Richard Berlin, MD, shares a poem by Pulitzer Prize winner Stephen Dunn. His poem, "Sweetness," can be found 

has been writing a poem about his experience of being a doctor every month for the past 23 years in

in a column called “Poetry of the Times.” He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, MA.

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“...sweetness comes as if on loan, stays just long enough to make sense of what it means to be alive, then returns to its dark source.” 

Sufficiently Sweet

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Beyond earning a medical degree, completing residency, and obtaining board certification and licensure, a psychiatrist's career grows to be illustrious with wisdom, curiosity, intellect, aesthetic sensitivity, compassion, empathy, generosity, and more.

10 Meditations on a Virtuous Career 

is a clinical social worker, a visual storyteller, and a creativity consultant.

According to Genesis in the Old Testament, there was a choice. One tree or the other within The Garden of Eden. The meaning of that choice and the resultant decision has been debated by scholars for millennia. One thing for certain, however, is that the central importance of the natural world has been emphasized since our birth into being. Earth Day was one of the first days of Creation!

My childhood Eden was just outside the door. I called it “The Woods.” It was a block-long plot of undeveloped land that separated the modest homes on our street from the busy avenue on the other side. The parents on our block, however called it by another name: the empty lot. That label implied that if a space did not boast buildings of some sort, then there was nothing of value to be found. What they saw as empty, I saw as full.

When I was about 7 years old, my friends and I would lose ourselves in play among the elm, oak, and maple trees that made up our forest world. What a perfect place for a game of hide and seek! Sometimes we brought our toy guns and played war. Though I was an anxious child, my confidence soared as I imagined myself as Audie Murphy, a real-life American war hero and star of the popular film, 

. Sometimes I would bring my trusty bow and arrow in order to hunt wildlife in the dense jungle. Squirrels and an occasional rabbit were my only quarry. The rabbits were rare and seemed quite exotic to me. These animals really had nothing to worry about. My bow was feeble, my arrow rubber tipped, and my reluctance to hurt any living thing a given.

While play certainly dominated my relationship with The Woods, there was something more fundamental I found there: a gravity and stillness I could find nowhere else in my young life. Things at home were often volatile, school was demanding, and friendships bred nervous jealousies and competition. But even just the thought of entering my sanctuary brought a gentle tingling to my body. It seemed to settle my soul. A view of a robin, oriole, or cardinal from our back window brought that same primal thrill.

Within the expanse of thriving trees was a tiny clearing that became my chosen place of contemplation, respite, and repose. My living room, I suppose. A fallen tree trunk laid out as a makeshift couch. Although it was hard and rough to sit on, I found it comforting. I felt like I was safe here, protected from the slings and arrows of daily life. Sometimes I wouldsit there, completely lost in thought, all of a sudden experiencing no thought at all, just my embodied self merging with the natural world. A sense of oneness, as I view it now.

Many times I brought a sandwich in a small brown paper bag. Although I was a voracious youngster, I patiently waited until lunchtime before I opened the bag. Even a sandwich had special meaning within the space and time of The Woods.

With the satisfaction of a full belly, I delighted in my special form of freedom. I would listen for birds singing their songs and sing a song of my own when the spirit moved me. That spirit moved me quite often. I had found my place in the world. Like the earth itself, this was a place that would live on forever. While I relied on the constancy of The Woods, I marveled at the changing seasons observing the rich pattern of growth and decay, death, and rebirth. I knew I would be grateful for the wonders of The Woods for the rest of my life.

That is, until my father gently gave me the dreadful news: “They are going to cut down your trees, Barry. I am so sorry.”

From my point of view, that would have been downright impossible. But I knew that my father was a truthful man who knew what he was talking about. After a moment of awkward silence, I just cried.

"They can’t do that! Why would they even want to do that,” I emphatically replied. Of course, these days, the answer seems obvious. They would “

.” That was their intention, indeed. Back then there was little or no pushback. Development was embraced as progress. It was a symbol of America’s post World War II prosperity.

But a sense of progress was not my concern. The strongest protest I could mutter was: “Shouldn’t we do something to stop them, dad? It’s just plain wrong!”

