There is no doubt about it. This has been an exhausting and stressful year. The global pandemic, rising unemployment, social distancing, the United States presidential election, wildfires, and then, of course, the so-called “

 For good reason, many have found the year to be among the most worrisome in recent memory.

Perhaps we can take some small comfort, however, in the knowledge that our ancient, medieval, and early modern forebears successfully stared down threats and misfortunes on multiple fronts. Living in a world they understood to be teaming with ominous apparitions, imposing creatures, and dark forces, they faced not only artificial and natural disasters, but also calamities of a supernatural kind. So, consider these 5 monstrous entities with whom our ancestors had to share this terrestrial plane.

Some of the earliest written sources we have from Mesopotamia confirm that belief in demons (from the Latin daemones) is very ancient indeed. Throughout antiquity, demons were generally considered to be neutral supernatural beings, equally capable of helping and harming humans. When malevolent, however, they could be cunning and take on different forms. There are numerous tales from ancient China, for instance, of demon dogs who acted like or possessed human beings. For example, according to the politician and historian Ying Shao (140 to 206 CE), when a dog showed up after the spirit of a dead man who had been terrorizing a household seemed to leave, residents decided to cane the poor beast to death.

In the Middle Ages, Europeans came to view demons as unequivocally diabolical, working, they believed, in concert with the Devil. Late-medieval writers spoke of demons, sprites, and goblins creeping around lakes, rivers, and mountains, killing miners, pestering animals, and luring men and women into damnable carnal relations.

 None of this talk, however, deterred most folk from continuing to appeal for aid from what were thought to be kindlier demons.

The ancient Greeks and Romans had a variety of names for what we call a ghost, including shade, manifestation, image, cloud, and breeze. Terms like these seem to suggest that ancient ghosts were perceived to be intangible, but in fact many were corporeal enough to eat, drink, hug, and even have sex. Tending to be either white or black in hue, they could appear as tiny winged creatures, 12-foot giants, or anything in between.

What is consistent in tales about ghosts well into the 19th century is that they generally appeared in order to remedy an injustice: either the departed had not been properly laid to rest and now sought an appropriate burial, or the dead party demanded revenge for their murder or killing. Unsurprisingly then, old battlefields especially were considered sites of large numbers of angry and harrowing specters.

Stories of human beings taking on the shape of a wolf also go back to antiquity, where it was believed that while some did so voluntarily, others were condemned to such fate as a punishment by a god. What made werewolves especially menacing and loathsome to the general public was the accusation that the creatures killed and devoured their human victims. In 16th-century Europe, suspicions that people were using magic to turn themselves into wolves led authorities to try, convict, and burn at the stake a number of individuals for the crime of lycanthropy.

One of the most infamous cases involved a German man known as Peter Stumpp, convicted and executed in 1589 for being a werewolf. Stumpp’s crimes were in fact quite gruesome, as he murdered at least 13 children and several men and women, apparently cannibalizing some of their bodies. As a punishment, he was tortured with hot pincers and had his flesh torn, his arms and legs broken, and his head cut off and displayed on a pike to ward off any other potential werewolves.

Werewolves are perhaps the most recognizable shapeshifters, but they certainly were not the only ones. Folklore is replete with reports of a wide range of shapeshifting beings, usually humans turning into animals or inanimate objects. Not all were malicious, but many were. The Ukrainian vedmak, a male witch capable of becoming a horse, a moth, or an inanimate object, consorted with the Devil and was said to kill livestock, destroy harvests, and bring disease. Slavic lore spoke of the leshy, a woodland man with green eyes, hoofs, horns, and a tail. It was believed the leshy could transform himself into plants and animals and enjoyed kidnapping women, confusing travelers, and even sometimes tickling people to death.

Europe certainly has not been alone in chronicling accounts of shapeshifting malefactors. Ancient Japanese folklore mentions a malevolent, shapeshifter called the tanuki. Originally described as a racoon-like dog, the tanuki was thought to be able turn itself into a human form, haunting and possessing people. In a particularly grisly anecdote, a tanuki killed an old woman, then turned her into soup, after which the tanuki took on the form of the old woman and fed the soup to the dead woman’s husband.

Ancient Greek sources speak of some magicians and witches having the ability to not only conjure and placate ghosts, but also raise the dead. There appears to be little to no evidence of individuals actually performing this art of necromancy. But descriptions of elaborate rituals succeeding in bringing corpses back to life, sometimes with grim consequences, were well known. In a particularly harrowing instance, a mother revivified her dead son, who then reprimanded her and predicted her imminent, violent death.

Medieval Europe was also the location of numerous sightings of the risen dead, an occurrence featured in a number of Jewish sources. The writings of German-Jewish Pietists (Hasidei Ashkenaz) of the late 12th and early 13th centuries, for example, offer up a bounty of monsters and monstrous creatures (demons, dragons, witches, vampires, werewolves), including the walking dead.

