Sharon Packer, MD

Slideshows

Refreshed sleep can be tough even during normal times. With up to 30% of Americans experiencing sleep problems, here are guidelines to a better night’s sleep.

Sleep Hygiene Tips to Prevent Insomnia

Virtual happy hours abound, but this is also quite worrisome, especially for those struggling with alcohol and substance use. Dr Packer offers alternative solutions in this video. She recently coined the term 

. The British ritual is built around the time of day circadian rhythms drop, when most people's concentration it at its lowest.

Social isolation presents a good opportunity to grow plants and herbs for tea. Certainly, we can purchase it online; but growing a simple garden in a pot or a window sill can reap many rewards. Such rituals are just perfect for people who struggle with anxiety and depression and they bring real joy. Enjoyable activities are known in psychiatry as behavioral activation and they are proven to help in emotional well-being in the long term, unlike substances like alcohol and drugs that have a very short window of pleasure and end in remorse and, for some, full-blown despair.

Wordsworth's Wisdom During Troubled Times

 is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

Articles

Virtual happy hours abound, but this is also quite worrisome, especially for those struggling with alcohol and substance use. Alternative solutions are offered in this video.

Ditch the Quarantini: Healthy Options for Psychological Well-Being

This is a composite case illustration purposes only. The details do not point to any one individual. Ed

When my patient told me about her newly discovered “virtual happy hours,” I was shocked and dismayed. Her moods had suffered whenever she lapsed into drinking too much alcohol. We’d already had the “talk” about women, both mentally and medically, and about how vulnerability to the effects of alcohol increases with age.

 the following week, I was even more disheartened. At a time when preserving public health is our highest priority, why would we want to encourage excessive alcohol use among the vulnerable?

We know from past experience that alcohol use disorder (and other drug use) soared post 9/11 and remained high, even after 

 The more forward thinking commentators speculate that the true death toll of 

 has yet to be tallied, because chronic alcohol overuse is a killer.

 The CDC tells us that alcohol claims twice as many American lives annually as opioids. Alcohol use is responsible for 88,000 deaths a year.4

Patients who attend New York 12-step meetings tell me that they often hear stories that trace relapses to 9/11. Contrarily, many tell me how much they appreciate the surge in virtual meetings online, as well as the ability to “attend” meetings in glamorous locales like LA or to revisit their hometowns (virtually) and to learn that some old drinking buddies are now sober. Those people have found helpful and healthful routes to our current corona virus predicament.

But what about the rest of us? Are there alternatives to breaking social isolation without breaking out a bottle of beer? For sure. How about tele-teatime? The varieties of available teas are endless. Learning about teas-and their native habitats-is a good way to while away the hours. An even better pastime for indoor moments is windowsill gardening: growing dainty chamomile flowers from seed and making tea from the flowers.

YouTube and internet gardening sites list an amazing array of mint plants. There is chocolate mint, peppermint, spearmint, licorice mint, and more. Should the quarantine stretch into summer, wilted hibiscus petals from the garden can be turned into a tasty tea and vibrant red one at that. (Petals are plucked and dried after prime blooming time, before they drop to the ground.) Sharing the cup of tea as well as posting photos of plants, with newfound and old friends, will be a pleasure without adversely impacting health.

is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY. 

1. Packer S. Jessica Jones (superhero), women and alcohol use disorders. In: Rayborn T, Keyes A, Eds. 

Jessica Jones, Scarred Superhero: Essays on Gender, Trauma and Addiction

. Jefferson, NC: McFarland, 2018.
	2. Stress and Substance Abuse: A Special Report After the 9/11 Terrorist Attacks. 

https://archives.drugabuse.gov/publications/stress-substance-abuse-special-report-after-911-terrorist-attacks

. Accessed March 26, 2020.
	3. Szalavitz M. How We Cope: What Do Addiction Rates After 9/11 Tell Us? Time. September 9, 2011. 

https://healthland.time.com/2011/09/09/how-we-cope-what-addiction-and-recovery-rates-after-911-tell-us

At a time when preserving public health is our highest priority, why would we want to encourage excessive alcohol use among the vulnerable?

Tele-Teatime During the Quarantine

Editor’s note: This article is an update to Dr Packer’s April 2014 article that appeared in Psychiatric Times, "Daffodils as Antidepressants (What Wordsworth Knew)."


