Dr Daven Morrison talks about the myriad of issues surrounding the current complex workplace. 

is Assistant Clinical Professor of Psychiatry at Chicago Medical School.

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 is a retired oncologist and the author of the book

 A Spiritual Pathway to Recovery from Addiction, A Physician's Journey of Discovery. 

Addiction occurs among doctors at the same rate as the general population. Dr Linville Meadows shares his own story with addiction recovery and rehabilitation. 

A Doctor Impaired

If you were to poll physicians and ask which specialty usually takes the lead in the management of chronic pain, no doubt an overwhelming majority would say anesthesiology, with a smaller number saying neurology and physiatry. However, probably few would say psychiatry.

It is odd considering the recent revision of the definition of pain by the International Association for the Study of Pain, the leading worldwide organization for medical professionals involved in the field of pain: “Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors.”

 This appears to be almost precisely with what psychiatry deals.

We already know that there is a high degree of comorbidity between depressive and anxiety disorders with chronic pain and, although it is commonly thought that the mental disorders are always secondary to the pain, research has shown that pain is a common presenting symptom of these disorders.

The papers in this Special Report discuss 2 other problems that frequently occur in those with chronic pain: sleep disorders and posttraumatic stress disorder (PTSD). We have known about the relationship between sleep disorders and chronic pain for years; however, the relationship between pain and PTSD is a more recent finding.

As with depressive and anxiety disorders, it is usually thought that if a sleep disorder is present in a person with chronic pain, the sleep issue is always secondary to the pain. However, this oversimplifies the relationship. The interaction between pain and sleep disorders is often a 2-way street, with each exacerbating the other. Both the pain and the sleep disorder need to be addressed.

Of course, the presence of any type of pain can impair sleep. Patients with peripheral diabetic neuropathic pain often report worse pain in their lower extremities during the night when they are trying to sleep. Those who suffer from complex regional pain syndrome in their lower extremities may complain that it is it painful to have sheets touch their skin due to allodynia, in which stimuli that do not usually cause pain do so. Patients with back pain often report problems with sleep due to pain although, curiously, laying down is the position they usually find most comfortable. In fact, if the pain is worse lying down, it is considered a red flag indicative of serious underlying pathology.

Similarly, disruption in normal sleep cycles can cause pain. More than 45 years ago, research found disruptive sleep in some healthy individuals precipitated the symptoms of fibromyalgia and resulted in widespread pain.

There are few studies on the treatment of comorbid pain and sleep disorders. Although both are commonly treated with medications, there is limited research on using pharmacologic agents when both problems are present. Most of the studies have looked at pregabalin in patients with fibromyalgia.

Opioids and benzodiazepines, medications that are frequently prescribed for patients with chronic pain, may actually exacerbate pain because they can cause hyperalgesia (eg, lower pain threshold). These agents can also exacerbate sleep disorders because of their disruption of normal sleep architecture. Sadly, many lay people and medical professionals mistakenly believe that the sedative side effects of these medications mean they will be beneficial for sleep.

There is much less research on chronic pain and PTSD, although there has been a growing interest in the past few years. 

A limiting factor of the data is that much of the research involves veterans. Due to the nature of our recent wars, many veterans suffer from painful injuries caused by explosions. They frequently suffer from traumatic brain injuries (TBI) of varying severity. In fact, both pain and sleep disorders have both been associated with TBI.

 Of course, few civilians who suffer PTSD have similar experiences, so the role TBI may play in the development of comorbid PTSD and chronic pain remains to be determined. 

In addition, research has shown that PTSD may not only be associated with both pain and sleep disorders, but also play a role in acute pain becoming chronic pain.

Since we have yet to identify a markedly efficacious treatment for PTSD, adding chronic pain as a factor further complicates care decisions. Furthermore, although there has been much speculation as to which factors predispose people to develop PTSD and chronic pain separately, we still have no final answer, and we have limited ability to predict who is at increased likelihood for developing both.

For all 3 problems—PTSD, sleep disorders, and chronic pain—psychologically based therapies appear to be among the most promising treatments. They also do not carry the same risks of exacerbating another condition as do medications.