 In most accounts, they proved to be quite friendly, even helpful. The fact, however, that most of these medieval zombies greeted the living with the refrain “I will not harm you” testifies to the fear they provoked.

It might be tempting to look back at stories like these and dismiss them as superstitious nonsense. But it is important to keep in mind that identifying, imagining, interpreting, and discussing monsters have been preoccupations of cultures since recorded time. There are reasons for this. Our word “monster” derives from Greek and Latin terms referring to a portent or warning of some kind. Monsters are messengers, perceived to be bearers of messages of great importance. In this way, they give communities an opportunity to declare some of their most cherished values, to teach lessons, and to inspire heroism. Today, we too have our own monsters to face (both man-made and natural) and like our ancestors, we invariably will use them to consider, debate, and struggle for the things we hold most dear.

is professor of history at Penn State University. He specializes in the history of psychiatry and mental health and is member of the 

1. Mike Baker. ‘Murder hornets’ in the U.S.: the rush to stop the Asian Giant Hornet. 

. Updated November 13, 2020. Accessed November 24, 2020. 

https://www.nytimes.com/2020/05/02/us/asian-giant-hornet-washington.html

3. Petzoldt L. The universe of demons and the world of the late middle ages. In: Petzoldt R, Neubauer P, eds.

 Demons: Mediators Between This World and the Other

Magic, Witchcraft, and Ghosts in the Greek and Roman Worlds: A Sourcebook

The White Devil: The Werewolf in European Culture

9. Shyovitz DI. Unearthing the ‘Children of Cain’: between humans, animals, and demons in medieval Jewish culture. In: 

Monsters and Monstrosity in Jewish History: From the Middle Ages to Modernity

. Idelson-Shein I, Wiese C, eds. Bloomsbury; 2019.

10. Shyovitz DI. The might of the living dead: thinking with zombies in the Jewish tradition. Paper presented at Workshop on Jewish Zombies, Penn State University, 26 October 2020.

Articles

Throughout history and across cultures, monsters have helped communities teach lessons and affirm their values. 

We Think We Have Problems? 5 Supernatural Entities the Premodern World Had to Worry About

 finds that suicide attempts during pregnancy and after childbirth are increasing, nearly tripling over the past decade Nearly 24,000 individuals are at risk for suicide. Suicide is already among the leading causes of deaths among new mothers, and pregnancy/post-delivery are considered risky times for depressive symptoms. 

“Suicide deaths are a leading cause of maternal mortality in the US. It is a public health crisis that has silently grown worse,” lead author Lindsay Admon, MD, MSc, an obstetrician-gynecologist at Michigan Medicine Von Voigtlander Women’s Hospital and researcher with the University of Michigan Institute for Healthcare Policy and Innovation, said to the press.

Evaluating data from the Maternal Behavioral Health Policy Evaluation (MAPLE) study, researchers found 2683 out of 595,237 insured mothers aged 15 to 44 across the US had suicidal ideation or thoughts of self-harm. According to the findings, the prevalence of suicidal thoughts or self-harm in childbearing individuals in the years pre- and post-pregnancy almost tripled between 2006 and 2017.

Maternal suicidality overall increased from 0.2 to 0.6%, with the greatest increases seen among Black; low-income; younger individuals; and people with comorbid anxiety, depression, or serious mental illness.

“The increases and disparities in suicidality over time, and the likelihood that suicidality is both under detected and under treated remains concerning,” stated Kara Zivin, PhD, senior author and professor of psychiatry and obstetrics and gynecology at the University of Michigan, who personally struggled with suicidality during her own pregnancy. “This research indicates we have more policy and clinical work to do to support struggling women and their families.”

Zivin also noted numbers can be hard to pinpoint, as maternal mortality statistics reported by the Centers for Disease Control and Prevention (CDC) excludes suicide deaths by listing them as incidental or accidental. However, during pregnancy, women are in much more frequent contact with their health providers. This increases opportunities for doctors to identify depressive symptoms during pregnancy and postpartum.

“We need to improve screening for mental health wellness during and after pregnancy,” Admon said. “We know that untreated mental health conditions put both moms and their children at higher risk for adverse health outcomes, including preterm birth and maternal suicide.”

Admon and her fellow study authors had this to say about what steps need to be taken in the future: “We need to seek health system and policy avenues to better identify suicidal symptoms in childbearing women. It’s critical that we intervene as early as possible and provide necessary therapies to reduce the risk of the most tragic outcome.”

1. Admon LK, Dalton VK, Kolenic GE, Ettner SL, et al. Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017. 

2. University of Michigan. Suicide Risk During Pregnancy, After Childbirth on the Rise. News release. November 16, 2020. 

https://www.newswise.com/articles/suicide-near-misses-during-pregnancy-after-childbirth-on-the-rise

Suicide attempts among pregnant or postpartum mothers have nearly tripled over the past decade. 