	For Dorothy, it was lions and tigers and bears. Yet she still made it to the Emerald City.

For us, it’s been tornados, volcanoes, epidemics, and more. Now we have 

; is the coronavirus here to stay? Or will we make it to our own equivalent of Emerald City? Although we can’t predict the extent of the epidemic at the time of this writing, I can confidently say that soon we will see leaves of green-that burst into buds-and that such greenery will be better and more beautiful than those ersatz emeralds that Dorothy sought.

If we focus on only the bad news, and click on every catastrophic online link, and harp on the devastation that nature brings, we might conclude that nature is a destroyer and nothing but. But that’s hardly the case, especially not when we think about daffodils and Wordsworth’s words, which are just as uplifting today as they were when he penned his since immortalized 

Luckily, it’s daffodil season, when stout green stalks push through the ground, breaking through patches of leftover snow and spearing fallen leaves still floating about since fall. It’s time to watch those green stalks lengthen, and become bright yellow buds, before bursting into daffodils.

At times like these, it’s easy to wax medieval, and to envision the death and devastation of the bubonic plague or the Black Death-which are not even remotely related to our current COVID concerns. Better to return to the Romantic Era, when 

 (1770-1850) produced his historic poem and when his suffering soul found salvation after chancing upon a random field of flowers.


	It was more than two centuries ago that William Wordsworth (1804) serenaded this symbol of spring. His poem about daffodils became the most widely read poem in the English language. In fact, it came to be called “Daffodils”-although that was not the true title of the poem. Wordsworth’s chosen title reminds us that the British bard was not always so upbeat. He was no stranger to sorrow himself. On the contrary, for Wordsworth was primed for depression, having lost each of his parents when he was still a young child.

Let’s begin with Wordsworth’s original title: “I Wandered Lonely as a Cloud.” Apparently, that was how he felt until he came upon “a crowd . . . of daffodils.” Then he became ecstatic, as he watched the daffodils sway in the spring breeze. That daffodil dance that Wordsworth described was world’s away from the morbid dance macabre that evolved during medieval plague years.

Wordsworth was way ahead of the curve in so many ways, as poets typically are (or so said Freud, in a prediction that few refute). Wordsworth’s attitude anticipated 19th century “nature cures” adopted by upscale asylums, which added tranquil landscapes to their therapeutic regimens.

 These tranquil landscape regimens stood in stark contrast to the much-maligned public institutions that functioned as poorhouses and prisons as well as holding pens for persons with mental illness.

Having recently endured intense isolation in a remote village, this sensitive soul chanced upon a solution to his plight. The sight of daffodils sprouting from the soil rescued him from the sadness of solitude that hung over his head like a cloud.

It wasn’t just Wordsworth who benefited from his observations. His words relieved the deep and dark depression of John Stuart Mills (1806-1873), who was born a few years after Wordsworth wrote, and who later became the 19th century’s most significant English-speaking philosopher.

If we examine his exact words, we can learn even more from his experiences.

“I wandered lonely as a cloud, That floats on high o’er vales and hills,” Wordsworth writes, “When all at once I saw a crowd, A host of golden daffodils; Beside the lake, beneath the trees, Fluttering and dancing in the breeze.”

The poem continues:
	Continuous as the stars that shine
	And twinkle on the milky way,
	They stretched in never-ending line
	Along the margin of a bay:
	Ten thousand saw I at a glance,
	Tossing their heads in sprightly dance.
	The waves beside them danced; but they
	Out-did the sparkling waves in glee:
	A poet could not but be gay,
	In such a jocund company:
	I gazed-and gazed-but little thought
	What wealth the show to me had brought: . . .

Wordworth, “couch cures,” mindfulness, and creative visualization


	When Wordsworth rhapsodized about the yellow flowers, it is doubtful that he expected his verse to translate into asylum treatments. It is even less likely that the poet foresaw Freud’s so-called couch cure, even though Wordsworth concluded:

For oft, when on my couch I lie
	In vacant or in pensive mood,
	They [daffodils] flash upon that inward eye . . .
	And then my heart with pleasure fills,
	And dances with the daffodils.