Since psychiatrists often treat PTSD and even sleep, there is little doubt they will see patients with comorbid chronic pain. Unless psychiatrists also are knowledgeable about pain and its management, we will not be able to provide optimal care for our patients.

 is in private practice in Philadelphia.

1. Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. 

2. Moldofsky H, Scarisbrick P, England R, et al. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and health subjects. 

3. Husak AK, Bair MJ. Chronic pain and sleep disturbances: a pragmatic review of their relationships, comorbidities, and treatments. 

4. Lavigne G, Khoury S, Chauny JM, et al. Pain and sleep in post-concussion/mild traumatic brain injury. 

5. Burns JW, Janssen, Lillis T, et al. The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. 

Articles

Chronic pain may not often be considered within the realm of psychiatry; however, chronic pain's relationships with sleep disorders and posttraumatic stress disorder make it an issue you can—and should—address.  

Psychiatry’s Role in the Management of Chronic Pain

Valproic Acid: Overused in Bipolar Disorder?

Giving Valproic Acid a Higher Priority in Bipolar Patients

I am pleased to be offered the opportunity to respond to the commentary by Bernardo Dell’Osso, Monica Macellaro, and Terence A. Ketter. I appreciate that these distinguished clinicians and scientists have taken an interest in this piece, especially because they largely agree with most of the points made, adding some validity to the perspectives presented.

They begin by proposing, without citing evidence, that valproate does not deserve a low priority in some subgroups of bipolar patients. They affirm that it can be reasonable for male and female patients not of child-bearing potential, especially the “very young” (presumably younger than the children and adolescents in the Wagner et al study

, in which valproate did not do better than placebo), and elderly females. They did agree that valproate had inferior results compared with most other competing antimanic medicines in the 3 meta-analyses cited. I can add the more recently published GERI-BD study involving 224 elderly inpatients (with equal numbers of men and women) that found, consistent with the meta-analyses, lithium to be superior to valproate for acute mania over 9 weeks and comparably tolerated.

The commentators then proposed that I failed to note contraceptives could mitigate the teratogenicity and related risks to offspring exposed to valproate. However, they fail to note that 50% of pregnancies are unplanned. Thus, it seems difficult to be confident in contraceptive adherence (especially should a hypomania or mania occur). Combining that consideration with the marginal efficacy in the evidence base and the very high risk of fetal harm, valproate still seems to be nearly the lowest priority option for women of child-bearing potential. Use of valproate in this population is considered to be a major public health problem in Europe.

The commentators next raise the possibility of “methodological limitations,” explaining the negative controlled studies of valproate in acute mania without describing them. The authors of the negative Hirschfeld et al study

 of valproate proposed that failure could have been due to their use of what they termed a “moderate” mean dose of 2200 mg daily. In the previous, only modestly positive study

, participants received a mean dose of 3350 mg daily. However, there were more side effects of somnolence, nausea, vomiting, and dizziness in that study. Few clinicians use such a high dose. Also, the authors noted that the protocol of the negative study encouraged earlier hospital discharge, which may have made it more difficult to find a difference from placebo. The negative study also allowed longer use of adjunctive lorazepam, which may have added support to the placebo group. However, shorter hospital stays are the standard today, and experts encourage liberal use of adjunctive benzodiazepines in treating mania.

 Thus, the conditions that may have resulted in valproate not being found efficacious in its most recent study are likely to be present in usual practice today.

The commentary discussed the lack of FDA-approval for valproate as a maintenance treatment. The cited maintenance study that failed to show efficacy indeed had faults—and one that is often mentioned is that the lithium group had more suicidal issues than the placebo group, contrary to most other evidence, suggesting that there was something peculiar about the patient sample. The commentators encouraged not making too much of FDA-approval as a basis for decision-making. They noted that the FDA has approved adding medications like second generation antipsychotics (SGA) to mood stabilizers including valproate and lithium. However, these SGAs are also efficacious and approved as monotherapies for mania, and in the design of all these enhancement studies, the patient must first have been on the valproate or lithium for 2 weeks and not responded before the SGA or placebo is added. So, these studies do not contribute to the evidence base for the efficacy of valproate: the improvement could have been entirely from the SGA. Other studies including the BALANCE 2-year trial of lithium versus valproate versus the combination found valproate far less effective than lithium.