Pregnancy and Postpartum Suicide Risk: The New Numbers 

Andrea Mendiola, MD, and Lilanthi Balasuriya, MD, MMS, discuss and present ideas from their article, 

is a Fellow, Connecticut Mental Health Center Hispanic Clinic, and

is a Fourth Year Resident, Department of Psychiatry, Yale University School of Medicine, New Haven, CT.

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is a clinical extern at McLean Hospital/Harvard Medical School Psychology and a third-year doctoral student at Boston University

a clinical psychologist and postdoctoral research fellow at Boston University.

is a professor of psychology at the Department of Psychology at Boston University, where he directs the Psychotherapy and Emotion Research Laboratory.

Anxiety disorders are impairing, distressing, and pervasive throughout society.

 Thus, research is focusing on how to develop and refine effective, evidence-based treatments for anxiety. To date, cognitive behavioral therapy (CBT) is the most effective psychotherapy available for anxiety disorders.

 The model of CBT assumes that anxiety and other emotional disorders are associated with maladaptive cognitions and behaviors.

 A typical course of CBT for anxiety disorders includes psychoeducation on the nature of anxiety and the particular disorder, cognitive restructuring techniques, and exposure to feared situations, objects, or memories.

Before the exposures, the therapist helps patients identify situations they avoid as well as subtle behaviors (ie, safety behaviors) in which they engage to ease their distress. It is generally believed that individuals develop specific fears due to conditioning that occurs in a particular context; in turn, these generalize to other contexts. The individual tends to avoid the feared situation due to the false belief that situation is dangerous or unmanageable. Avoidance is assumed to maintain the fear as well as this false belief. During exposure therapy, patients systematically enter anxiety-provoking situations until there is a significant reduction in the anxiety response due to extinction learning.

 In addition, exposures serve as behavioral experiments aimed at testing the validity of maladaptive cognitions and feared outcomes. By modifying these maladaptive cognitions, emotional distress and engagement in maladaptive behaviors will decrease, and the individual can learn a new safe memory associated with the previously feared stimulus or context.

Despite the superior efficacy of CBT, there is still considerable room for improvement.

 Researchers have supplemented CBT with anxiety-reducing pharmacotherapies, as some individuals do not improve—or improve sufficiently—with exposure alone. However, augmenting exposure with anxiolytic drugs has resulted in minor success. Furthermore, these augmentation strategies may result in less successful treatment outcomes, as individuals may attribute treatment gains to medication rather than to their own effort, thereby undermining self-efficacy. More recent approaches have focused on strengthening CBT education, utilizing pharmacotherapy that affects the neurobiology implicated in the fear extinction processes.

 This approach aims at enhancing the memory processes underlying extinction. 

Fear extinction is a prime area of research in the anxiety literature, as researchers continue to investigate novel and effective ways to reduce the salience of distressing memories and replace these with more neutral memories. One such pathway, the N-methyl-D-aspartate (NMDA) receptor in the basolateral amygdala, is known to play an important role in controlling neural plasticity and memory. Recent research suggests that NMDA activity mediates fear extinction.

 As such, a compound known as d-cycloserine (DCS) has been demonstrated to augment extinction learning by serving as a partial NMDA agonist.

Because DCS has long been used as an antibiotic medication for treating tuberculosis at high dosing for an extended period of time, it can be safely administered as a cognitive enhancer in exposure therapies for anxiety disorders at much lower dosing for a much shorter period of time. Accordingly, a vast body of research focuses on translating preclinical basic neuroscience findings about DCS into clinical trials with humans diagnosed with a large range of anxiety disorders.

The first human trial of DCS as an augmentation strategy for exposure in patients with anxiety yielded promising results.

 The effects of a single dose of DCS taken prior to exposure sessions by patients with acrophobia were examined. Results revealed that DCS significantly enhanced extinction learning after the 2 sessions of acute treatment and at 3 months follow-up. Patients randomly assigned to the DCS condition subsequently reported less avoidance of heights in their daily activities after study completion. Therefore, DCS appeared to enhance the memory of successful exposure experiences and influence subsequent willingness to confront fearful situations. This promising study led to a further line of research that aimed to elucidate the possible enhancing effects of DCS on various anxiety disorders.

Subsequent studies from our group on social anxiety disorder and panic disorder found similarly successful results for DCS as an augmentation strategy.

 Other studies, however, presented null effects.

 Of particular interest and concern was 1 trial with posttraumatic stress disorder (PTSD). It found that patients who received DCS reported more symptoms at posttreatment than those who received placebo.

 As will be discussed further in this article, this study suggests that DCS might also augment fear memory reconsolidation and, therefore, might produce counter-therapeutic effects under certain circumstances.