“It doesn’t work that way,” my father said apologetically. Looking back today from an adult perspective, I recognize my impulse to save The Woods was a prelude to our current urgency to save the planet.

Soon came the indifferent machines, clear cutting my wilderness until it was no more than logs, trunks, and stumps. Severed limbs lying everywhere. More machines came and went until there was nothing left but dirt. I told my father that I heard The Woods crying. He knew better; it was the tears of my broken heart.

Then, the smell of black death. Toxic petroleum-based asphalt that smothered the earth. This was a forever proposition. Nothing was going to grow there again!

There was no way I could defeat the enemy. I had neither the tools nor resources to beat back the attack. My clever father, however, recognized a way to hang on to dear life. This, fortunately, happened before the destruction began.

“Grab the shovel, Barry, and come with me.” I did as he asked and joined him on our holy mission, following him intoThe Woods. I, in turn, led my father to my sacred spot. I wanted him to know where my heart had led me. He sat on my couch and silently surveyed the area around us.

“Let’s pick a young and healthy tree. That’ll be your tree,” he said. “Start digging, I’ll help if you need me.”

I didn’t. I planted that shovel into the ground surrounding my tree and went to work. As if I was participating in a sacred ritual, a rite of passage. Although small in stature, I made up for my limitations with sheer will and determination. I cherished the dirt that covered me as if it were a coat of honor. As if I was now a part of The Woods myself and this single tree had transformed into the biblical Tree of Life.

My father and I dragged the lone survivor out of The Woods, past the alley, and on into our backyard. Working together, we dug a big hole in the center of the yard and gently placed the tree in its new resting place. We surrounded it with wooden stakes secured by wires so as to protect it from the shock of transplant and the vicissitudes of weather.

I often worried about my tree. Many summer nights, I snuck out of the house to lie under it, imagining that we were together in The Woods. I was, however, always on guard, ready to repel any surprise attack by the determined machines. With my bow and arrow at my side I pointed my flashlight toward the blacktop. Let ‘em try!

Underneath the canopy of leaves, I looked up to marvel at the stars. I wondered if they shone their lights to protect the Earth as I protected my tree. Was there someone out there watching over us all, assuring that everything would be alright? Or did life here on Earth rely solely on human caretakers to survive? Would enough people take on the task? That seemed uncertain given what I witnessed with The Woods.

Some 60 years later, as an adult, I returned to view and contemplate my childhood home. I approached the current residents for permission to enter their backyard. How had my tree adjusted after all this time? Did it whither or flourish? Was it even still there?

There was little left of the backyard as I remembered. It was all tree. One sturdy oak took up the entire space. Anchored by a strong trunk, thick limbs, and plentiful green covered branches, it was a grand tree. In its noble reach, it welcomed me and proclaimed its proud survival. The owners allowed me to sit underneath.

I reclined under the tree, once again feeling the stillness I had experienced as a child. It was as if my tree had transformed into the entirety of The Woods.

The woman stepped forward and spoke. “You know, that tree is sacred to our family. Our young boy sits under it all the time. He insists that it is his tree.”


She giggled, as if embarrassed by his boast.

"Would you give him a message from me?” I asked softly.

To see more on Earth & Psychiatry, please see

The Power and Potential of Earth Week and Psychiatry

Articles

All it takes is one tree, one connection…

Our Trees of Life

Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been 

 both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.

On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”

This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.

These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.

A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.

 the effects of race and ethnicity on the care individuals received for chronic pain.

 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.

Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have 

 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.

Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that 

 patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.

 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.

In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry 

Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of 

, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.

The extent to which race, socioeconomic status, and 

 contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of 

It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.

The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.

is in private practice in Philadelphia, Pennsylvania.

2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. 

Health, Disease, and Illness: Concepts in Medicine

Racial and ethnic disparities in the treatment of chronic pain

4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. 

5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. 

6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. 

Access to care for chronic pain: racial and ethnic differences

7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. 

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. 

Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004

9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. 

10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “

We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.