 Effectiveness as a maintenance treatment should be an important consideration in choosing a medication for an acute episode. 

After some remarks in agreement with the article, the commentary discusses the relative weight gain from valproate versus olanzapine. The authors assert that even if valproate causes more weight gain than olanzapine in head-to-head trials, olanzapine is more widely avoided. This is likely true. Probably both should be avoided in favor of other agents for mania at least for first-line use, as asserted in important national and international guidelines.

Next, there is mention of the relative benefit or harm from valproate versus lithium in patients with suicidal tendencies. There is nothing of importance in the literature to suggest that valproate has any benefit for this common problem in patients with bipolar disorder, even if, as the commentary authors assert, the FDA’s suicide risk warning on valproate was not based on strong evidence.

On the other hand, I agree with the importance of mentioning that carbamazepine, which may have a larger effect size for efficacy in acute mania, has almost as many problems for women of child-bearing potential. It also carries the same suicide risk warning that the FDA required for anticonvulsants.

In the final remarks, the commentary reiterated and added evidence that valproate is being very widely used especially in the United States, but that agreed that lithium, SGAs, lamotrigine, and carbamazepine should figure prominently in selecting medication for bipolar patients. The purpose of my article was, indeed, to urge clinicians to reappraise their preference for valproate. 

is associate professor of psychiatry, Harvard Medical School, and

co-lead psychiatrist at the US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, MA. 

1. Wagner KD, Redden L, Kowatch RA, et al. A double-blind, randomized, placebo-controlled trial of divalproex extended-release in the treatment of bipolar disorder in children and adolescents. 

2. Young RC, Mulsant BH, Sajatovic M, et al. GERI-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients With Bipolar Disorder. 

3. Sher J, Frank JW, Doi L, de Caestecker. Failures in reproductive health policy; overcoming the consequences and causes of inaction. 

4. Hirschfeld RM, Bowden CL, Vigna NV, Wozniak P, Collins M. A randomized, placebo-controlled, multicenter study of divalproex sodium extended-release in the acute treatment of mania. 

5. Bowden CL, Swann AC, Calabrese JR, et al. A randomized, placebo-controlled, multicenter study of divalproex sodium extended release in the treatment of acute mania. 

6. Mohammad O, Osser DN. The psychopharmacology algorithm project at the Harvard South Shore Program: an algorithm for acute mania. 

7. Geddes JR, Goodwin GM, Rendell J, et al. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial. 

8. Kessing LV, Hellmund G, Geddes JR, Goodwin GM, Andersen PK. Valproate v. lithium in the treatment of bipolar disorder in clinical practice: observational nationwide register-based cohort study. 

David Osser, MD, comments on the low priority of valproate for treating patients with bipolar disorder. 

Reappraising a Preference for Valproate

We read with interest the article by David N. Osser, MD, “Valproic Acid: Overused in Bipolar Disorder?”. Other authors have taken exception to the National Institute for Health Care and Excellence (NICE) Bipolar Guideline’s similar approach to valproic acid (VPA), namely to avoid this medication in women of child-bearing potential.

 Indeed, we think that to give VPA such a low priority for all patients with bipolar seems like an over-response to VPA’s limitations, as this medicine can be effective and well-tolerated in males, as well as in females not of child-bearing potential (especially in very young or older females). Admittedly, VPA needs to have an extremely low priority in women of child-bearing potential due to the important risks of neurodevelopmental delays and polycystic ovary. The article correctly points out this fact; however, it fails to note mitigating information such as treatments for the latter include hormonal contraceptives.

The article stated that the last 2 VPA studies were negative, and VPA has a small effect size in acute mania.

 However, even though the last 2 controlled trials were negative, perhaps due to methodological limitations, divalproex sodium and divalproex sodium extended release are currently FDA-approved for the treatment of acute mania in monotherapy, in consideration of the efficacy showed by previous results on adults.

 In addition, 1 negative study from the point of view of efficacy was positive from the point of view of safety (rather than efficacy) in children and adolescents.