These studies revealed the complex therapeutic and counter-therapeutic effects of DCS. The 3 main literature findings should be carefully considered when using DCS in exposure therapy: (1) Effect of dose and timing of administration; (2) DCS as an accelerator of early treatment response; (3) Specific conditions in which DCS can lead to fear reconsolidation and worsen symptoms.

Effect of Dose and Timing of Administration

DCS Dosing and dose timing could explain the inconsistent findings from previous studies. The results from several animal and human studies suggest that DCS only shows the extinction augmentation effect when administered in low (eg, 50 mg) and isolated (ie, acute) dosing, but not when administered chronically (ie, repeatedly over an extended period of time).

Timing is another important issue. Peak blood levels of DCS typically are evident 4 to 6 hours after ingestion. Extinction learning processes usually happen at the end of an exposure session. Therefore, DCS is likely to be most effective when administered within 1 to 2 hours before an exposure session. Indeed, studies demonstrated that DCS administration 1 to 2 hours before exposure achieved greater effects than studies DCS administration multiple hours before exposure.

 These results hint at a rather narrow therapeutic window of DCS, as it appears DCS needs to be administered acutely and in small doses approximately 1 to 2 hours before exposures.

DCS as an Accelerator of Early Treatment Respons

Rather than directly targeting anxiolysis, DCS is used to enhance consolidation of the therapeutic learning offered by CBT. As DCS is a cognitive enhancer, it was reasonable to expect that DCS would strengthen the benefits of CBT through faster learning. Studies that examined the application of DCS for obsessive-compulsive disorder (OCD) revealed that DCS had an effect that attenuated with subsequent administrations.

 These results provided the first hints that DCS primarily acts by accelerating treatment response in the early part of therapy.

Furthermore, with repeated exposure sessions, studies have revealed that exposure alone can eventually show similar effects to the initial DCS augmentation effects. This apparent catch-up effect has also been shown in animal models and human trials for social anxiety disorder, agoraphobia, and panic disorder.

 Although these studies did not show an advantage at the end of treatment in terms of response or remission rates for DCS, faster treatment response can have far-reaching effects. For example, a rapid reduction in distress and disability is linked with a lower dropout rate, as treatment gains are realized more quickly.

The mixed results of the efficacy of DCS may be partially explained by the fact that DCS might not only augment fear extinction learning, but also fear memory reconsolidation, or the stabilization of a fear-related memory after initial fear acquisition.

 For example, we found in one study that DCS can actually worsen symptoms by enhancing reconsolidation of fear memory when treatment ends with the individual in a high state of fear.

 Since DCS has the capacity to consolidate both extinction and reconsolidation processes, it may be vital to ensure that extinction learning is the predominant process occurring during DCS-augmented sessions.

Post-session DCS administration augmented exposure sessions only when exposure sessions were deemed successful and ended with low levels of fear.

 Accordingly, administering DCS post-extinction learning and judiciously (only after sessions wherein extinction learning is evident) may prevent potentially deleterious effects of DCS. Furthermore, posttreatment fear (rather than a change in fear) should be used as an index for predicting DCS augmentation effects.

Evidence for DCS as an augmentation strategy for CBT for anxiety disorders has been promising, thanks to small placebo-controlled trials across the anxiety disorders. Yet, as research on DCS augmentation has progressed to more diverse protocols and large multicenter trials, the effect size for its benefit has started to falter.

 Subsequent studies and closer examination of the existing data shed light on the mechanism of DCS as a cognitive enhancer in exposure therapy. These studies have revealed important moderators for the use of DCS and guidance for accurate and effective use. There is ongoing research to determine if DCS can be applied to CBT that does not rely solely on exposure interventions. These types of treatments include cue exposure for substance use disorders,

 exposure to feared foods and weight restoration in eating disorders, cognitive restructuring for depression, and imaginary re-scripting therapy for PTSD. Future studies are needed to confirm augmentation effects and to explore whether, like the application of DCS to anxiety disorders, judicious use of DCS is warranted.

A recent individual participant level meta-analysis shed additional light on the use of DCS for exposure-based cognitive behavior therapy.

 Mataix-Cols et al meta-analysis revealed that DCS had a small but significant augmentation effect at posttreatment, with mixed support for the maintenance of its effects at follow up. Importantly, results revealed significant decrease in the augmentation effect of DCS across the time frame covered by the meta-analysis (21 studies published across a 14-year period). In a reanalysis of this meta-analysis, Rosenfield et al.

 examined potential explanations of the apparent declining effect and provided important concrete suggestions for dosing and dose timing.

 Data indicated that participants might benefit most from about 9 doses of DCS, and from administering the doses more than 60 minutes prior to exposure. Additionally, the recommended dose is 50 mg, as the data did not support improved effectivity for greater than 50 mg dosage. Optimizing DCS administration might achieve substantial improved treatment outcomes.