Race, Ethnicity, and Chronic Pain

Alcohol use, diabetes, and HIV are medical comorbidities that are independent risk factors for tardive dyskinesia (TD). 

 for TD include older age, African-American race, early extrapyramidal symptoms, and a higher dose and longer duration of exposure to antipsychotics.

Treatment of neurolept-induced tardive dyskinesia

Non-therapeutic risk factors for onset of tardive dyskinesia in schizophrenia: a meta-analysis

PsychQuiz: Consequences of Tardive Dyskinesia

Poll

Major risk factors for onset of tardive dyskinesia are considered.

PsychQuiz: Tardive Dyskinesia Risk Factors

Binge drinking is defined as consumption of 5 or more standard drinks on 1 occasion for males, or 4 or more for females, bringing blood alcohol concentration to 0.08 grams of alcohol per deciliter or higher.

 These drinking patterns lead to serious health and safety risks, including 

 from unintentional injuries such as motor vehicle crashes,

 suicide attempts as well as other mental health issues, legal charges, and, over the long term, damage to the liver and other organs.

Perhaps not surprisingly, national surveys have found that half of full-time 

 aged 18 to 22 years consumed alcohol in the previous month, and one-third engaged in binge drinking.

 In addition to the previously noted negative impacts, academic performance is also compromised, with 1 in 4 students endorsing academic difficulties (ie, missing class or falling behind on assignments) due to alcohol consumption.

 to perform poorly on tests and projects compared with those who drink but do not binge (40% vs 7%) and are 5 times more likely to miss a class.

 Although not all individuals who drink develop an addiction, consumption and especially binge drinking patterns are often preludes to an addiction, with approximately 9% of college students meeting criteria for alcohol use disorder.

 Lack of screening may also underestimate the magnitude of the problem.

The first few weeks of freshman year are often a period of heavy drinking and alcohol-related consequences. Social pressures and expectations during new-found independence, widespread availability and access to alcohol, unstructured schedules with mounting academic pressure, and lack of parental interactions all play a role. Alongside these stressors, many students have preexisting personality traits that may account for the use and misuse of alcohol during college.

Neuroticism, 1 of the 5 higher order personality traits, is defined by high emotional instability, depressed mood, low frustration tolerance, and anxiety. It also has been found to positively predict alcohol consumption (social intake within recommended parameters)

 and alcohol use (intake beyond recommended parameters that can lead to addiction).

 Only 1 previous study of 200 college students evaluated the implications of personality types; that study found high neuroticism and low conscientiousness predicted more 

aimed to better understand the role of personality and neuroticism in college alcohol use/misuse among freshman, above and beyond the reported levels of stress. The starting hypothesis revolved around the notion that negative affect faces of neuroticism, and primarily 

, are more strongly associated with alcohol use and misuse than stress when accounting for other personality domains.

 conducted a cross-sectional outpatient study, which was approved by the Institutional Review Board. Survey data was collected from participants during the first 8 weeks of their first college semester. Participants included 211 female and 90 male matriculating college freshmen with an average age of 18.58 years (SD = 0.39) from 2 campuses of a private university in the southeastern United States, spanning both urban and rural areas. Students were recruited via fliers posted on campus and during frequent in-person undergraduate events.

Data was acquired via online surveys of behavioral, health questionnaires, and cognitive assessments. Most surveys were completed within 3 weeks of the study initiation, and participants received a $15 gift card for completion. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Alcohol Use Disorders Identification Test (AUDIT) were used to assess alcohol use and misuse (

Endorsement of use 1 or more times on the ASSIST prompted the administration of the AUDIT, a 10-item questionnaire with a maximum score of 40 for which the higher scores indicate more severe and hazardous, harmful, excessive alcohol use/misuse. Stress was assessed using the Perceived Stress Scale (PSS), a 14-item self-reported measure of stress with each stress symptom scored on a 4-point Likert scale, where 0 = never and 4 = very often (maximum score of 56). Personality was assessed using the 44-item version of the Big Five Inventory (BFI), which measures 5 dimensions of personality (openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism).

Ten facet traits were also calculated to assess more specific personality characterization within the 5 domains: openness, aesthetics, and ideas; conscientiousness, order, and self-discipline; extraversion, assertiveness, and activity; agreeableness, altruism, and compliance; and neuroticism, anxiety, and depression.

