being approachable and accessible sets this practice apart from traditional psychiatry practices.

On my end, your information is housed in a HIPAA-compliant portal, on your end, it’s as easy as texting a friend 833-AYS-PSYC or 833-297-7792

Reference
American Psychiatric Association. (2013). Agoraphobia. Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596.807874

Until We Can End Mental Health Stigma, We Work Around It

“I would never want to have a mental health diagnosis on my record”

A quote from Gold, Andrew, Goldman, & Schwenk (2016) retrieved from https://buff.ly/2yRTVh8 These researchers found the reason many female physicians will not obtain mental health care is due to their concerns for having a mental health diagnosis in a permanent, sharable, electronic medical record. This concern is valid. Physicians must often report their depression, anxiety, mood disorder, or substance abuse issues to the board of medicine. Physicians often must sit in front of their licensing boards and hope someone who they don’t know, doesn’t further stigmatize them. They worry they will lose their license due to the board findings.

Many factors play into the tragedy of the epidemic of physician suicide- moral injury, burnout, dehumanizing electronic medical records, bureaucracy, and also ACCESS & STIGMA! We need to do better for the mothers & fathers of medicine.

One day I was speaking with my colleagues about the privilege of treating those in the field. We all acknowledged we have a quiet system for psychiatric treatment on the “down-low” for physicians and clinicians, and those in the public eye. We bring the person in on off-hours, paper chart kept in a lockbox and other privacy measures. We all agreed it would be nice if there were no stigma, no need to do this, but we all do it. #endphysiciansuicide

Telepsychiatry provides a de-stigmatizing, accommodating, private way for physicians, clinicians, and those needing anonymity to get treatment for mental health or substance abuse support. At Your Service Psychiatry, PLLC offers the ability to seek treatment outside of an electronic medical record system, alternative consent sign-up, scheduling, and payment. Those who need additional privacy measures may call or text 833-AYS-PSYC (833-297-7792) for details on exclusive care.