Beyond the important clinical implications of DCS literature, it is an excellent example of translational research from neuroscience to clinical science that directly translates findings from animal studies to clinical trials in humans. We hope that rather than simply combining treatment strategies, which aim for a cumulative effect, future research will continue to focus on elucidating the specific circumstances in which clinical applications (novel and traditional) may (or may not) be successful. This might allow clinicians to tailor treatments accurately to achieve the best possible results for their patients. 

Dr Hofmann receives financial support from the Alexander von Humboldt Foundation (as part of the Humboldt Prize), NIH/NCCIH (R01AT007257), NIH/NIMH (R01MH099021, U01MH108168), and the James S. McDonnell Foundation 21st Century Science Initiative in Understanding Human Cognition – Special Initiative. He receives compensation for his work as editor from SpringerNature and the Association for Psychological Science, and as an advisor from the Palo Alto Health Sciences Otsuka Pharmaceuticals, and for his work as a Subject Matter Expert from John Wiley & Sons, Inc. and SilverCloud Health, Inc. He also receives royalties and payments for his editorial work from various publishers. 

1. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. 

2. Hofmann SG, Asnaani A, Vonk JJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses. 

3. Hofmann SG, Carpenter JK, Otto MW, et al. Dose timing of D-cycloserine to augment cognitive behavioral therapy for social anxiety: study design and rationale. 

4. Bouton ME, Westbrook RF, Corcoran KA, Maren S. Contextual and temporal modulation of extinction: behavioral and biological mechanisms. 

5. Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. 

 Enhancement of psychosocial treatment with D-Cycloserine: models, moderators, and future directions. 

7. Davis M. Role of NMDA receptors and MAP kinase in the amygdala in extinction of fear: clinical implications for exposure therapy. 

8. Mataix-Cols D, Fernández de la Cruz L, Monzani B, et al. D-cycloserine augmentation of exposure-based cognitive-behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders: Systematic review and meta-analysis of individual participant data. 

9. Ressler KJ, Rothbaum BO, Tannenbaum L, et al. Cognitive enhancers as adjuncts to psychotherapy: use of d-cycloserine in phobic individuals to facilitate extinction of fear. 

10. Hofmann SG, Meuret AE, Smits JAJ, et al. Augmentation of exposure therapy for social anxiety disorder with d-cycloserine. 

11. Siegmund A, Golfels F, Finck C, et al. D-cycloserine does not improve but might slightly speed up the outcome of in-vivo exposure therapy in patients with severe agoraphobia and panic disorder in a randomized double blind clinical trial. 

12. Litz BT, Salters-Pedneault K, Steenkamp M, Et al. A randomized placebo-controlled trial of d-cycloserine and exposure therapy for post-traumatic stress disorder. 

13. Hofmann SG, Otto MW, Pollack MH, Smits JA. D-cycloserine augmentation of cognitive behavioral therapy for anxiety disorders: an update. 

 D-cycloserine augmented exposure therapy for obsessive-compulsive disorder. 

15. Ren J, Li X, Zhang X, et al. The effects of intrahippocampal microinfusion of D-cycloserine on fear extinction, and the expression of NMDA receptor subunit NR2B and neurogenesis in the hippocampus in rats

. Prog Neuropsychopharmacol Biol Psychiatry.

16. Hofmann SG. D-cycloserine for treating anxiety disorders: Making good exposures better and bad exposures worse. 

17. Hofmann SG. Schrödinger’s cat and d-cycloserine to augment exposure therapy – both are dead and alive. 

18. Smits JAJ, Hofmann SG, Rosenfield D, et al

 D-cycloserine augmentation of cognitive behavioral group therapy of social anxiety disorder: prognostic and prescriptive variables. 

19. MacKillop J, Few LR, Stojek MK, et al

 D-cycloserine to enhance extinction of cue-elicited craving for alcohol: A translational approach. 

20. Rosenfield D, Smits JAJ, Hofmann SG, et al

 Changes in dosing and dose timing of d-cycloserine explain its apparent declining efficacy for augmenting exposure therapy for anxiety-related disorder: an individual participant-data meta-analysis. 

D-cycloserine may help patients with anxiety disorders, or it might make their anxiety worse. Find out how to use it safely. 

D-cycloserine for Anxiety Disorders: What Psychiatrists Need to Know

His explanation was given clearly enough. I was just not able to process what he said. The young man was there for a follow-up outpatient visit, his third since he had been discharged from a 30-day residential substance abuse program. His original ticket to the program had been a short detox stay in hospital after an opiate overdose. The overdose had been a close call. The fast action of the paramedic administering naloxone was the only thing that kept him alive.