Analyses controlled for campus site (rural vs urban), sex, and individual week of study enrollment (school obligations as potential stressors fluctuated between study weeks). The investigators examined partial correlations between predictions while controlling for covariates. They used multiple regression analysis to examine the conditional and joint effect of personality and stress on alcohol use and misuse.

Of the sample, 54% (or 164 individuals) endorsed use of 

 at least once in their lifetime. Descriptive statistics of all covariates were accounted for, and across covariates sex and week of study enrollment were only modestly associated with AUDIT scores (male gender and more weeks since college commencement somewhat associated with higher AUDIT scores); site of the campus was not. Despite this, a t-test concluded that there were no gender differences between alcohol use and misuse (t(161) = -1.89, P = .06). Among partial correlations, the participants’ AUDIT scores were positively correlated with PSS scores (r = .17, P = .003) and neuroticism (r =.31, P < .001), and negatively correlated with agreeableness (r = −.12, P = .031). Stress was significantly correlated with all the personality domain scores except for openness to experience.

Regression analyses provided less biased estimates of personality and stress on AUDIT. To elucidate the relationship between neuroticism, stress, and 

 and misuse (given the discrepancy between the partial correlation results and the multiple regression model), the neuroticism facets were explored as outcome measures. Analyses that used the neuroticism facets (depression or anxiety) in place of the neuroticism domain found that neuroticism-depression was positively associated with higher AUDIT scores when accounting for PSS and domain-level 5 personality traits (β = .23, P = .028; adjusted R

Exclusion of all personality traits except for neuroticism-depression did not explain more variance in AUDIT (adjusted R

= .10, F (5, 152) = 4.56, P < .001). Interaction effects found that neuroticism as a domain moderated the relationship between PSS and AUDIT (β = .16, P = .040; adjusted R

 = .12, F (10, 146) = 3.16, P = 0.001). This interaction was found to be unique. Neuroticism-depression score moderated the relationship between PSS and AUDIT-T (β = .18, P = .020; adjusted R

 = .14, F(11, 145) = 3.22, P < .001. At low levels of the depression facet, stress was negatively associated with alcohol use and misuse, but at high levels of the depression facet, stress was positively associated with alcohol use and misuse (

Figure. Correlation Between Stress, Alcohol Use, and Depression

This study supports the notion that neuroticism, and specifically the neuroticism-depression facet, appear to be the most robust predictors of alcohol use and misuse among incoming freshmen and could serve as useful population risk indicators. At low levels of the depression facet, stress was negatively associated with 

 and misuse; at high levels of the depression facet, however, stress was positively associated with alcohol use and misuse.

Investigators branched off previous studies exploring the roles of personality or stress on college drinking. They analyzed survey results data from Wave I of the MAPme Project, a longitudinal study of biobehavioral health and substance use during college. Those findings showed that personality characteristics and 

 play a significant role in the severity of problematic alcohol use and misuse, but certain traits are more significantly associated with alcohol involvement than others. The neuroticism-depression facet was a better predictor of alcohol use and misuse than the neuroticism domain, and this facet accounted for unique variance even when controlling for stress and other personality facets and domains. Stress did not account for unique variance in harmful and hazardous alcohol use and misuse beyond personality traits.

Unfortunately, this study had a number of limitations. Due to issues with the sample population, the findings may not generalize to other student populations. This study was conducted using a primarily Caucasian group from a private university located in the southeast US, without ensuring varied socioeconomic statuses. Similarly, although the sample encompassed both urban and rural participants, they were located in the same part of the country. The study also included a greater proportion of women compared to men, which may have skewed the baseline starting characteristics and outcomes.

Other issues can impact the findings. For instance, there were fairly low numbers of reported alcohol use among the sample to confidently generalize findings. Compensation offered to participants may add external biases and contribute to participant selection and participation.

The authors used a single-domain, self-reported assessment of stress, associated with increased likelihood of response bias and social desirability bias. More comprehensive and objective measures of stress levels might include physiological assessment, such as skin conductivity, heart rate, or cortisol measures that have shown be strongly associated with perceived stress.