The article correctly pointed out that VPA was not FDA-approved for bipolar maintenance treatment. However, this may have been due to the “non-enriched” (for acute valproate response) design of the VPA bipolar maintenance study.

 Indeed, VPA can be an effective bipolar maintenance treatment if using an “enriched” (for acute valproate response) design.

 It can be challenging to link logic to FDA-approval status of medications, as several second-generation antipsychotics (SGA) have already been FDA-approved to add to VPA (or lithium) in drug-resistant bipolar maintenance treatment. Additionally, lurasidone was FDA-approved to add to VPA (or lithium) in treatment-resistant acute bipolar depression.

The piece noted that a few small studies (4 studies with 142 participants) have been consistent with VPA efficacy in acute bipolar depression.

 However, in the absence of economic incentive, it may be unlikely that a larger acute bipolar depression VPA study will be undertaken.

VPA may be more effective than lithium in bipolar mania with dysphoria.

 This is an important consideration, given the importance of bipolar mixed states in DSM-IV-TR

 and the emerging importance of mixed depression in DSM-5.0.

Head-to-head studies suggest more weight gain with valproate versus olanzapine, as noted in the article. However, olanzapine (even with fluoxetine) has been even more widely avoided than valproate due to risks of weight gain and metabolic abnormalities.

The article stated that suicidality (suicide or suicide attempt) was twice as likely with VPA versus controls. However, this statement is problematic if lithium (which has anti-suicide effects) is the control agent. Even compared with placebo, the number of suicide events was too small to allow any conclusion about VPA effect on suicidality. Nevertheless, the FDA has included an anticonvulsant suicidality warning for valproate and other anticonvulsants (including carbamazepine).Carbamazepine appears to be a poor option for women of child-bearing potential as it also entails teratogenicity (including spina bifida) and has multiple drug interactions (including interfering with hormonal contraceptive efficacy).

Liver dysfunction and, less commonly, pancreatitis, thrombocytopenia, and polycystic ovaries are other significant adverse effect issues with VPA, as explained in the article. Although this is true, it also makes it clear in whom VPA needs to be carefully avoided—women of child-bearing potential, patients with low platelets, and hepatic transaminases over twice the upper limit of normal.

The article correctly stated that VPA was widely used in the treatment of bipolar disorder and, in fact, in a recently published multicenter report, including American (Stanford) and Italian (Milan) patients with bipolar disorder, it was the most common individual mood stabilizer (33% of the overall sample). In particular, individual VPA usage was higher in Milan than Stanford for both patients with BDI (44.4% versus 35.9%) and BDII (26.9% versus 11.3%); patients with BDI had significantly higher rates of taking VPA compared to those with BDII (40.1% versus 17.5%).

Although VPA has utility in bipolar disorder, we agree that clinicians should think of lithium, second-generation antipsychotics, lamotrigine, and carbamazepine prominently in selecting medication for bipolar disorder patients.

is an associate professor of psychiatry at the University of Milan and Director of the Psychiatric Clinic of the Ospedale Luigi Sacco-Polo Universitario of Milan, Italy. He is also Scientific Advisor at the Department of Psychiatry and Behavioral Sciences of Stanford University and Co-Chair of the International College of Obsessive Compulsive Spectrum Disorders (ICOCS). 

is resident in psychiatry at the University of Milan. 

of psychiatry and behavioral sciences, and founder and chief of the Bipolar Disorder Clinic at Stanford University.

1. Curtis D, Kerr M. NICE recommendations for valproate treatment are unhelpful. 

2. Vasudev K, Mead A. Use of valproate in women of childbearing potential: pre- and post-NICE bipolar guidelines. 

3. Kowatch RA, Scheffer RE, Monroe E, Delgado S, Altaye M, Lagory D. Placebo-controlled trial of valproic Acid versus risperidone in children 3-7 years of age with bipolar I disorder. 

5. Bowden CL, Davis J, Morris D, Swann A, Calabrese J, Lambert M, et al. Effect size of efficacy measures comparing divalproex, lithium and placebo in acute mania. 

6. Bowden CL, Brugger AM, Swann AC, Calabrese JR, Janicak PG, Petty F, Dilsaver SC, Davis JM, Rush AJ, Small JG, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group. 