He was the youngest son of 2 faculty members at a private high school and appeared to have been raised well enough, in a liberal sort of non-pressured way. Not particularly motivated by his own hopes, he had a bachelor’s degree in fine arts and steady job as a waiter at an east-Asian restaurant. The motherly traditions of the restaurant owner was to gather all the staff together after the restaurant closed for the night and insist that they sit together at the biggest table and consume remarkable portions of the best food while being urged on by their matron: “Have some more! Have some more!”

This event was perhaps the only socially engaged moment of his week. He lived with a person who he referred to as his girlfriend, but neither of them seemed committed to the relationship. I had noted, but not made much of, the seeming emptiness of his life in prior visits. Even with that caveat, during the prior follow-up visits, I had been able to check all the boxes that represented the agency’s aspirations for his success. He had reported neither cravings nor any sense of missing his opiate drugs.

He now described to me his most recent overdose and the experience of coming to consciousness in the ambulance as he was being transported to the hospital emergency department. This time the hospital did not even bother to admit him or notify us that he had overdosed again. Both he and his girlfriend were (to use his term) “messing” with fentanyl. He was amused at the amazement in my voice when I asked why. “There was nothing good at the movies,” was his reply. Yes, he and she knew that fentanyl was deadly. Still, that risk was part of what made it recreational for them. Not quite as definitive as Russian Roulette, but certainly life-endangering. So, for a second time, his life had been saved by naloxone, which ambulances had only started carrying 10 years ago.

That moment of dumbfounded amazement was my introduction to the opioid crisis, which seems to have only gained momentum since that time. Opioid overdose deaths rose steadily from that date to 2018 when we saw a “

significant decrease …. to 46,802 deaths

 Most prognosticators are suggesting that the death rate will rise again in the year of COVID-19, with its emotional stress and enforced lack of productive activity. The journals and editorials of the medical establishment have bemoaned the overly casual prescribing of pain medications as the initiating cause of this great disaster. A regiment of state attorneys general have joined in suits against big pharmaceutical companies for promoting use of high-potency opioids and have impressed juries with their arguments. The accepted story line is that individuals with addiction are being victimized by the availability of opioids in the country.

Through all of this public hand-wringing and wrangling for ever-more money for addiction treatment, I have not seen a single article that has pointed to the evident fact that a huge number of Americans do not seem to regard their own lives as worth living. The media of the country, as well as much of the institutional health effort, has described the opioid epidemic as if it is outside of the larger picture of what some are calling deaths of despair. In the year 2018, deaths from heroine (15,000) methamphetamine (13,000), cocaine (15,000), 

 are all rising right along deaths due to opioids.

Perhaps it is only a partial truth, but to me it seems individuals who die of these causes do not feel that their own lives are worth protecting. The authorities that society has charged with understanding this rolling disaster are themselves self-motivated and curious individuals who have achieved much in their lives. The existential experience that one’s own life is not worth protecting is so distant from their experience that they simply do not or cannot have the imagination to carry the conversation into that realm.

 reports: “Emergency department patients who survive an opioid overdose are 100 times more likely to die of an unintentional overdose and 18 times more like to die of suicide within a year than patients who visit the emergency department for other reasons.”

 I can hardly imagine an individual unintentionally getting the dose wrong and overdosing. But having had such a terrifying brush with death, I would have expected increased caution after that close call. On the contrary, “of the 21,080 who were revived from an opiate overdose by ER visit, 368 died within a year of an unintentional overdose,” and another 29 died of what was judged to be an intentional opioid overdose. Other research quotes similar sequences for those revived from sedatives and hypnotics. The conclusion offered is: “...patients who survive an opioid overdose, whether unintentional or intentional, should be carefully evaluated for substance use disorders and suicide risk …[and]… receive appropriate referrals for follow-up substance use and mental health care.”

This article (and many like it) do not explore the possibility that there might be something other than the standard explanation of substance use disorder. Is it not possible to ask the question as to whether these individuals are trapped in a world that provides no sense of meaning or engagement for them? Without a sense of meaning or engagement, they might have no reason to protect their own lives and, like the young man who initiated me to this world of despair, would be as happy messing with fentanyl as they would be to go to a good movie in the evening. Spending more money on drug rehabilitation will not move the needle on the death rate for that group of individuals.

In this conversation I find the pastoral care literature much more relevant than the psychiatric literature. That literature carries the concept of an 

. These orienting systems are a specific theme of these columns, or how we think about ourselves. Orienting systems are defined as: “Embedded beliefs and values, perhaps outside of one’s awareness but enacted in one’s practices, especially under stress.”

 The idea of orienting systems is more specifically defined by the psychologist Kenneth Pargament, PhD, who I first became aware of when he presented the Oskar Pfister Award Lecture at the 2009 American Psychiatric Association meeting.