The study employed the AUDIT-Total score, which confounds alcohol consumption and problematic alcohol use behaviors. The study participants reported low alcohol use and misuse behaviors, but the tool was not well prepared to detect unique effects of each of these constructs. Thus, future research could expand on this study by examining alcohol consumption and problems separately.

This study is limited by its cross-sectional design. To best examine the relationship between stress and personality on alcohol use and misuse, future studies could take a longitudinal state-trait perspective, treating personality and neuroticism specifically as stable traits and stress as a state.

Fortunately, data from this sample will continue to be collected until the students graduate, allowing longitudinal examinations into alcohol use and misuse trajectories, and the associations between stress, personality traits, and hazardous and harmful alcohol use.

So what does this mean for clinical practice? When presented with highly stressful circumstances, high neuroticism-depression in individuals predicts propensity to use and misuse alcohol. Similarly, people with high neuroticism-depression are likely to drink more when stressed, but low neuroticism-depression seems to be protective, with these individuals using and misusing alcohol at lower rates. Finally, the BFI domains and faces seem to have a role in alcohol use/misuse, above stress levels. These could be used as screeners for population risk indicators among incoming freshmen.

is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for

The author reports no conflicts of interest concerning the subject of this article.

An earlier version of this article appeared online on February 10, 2021, under the title Neuroticism-Depression: What Is It and Does It Play a Role in College Drinking? and has since been updated for print. -Ed

1. National Institute on Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking. 

https://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/Newsletter_Number3.pdf

2. Hingson R, Zha W, Smyth D. Magnitude and trends in heavy episodic drinking, alcohol-impaired driving, and alcohol-related mortality and overdose hospitalizations among emerging adults of college ages 18-24 in the United States, 1998-2014. 

3. Hingson R, Heeren T, Winter M, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24: changes from 1998 to 2001. 

4. US Department of Health and Human Services. Center for Behavioral Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2019 National Survey on Drug Use and Health. Table 6.21B—Types of Illicit Drug, Tobacco Product, and Alcohol Use in Past Month among Persons Aged 18 to 22, by College Enrollment Status and Gender: Percentages, 2018 and 2019. Accessed February 5, 2021. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect6pe2019.htm#tab6-21b

5. Wechsler H, Lee JE, Kuo M, et al. Trends in college binge drinking during a period of increased prevention efforts. Findings from 4 Harvard School of Public Health college alcohol study surveys: 1993-2001. 

The introduction of the heavy and frequent drinker: a proposed classification to increase accuracy of alcohol assessments in postsecondary educational settings

7. US Department of Health and Human Services. Center for Behavioral Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2019 National Survey on Drug Use and Health. Table 6.23B—Alcohol Use Disorder in Past Year among Persons Aged 18 to 22, by College Enrollment Status and Demographic Characteristics: Percentages, 2018 and 2019. Accessed February 5, 2021. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect6pe2019.htm#tab6-23b

8. Stanciu CN, Penders TM, Wuensch KL, et al. Underutilization of screening tools for alcohol use disorders – part I: results from survey of practices among North Carolina mental health providers and brief review of available instruments. J Alcohol Drug Depend. 2017;5(5):100282. Accessed February 5, 2021. 

https://www.longdom.org/open-access/underutilization-of-screening-tools-for-alcohol-use-disorderspart-iresults-from-survey-of-practices-among-north-carolina-mental-he-2329-6488-1000282.pdf

9. Allen MS, Vella SA, Laborde S. Health-related behaviour and personality trait development in adulthood. J Res Pers. 2015;59:104–110.

10. Cooper ML, Agocha VB, Sheldon MS. A motivational perspective on risky behaviors: the role of personality and affect regulatory processes. J Pers. 2000;68(6):1059-1088.

11. Loukas A, Krull JL, Chassin L, Carle AC. The relation of personality to alcohol abuse/dependence in a high-risk sample. J Pers. 2000;68(6):1153-1175.