7. Bowden CL, Swann AC, Calabrese JR, et al. A randomized, placebo-controlled, multicenter study of divalproex sodium extended release in the treatment of acute mania. 

8. Wagner KD, Redden L, Kowatch RA, Wilens TE, Segal S, Chang K, et al. A double-blind, randomized, placebo-controlled trial of divalproex extended-release in the treatment of bipolar disorder in children and adolescents. 

9. Bowden CL, Calabrese JR, McElroy SL, Gyulai L, Wassef A, Petty F, et al. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Divalproex Maintenance Study Group. 

10. Bowden CL, Swann AC, Calabrese JR, McElroy SL, Morris D, Petty F, et al. Maintenance clinical trials in bipolar disorder: design implications of the divalproex-lithium-placebo study. 

11. Bond DJ, Lam RW, Yatham LN. Divalproex sodium versus placebo in the treatment of acute bipolar depression: a systematic review and meta-analysis. 

12. Wang PW, Nowakowska C, Chandler RA, Hill SJ, Nam JY, Culver JL, et al. Divalproex extended-release in acute bipolar II depression. 

13. Swann AC, Bowden CL, Morris D, Calabrese JR, Petty F, Small J, et al. Depression during mania. Treatment response to lithium or divalproex. 

14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association; 2000.

15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association; 2013.

16. Ketter TA, Post RM, Worthington K. Principles of clinically important drug interactions with carbamazepine. Part I. 

17. Ketter TA, Post RM, Worthington K. Principles of clinically important drug interactions with carbamazepine. Part II. 

18. Davis AR, Westhoff CL, Stanczyk FZ. Carbamazepine coadministration with an oral contraceptive: effects on steroid pharmacokinetics, ovulation, and bleeding. 

19. Dell’Osso B, Cremaschi L, Arici C, et al. Differential core pharmacotherapy in bipolar I versus bipolar II disorder and European versus American patients not in a syndromal episode. 

Is valproic acid dismissed out of hand? Three doctors discuss its potential as a treatment. 

Giving Valproic Acid a Higher Priority in Bipolar Patients 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times®.

Dr Steven Moffic says it well: COVID-19 Is making almost everyone tense. What can we do about this uncomfortable strain? 

Worldwide Tensions Rise 

Not only in America, but throughout the world, difficult conversations are taking place in many homes. Behind closed doors, children are exposed at early ages to discussions about heavy topics like violence, hate, and human cruelty.

I am blessed to have three daughters. I try to create a safe and sane home for them, but I have never imagined engaging them in some of these talks, especially here in the United States, and in the 21st century.

When I moved to Portland, Oregon in 2009, I thought the city’s nickname (the Rose City) was a sign that things would be much safer and more comfortable for my family. Similarly, my wife believed that moving from the southern to the northwestern part of the country would make things easier for us as 

But shortly after arriving, a young Somali boy was accused of planning a terrorist attack in one of the city’s busiest spots, the Pioneer Square. We found ourselves working with community leaders and the Muslim youth on topics like emotional safety and well-being, how to be a proud American Muslim, strengthening family ties, and improving the relationship between the community and its neighbors and law enforcement agencies.

Fast forward to 2011, a bloody civil war started in my home country Libya. I left my small immediate family behind to care for my extended family overseas, trying to heal some of the many psychosocial wounds of that protracted conflict. I lost friends and loved ones to violence and extremism. My wife and children had to live through periods of uncertainty and high anxiety every time I boarded a plane and partook in that dangerous journey.

We thought and prayed the new decade would bring a better energy, but the year 2020 has been one of the most challenging years of all. Here in Oregon we have been struggling to breathe, literally and metaphorically. It is not only the threat of the 

 (COVID-19) to our respiratory system, but also the systemic knee of injustice on the necks of our black brothers and sisters and the wave of hate facing minorities and people of color. The mask can help with the former crisis, but unmasking is what is needed for the latter.

It became the norm to talk with kids about their identity and self-worth, about micro- and macro-aggressions, about speaking up on behalf of the voiceless, but also about how they can defend themselves when someone decides to attack them verbally or physically. After the Portland max train stabbing incident and the New Zealand mosque shooting, we spent time and energy brainstorming ways on how to stay alive and feel safe at our places of social gatherings and worship. Trauma steals precious moments and impacts the potential for beauty.