 His work recognizes that the orienting systems of different individuals are very different. Some are deliberate beliefs that have been taught in some kind of formal religious education, but most of them have been informally taught in the school of experience or absorbed by imitation of parents. No matter how a person has assembled their orienting system, Pargament says it must meet 4 criteria

1. Must be complex enough to bear the weight of suffering.

2. Must integrate one’s values and beliefs with one’s actual practice.

3. Must be a flexible enough spiritual basis to cope with stress.

4. Must incorporate beliefs of the goodness of life or goodness of God that foster self-compassion and compassion for others.

The idea that healing from addiction involves spiritual practice is not a new idea. 

 of Alcoholics Anonymous (AA) makes repeated references to spirituality. In an appendix written shortly after the first edition emerged, spirituality was explained in this way

Quite often friends of the newcomer are aware of the difference long before he is himself. He finally realizes that he has undergone a profound alteration in his reaction to life; that such a change could hardly have been brought about by himself alone. What often takes pace in a few months could seldom have been accomplished by years of self-discipline. With few exceptions our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves.

These genteel words were penned in 1939. The AA movement continues to be the most effective and most accessible program for dealing with alcoholism. Modifications of this format are now widely used for other addictions as well. With the concept of orienting system as our lens, my reading of 

 concludes that the conscious intent of the program was to support individuals in replacing an experience of vacuity with a strong sense of self. I hasten to say not an inflated sense of self, but a self that acknowledges and claims its own scars and wounds. To reflect back to Pargament, a self that is complex enough to bear the weight of suffering, and still claim that life itself is good. Traditional religions, whatever their shortcomings, did convey this sort of orienting system to their adherents. The liberal tradition, wishing to free itself from the baggage of a supernatural lawgiver, appears to me to have not figured out how to sustain the function of incorporating individuals into a functional orienting system.

With some 64,000 individuals dying annually from self-administered recreational drugs in the United States, it seems evident that the solution necessarily lies outside the narrow understanding of medical addiction management, with its focus on dopamine reward systems. Is it possible with our national concern for separation of church and state to work through government funded programs to work on the issue of vacuous lives? Or are we locked into rules which will require us to continue to spend money on things we consider totally secular to deal with a problem that is at base a question of meaning?

This set of columns is titled “Body Mind Alliance: How We Think About Ourselves.” Up to this point I have been referring to how our patients think about themselves. We can, of course, flip the lens and inquire as to how we think about ourselves. What is the orienting system upon which we ourselves rely? Is it not true that we are almost always blind to our own orienting systems and too easily assume that all of our clients think about themselves in more or less the same way that we think about ourselves? And how is it that we can manage to catch sight of our own orienting system since it is so fully integral to ourselves? Would I have ended up with an understanding of my own orienting system if I had followed the advice of my residency faculty and gone into analysis as my co-residents did? Do we not often lose track of the fact that how we think about ourselves is intensely individual? The parallel to that statement is that how our patients think about themselves is intensely individual and beyond our control or prescription pens. To the degree that we assume the normative nature of our own orienting systems when we talk about deaths of despair, we will altogether miss the main conversation.

is a community psychiatrist contracting telepschiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

The opinions expressed in this article are those of the author and do not necessarily reflect the opinions of 

What do you think? Do you have an orienting system? 

Share comments with your colleagues by emailing 

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

1. National Institute on Drug Abuse. Overdose Death Rates. March 10, 2020. Accessed November 24, 2020. 

https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates

2. National Institute of on Alcohol Abuse and Alcoholism. Alcohol Facts and Statistics. Updated October 2020. Accessed November 5, 2020. 

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics

3. National Institute of Mental Health. Suicide. Accessed November 5, 2020. 

https://www.nimh.nih.gov/health/statistics/suicide.shtml

4. D’Arrigo T. Risk of suicide, unintentional death soar after nonfatal overdose. 

https://en.wikipedia.org/wiki/Oskar_Pfister_Award

7. Pargament K. Spirituality: a pathway to posttraumatic growth or decline? In: Calhoun L, Tedeschi R, eds. 

Handbook of Post Traumatic Growth: Research and Practice

Drug use is not only a consequence of addiction. It can also be a response to a deeper, existential problem. 

Dying Without a Dream

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It’s nice to be remembered, especially in the face of a trying year. Check out these editors' picks that won't break the bank.

10 Black Friday Gifts for Your Colleagues

Back in July, John Read, PhD, Tony Morrison, DClinPsy, and Rachel Waddingham, wrote the article 

Traumas, Adversities, and Psychosis: Investigating Practical Implications

. In this video, they expand on and discuss the topics of trauma and psychosis. 

is a psychologist and mental health researcher from England. He is professor of clinical psychology in the University of East London's School of Psychology. 

is a Professor of Clinical Psychology at the University of Manchester and is also Associate Director for Clinical Research at Greater Manchester West Mental Health Foundation Trust. 

is a freelance trainer and consultant, a writer, a practitioner, a researcher, speaker, PhD student at

Nottingham Trent University, and Chair for the

Joining together to discuss psychosis, 3 doctors share their experiences and opinions on the various ways to respond and help patients with trauma. 