12. Goldstein AL, Flett GL. Personality, alcohol use, and drinking motives: a comparison of independent and combined internal drinking motives groups. Behav Modif. 2009;33(2):182-198.

13. Ruiz MA, Pincus AL, Dickinson KA. NEO PI-R predictors of alcohol use and alcohol-related problems. J Pers Assess. 2003;81(3):226-236.

14. Martin KP, Benca-Bachman CE, Palmer RHC. Risk for alcohol use/misuse among entering college students: The role of personality and stress. Addict Behav Rep. 2020;13:100330. ❒

Although not all college students who drink develop an addiction, consumption and especially binge drinking patterns are often preludes to an addiction, with approximately 1 in 10 students meeting criteria for alcohol use disorder.

Exploring the Link Between Neuroticism-Depression and College Drinking

One year ago, Amilcar Arnaldo Tirado, MD, MBA caught coronavirus disease-2019 (COVID-19). He was hospitalized and honestly feared for his life. “This is it,” he told himself. “This is how your story ends.”

. More recently, he wrote a follow-up reflection on his experience and what he has learned: “

In this Mental Health Minute, Dr Tirado discusses his latest article and elaborates on the personal, medical, and political dimensions of the pandemic.

is a forensic psychiatrist at Lincoln Medical Center in the Bronx, New York, and assistant clinical professor of psychiatry at Weill Cornell Medicine, New York, New York. The author reports no conflicts of interest concerning the subject matter of this article.

How has the pandemic affected your practice? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

A year after being hospitalized with COVID, a physician considers the pandemic’s larger meaning for American medicine—and for American society.   

Lessons From a Difficult Year

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

In the wake of the attack that left a Capitol policeman dead and another wounded, the individual identified as responsible reportedly 

told friends that he had “afflictions.”

 This term, freighted with so much history, caught my attention. Let me hasten to add that I have no intention of speculating on the mental state or possible diagnosis of the individual who slammed his car into the 2 police officers and was later killed. Rather, I want to explore the term “afflictions” in the broad context of how we describe and understand the most serious psychiatric conditions we treat. I will not say much here about the terms “disease,” “disorder,” or “illness”—terms that have been debated, conflated, and promiscuously tossed around in the medical and psychiatric literature for 

 meaning, “to knock or strike down, ruin, distress severely.”

 This definition nicely captures 2 key features of the most severe conditions treated by psychiatrists; namely, suffering (“distress severely”) and incapacitation (“knock or strike down”). The term affliction, so defined, maps reasonably well onto what the psychiatric literature calls serious mental illness (SMI). The National Institute of Mental Health

 as, “…a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI.”

A somewhat richer description of SMI is provided by the 

: “We define SMI as severe psychiatric diseases with symptoms that put individuals who experience them at the greatest risk for criminal justice involvement, homelessness, hospitalization and/or involuntary treatment. Typically, these are disorders with psychotic features, although mania also can elevate risk.”

These definitions are useful starting points, but they do not fully capture the felt experience of affliction. Here we are well served by harking back to the urtext of afflictions, the Bible. Thus, in the Book of Job, this apparently blameless and upright man, Job, learns that his sheep, servants, and 10 children have all died, after which Job rips his clothes and shaves his head in sorrow. It gets worse: Job soon finds himself covered with terrible skin sores. He cries out to God, “Your hand shaped and fashioned me, then you destroyed every part of me” (Job 10:8-9). Now, that is affliction!

We can see something of the all-encompassing physical and psychic pain of affliction in this passage from William Styron’s memoir, 

. Here, Styron describes his depressive bouts:

What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the grey drizzle of horror induced by depression takes on the quality of physical pain…[and] comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room…The pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne… The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come--not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul…

Notably, Styron refers to severe depression as “this ancient affliction.”

We find similarly harrowing descriptions by patients who have been diagnosed with schizophrenia and related psychoses. Thus, law professor Elyn Saks, PhD, author of 

 described her psychotic episodes as follows:

It’s like a waking nightmare. You’re terrified, you’re confused, you have beliefs that are bizarre and frightening and confusing. I hallucinate a little bit, but not much. Mostly I form delusional beliefs, like that I have killed lots of people with my thoughts, or people are setting off nuclear explosions in my brain, or my brain’s going to leak out of my ears and drown people.”