I recently participated on a panel discussion about combating hate. A young black female stated that, “at least [things] are not as bad for this generation as it was for our fellow citizens in the 1950s and 60s.” That really broke my heart. Just because hate and violence are “not as bad,” does not mean things are OK. Children should not have to settle for a dysfunctional world.

“The talk” we thought we would have with our children is about how to survive the emotional turmoil of puberty. In the black community, that talk is also about how to stay alive in America. In the Latino community, it may be about the immigration system. In the Muslim community, it may be about terrorism. Hate is horrible, and it not only makes survivors doubt their own beauty, but it also makes us miss out on each other’s beauty.

We thought COVID-19 was only going to impact our ability to breathe, but then Mr Floyd’s death reminded us of the ugly pandemic of oppression. In Oregon, the smoke of the wildfires stirs different discussions about existential themes, like our relationship with God and the meaning of life.

Is it bad that our children are growing up very quickly and having these mature conversations at a young tender age, or is that the new norm? My hope is that trauma will eventually produce a more resilient generation and a more compassionate and cohesive society, I believe that many trauma survivors become better humans not despite, but because, of their trauma stories.

is a practicing psychiatrist in Providence Healthcare System, Portland, OR. He reports no conflicts of interest concerning the subject matter of this article.

This article was originally posted on September 21, 2020, and has since been updated. -Ed

With the state of the world, there are so many difficult conversations about racism, hatred, and violence that we need to have with our children. 

Behind Closed Doors 

"I'm anti-gunshot wound," Rozel says. "Not anti-second amendment." 

is the Medical Director at resolve Crisis Services and President of the American Association for Emergency Psychiatry. He is also an associate professor of psychiatry and adjunct professor of law at the University of Pittsrburgh. 

March 2020, as Dr Jack Rozel tells it, saw the most guns ever sold in 1 month. What is motivating this fear-driven purchasing? Better yet, what can you do to understand and prevent gun violence? 

Understanding What Drives Gun Violence

Spooky or cute? Scary or whimsical? What do you see in this image when you think about Halloween? 

Hermann Rorschach was a Swiss Freudian psychiatrist and psychoanalyst. Dr Rorschach is remembered for having developed the Rorschach inkblot test. The purpose was, in part, to analyze and interpret the nuances of each 

answer given by the patient in order to delve into the unconscious.

 cues also convey important information about the patient. Psychiatrists know this. Thousands of hours of training go into honing their skills to listen and observe how patients communicate with them and the world around them.

 report that well over half of communication is nonverbal. They also note that the clinical setting often places too much value on the spoken word: "Many nonverbal behaviors are unconscious and may represent a more accurate depiction of a patient's attitude and emotional state."

To gain insight into the patient's state of mind (or yours, if you're taking this test), observe her as she interprets a piece of art (in this case, a Rorschach-

 ink blot). Take in the information as you ask, “What do you see?”

Before the answer comes, ask her to think about Halloween. Gaze at the image and reminisce. Where is she looking? Down? Up? Around? At her hands? At the ceiling? Does she lick her lips as she recalls the sweet and salty flavors of treats from a decade ago? Does she crack a smile?

These cues may help us understand the true nature of the image--and perhaps one's state of mind.

1. Foley GN, Gentile JP. Nonverbal communication in psychotherapy. 

This article was originally posted on October 29, 2015, and has since been updated. -Ed

Scary or sweet? Read about the value of nonverbal communication and have some spooky fun.

Spooky Rorschach

Slideshows

The viewing of horror films, though paradoxical, can be therapeutic through sensation-seeking, catharsis, and existential relief of our deepest fears.

The Pervasive Fear of Going to Work

A Doctor Impaired

Psychiatry’s Role in the Management of Chronic Pain

Reappraising a Preference for Valproate

Giving Valproic Acid a Higher Priority in Bipolar Patients

Worldwide Tensions Rise

Behind Closed Doors

Understanding What Drives Gun Violence

Spooky Rorschach

10 Films About the Horrors of the Mind