A Dialogue on Psychosis and Trauma

I don’t expect punishment or prizes
for my work with violent boys in court-ordered care,
though I’ve been accused of experimenting
on them like they’re dogs, which reminds me
of Dr. Pavlov and the pack of thirty-five mutts
he taught to respond to bells and music,
his notebooks filled with love for each one,
especially little Druzok, Russian for best friend.

But Pavlov’s dogs and his century-old Nobel
hold no interest for the mother crying on my phone—
a judge says her son meets criteria for discharge,
and she begs me to keep him until he’s eighteen,
two more years sheltered from street gangs
she fears will eat him alive. And I share her fear
because I know what happened to Pavlov’s dogs—
World War II, Leningrad starved by a three-year
Nazi siege, a million dead, food supplies bombed
into dust, a police unit formed to fight cannibalism,
Druzok, Bailak, Murashka, and Rex ripped
from their cages, warm hearts and bloody flesh
devoured, paws gnawed down to bone.

is an instructor in psychiatry, University of Massachusetts Medical School, Worcester, MA.

A mother begs the court to keep her son incarcerated for fear street gangs will eat him alive.

Discharge Planning

COVID-19 has caused a surprising change in vaping and other substance usage in young adults aged 18 to 25. According to a recent 

 by Mayo Clinic during the pandemic, 44% of young adults decreased vaping, while 27.9% increased their use. Nearly 70% increased their alcohol consumption, while 47.3% decreased tobacco product use. Of those who used marijuana, 39.2% increased use, while 36% decreased use.

“Substance use is highest in the young adult age group, so we wanted to target this population,” Pravesh Sharma, MD, a psychiatrist at Mayo Clinic Health System in Eau Claire, WI, and the study’s lead author, said to the press. “We would like to understand why they vape and what their attitudes were regarding the potentially harmful nature of vaping.”

Before the pandemic, Mayo Clinic researchers were studying the potential harm of vaping to the respiratory system. With the onset of COVID-19, however, the survey shifted course. Rather than solely assessing the factors influencing vaping, the new, adjusted survey investigated young adults’ use of other common substances, such as alcohol, marijuana, and tobacco; and asked questions to better understand the effects of daily stresses during a public health crisis.

“As COVID-19 came on the scene, it was primarily thought to have severe respiratory implications,” said Sharma. “Since we were about to launch a study examining the factors associated with vaping use, which can lead to lung injury, it made sense to revise our questionnaire slightly to address the broader question of the use of vaping and other common substances during a respiratory disease pandemic.”

The survey was sent out in April to approximately 6119 young adults who had been seen in Midwestern Mayo Clinics within 4.2 months before the pandemic. Its release followed the stay-at-home orders and social distancing mandates issued by state and local governments.

Of 1018 respondents, more than half reported vaping, using marijuana, using tobacco, or drinking alcohol during the COVID-19 pandemic. (The authors note that the study’s limitations include a reliance on self-reporting and a 16.6% response rate.)

“We did see some reduction in inhaled substances, which could mean that young adults were reacting to the news coverage of COVID-19’s respiratory effects,” said Sharma.

An interesting, unintended discovery was also made: the more lonely, depressed, or anxious the survey respondents felt, the more likely they were to add or substitute another substance. Perhaps, as Sharma suggested, this was due to an attempt to cope with limited social interactions and strain.

“During the time of this pandemic, screening for substance use, loneliness, anxiety and depression is crucial,” Sharma stated. “Just asking, ‘How are you holding up during this difficult time’ goes a long way.”

1. Sharma P, Ebbert JO, Rosedahl JK, Philpot LM. Changes in substance use among young adults during a respiratory disease pandemic. 

2. Mayo Clinic. Changes in vaping, other substance use, another side effect of COVID-19. News release. November 19, 2020. 

https://www.newswise.com/coronavirus/changes-in-vaping-other-substance-use-another-side-effect-of-covid-19/?article_id=742048&sc=dwhr&xy=5013482

How has the COVID-19 pandemic affected the way young adults use substances like vaping, alcohol, and marijuana? 

A Shift in the Air: Changes in Young Adults’ Vaping and Substance Use During COVID-19

Obesity can have a major impact on a patient's overall health, and depression can have an unpredictable effect on a patient's weight. Therefore, they need to be vigilant in their food choices and exercises. Susan J. Noonan, MD, MPH, talks more. 

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do

Depression can cause weight loss or a loss of appetite... or it could cause weight gain and an increased appetite. Here is some need-to-know information on weight control and mood disorders. 