Can the Concept of Affliction Be Applied in Psychiatry?

To be sure, not all individuals who acknowledge having serious psychiatric problems describe themselves as “afflicted” or “suffering.” Nor do they allow themselves to be defined by their psychiatric diagnosis. Thus, the pediatrician Mark Vonnegut, MD—originally diagnosed with schizophrenia, but later re-diagnosed with bipolar disorder—has not only enjoyed an illustrious medical career, but has also raised 3 sons, and led a flourishing creative life. He has important 

things to say about psychiatric treatment

Medications have side effects. No one who doesn’t need them should take them—I know I certainly wouldn’t. It’s a painful truth that medications and psychiatric hospitals, the faults of which could fill volumes, have both saved me, and made a good life for myself possible. For that, I am grateful.

Alas, not all individuals with serious psychiatric problems fare as well as Dr Vonnegut. There are hundreds of thousands of individuals whose psychiatric symptoms truly do constitute afflictions—i.e., enduring states of such intense or prolonged suffering and incapacity that they amount to disease.

 These states differ radically from everyday anxiety, or from grief, which is typically an understandable and adaptive 

It is deeply misleading and clinically insensitive to trivialize psychiatric afflictions as mere problems in living

 As Allen Frances, MD, has noted, “Schizophrenia and other severe psychiatric disorders clearly have a strong biological contribution and cause a qualitatively, as well as quantitatively, different level of suffering far beyond the 

Unfortunately, as several psychiatrists and mental health advocates have argued, we have badly underfunded clinical research and treatment of serious mental illnesses like 

 To press the point further, psychiatrist James C. Beck MD, PhD, has argued that, “Psychiatry should be the specialty that treats patients with severe mental disorders: schizophrenia, bipolar disorder, major depression, severe PTSD, and others.”

The Problem with the Term “Affliction”

Although the concept of affliction usefully captures the felt experience of severe and persistent psychiatric disturbances, it also comes with some unhelpful theological baggage. For example, in 

, we read, “Fools because of their transgression, and because of their iniquities, are afflicted.”

The connotation that troubles me is [that] of deserved affliction for sins committed. Those with mental illness suffered terribly... because they were seen as pawns in God’s battle with the Devil. Our patients are afflicted enough without the weight of additional stigma [and] moral opprobrium that they are “afflicted” as punishment for their sins (Allen Frances, MD, email communication, April 4, 2021).

Point taken. The last thing we want to do is exacerbate our depressed patients’ feelings of sinfulness—which, in some cases, may reflect a psychotic process. So, to answer my own rhetorical question in the title of this piece—no, we do not need a 

. However, the concept of afflictions may prove useful in understanding our most severely ill patients.

But wait—perhaps we do need a new manual to supplement the DSM-5, after all: one that focuses laser-like on the most serious and incapacitating psychiatric disease states. At a minimum—and this list is not exhaustive—such a manual would include schizophrenia and related psychoses; bipolar disorder/manic-depressive illness; melancholic or psychotic forms of major depression; the dementias; and the more severe and intractable forms of autism, obsessive-compulsive disorder, and posttraumatic stress disorder. (Arguably, the self-injurious forms of borderline personality disorder could also be included, but the personality disorders in general are a hard case.)

Some of our patients may use the language of “affliction,” but many will not. Our task is not to impose a linguistic framework on their experience, but to understand and empathize with that experience. And as far removed from usual experience as psychiatric afflictions are, there is a more complicated truth underlying them. As Vonnegut remarks, “Just because you don’t hear voices, doesn’t make you a model of mental health… no one among us is 100 percent crazy, and no one is 100 percent sane.”

 Indeed, a rabbinic teaching tells us that all human beings are “broken vessels.”

 As scholar Jeffrey L. Rubenstein puts it, “Even those who have not suffered disabilities, handicaps, and or illnesses bear the scars of life on their bodies and hearts.”

Affliction is not the same thing as a mental illness, but psychiatrists may be called upon to treat it just the same. 

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