In other words, Wordsworth has flashbacks of flowers, and delights in reexperiencing those daffodils. Unlike trauma survivors who revisit the same painful situations through daydreams and nightmares, Wordsworth deliberately conjures up images of those beautiful botanicals. He uses his recollections to his best advantage. In contrast to analysts and some insight-oriented therapists or exposure and response specialists who excavate their patients’ painful recollections, with the hopes of effecting a catharsis or entraining new responses, Wordsworth stays on the surface. Like contemporary practitioners of “mindfulness” methods, Wordsworth experiences the moment as he redirects his gaze and focuses on the first signs of spring: the daffodils.

There are many parallels between Wordsworth’s approach and experimentally proven contemporary treatments. Today, we teach related techniques to persons with PTSD. Called “creative visualization” or “imagery rehearsal,” those approaches substitute pleasant and peaceful imagery for unsettling thoughts and distressing memories. This pleasant approach-exposure to delightful daffodils-is far-removed from 

 that requires re-exposure to painful past events (although desensitization has its proponents and its place).


	Taking a cue from Wordsworth-but without crediting his verse-New York City officials planted 10 million daffodils bulbs after 9/11, to assuage the distress left by the deaths that followed the destruction of the Twin Towers. Wordsworth himself spotted “Ten thousand . . . at a glance.” For him, that sufficed-but the Big Apple had to be bigger, if not better. In 2007, daffodils became New York City’s official flower and New Yorkers could deflect painful memories of the past, by wandering through streets and parks, searching for specks of gold (gold flowers, that is).

How can daffodils help us today, at a time when psychopharmacological treatments advance by the day, and when more and more high-tech neuromodulators are being brought to market, but when the public’s skepticism about Big Pharma and its profit motive push forward just as fast?

Returning to the romantic era, and reexperiencing the “natural supernaturalism” espoused by Wordsworth,

 seems strangely out of date, or at least out of place in an urban area. Still, many insist that flowers boost their moods, sometimes even better than medications or meditation. Gardening therapy is growing, both in popularity and in respect. Some people are ready to dig into the earth, to plant bulbs that bloom in early spring, while others prefer to enjoy their neighbors’ efforts or visit public parks. For those who question the value of natural approaches, or find them too atavistic or simplistic, 

 bulletins often list studies about nature cures, some better constructed and more credible than others, but most are enticing enough to try.

Scientific studies from the University of Copenhagen identified chemicals in daffodils that cross the blood-brain barrier, which led to speculations that daffodils may help synthesize better antidepressants at some point in the future.

 It remains to be seen if those studies will be replicated, or if that data will prove profitable enough for Big Pharma to pursue, but, right now, we know that Wordsworth’s wisdom about daffodils persists.

Not everyone can enjoy daffodils (or other flowers) first-hand. For those who suffer from hay fever or other allergies, or shun the sun for medical reasons, YouTube offers an abundance of 

 readings online. World-renowned actors post polished poetry performances online (at no cost to the viewer). Many Wordsworth readings are more homespun and heartfelt. Slideshows of photos and paintings add to the listening experience and allow even the homebound-or the quarantined-to join Wordsworth’s ritual of “dancing with daffodils.”

Loneliness: a contemporary affliction or the “human condition”?


	Wordsworth was prescient in other important ways as well. He admittedly ached from the 

 that is said to be endemic in contemporary American and British society. Or so say recent studies by Cigna, a mammoth insurance company that sells life, disability, and medical policies, tracks mortality and morbidity trends and has a vested financial stake in identifying-and preventing-factors that adversely affect its insurance claims.

Reading Wordsworth reminds us that “loneliness” is hardly the recent invention that it has been made out to be. JAMA published an important piece on loneliness back in 1980 as well as a more updated article.

 Loneliness is also the province of poets and is sometimes the catalyst of creativity. Since we can expect loneliness to skyrocket if quarantines and curfews and social distancing persist, we can take a cue from Wordsworth and at the very least, we can look at daffodil sites online, if not in person, even if city officials limit our use of public parks. (Dafflink.org, operated by the American Daffodil Society, can keep even the most restless busy.)


	As fond as I am of Wordsworth’s poem, I feel compelled to add a disclaimer: it is entirely possible that Wordsworth was suffering from 

 when he spotted the daffodils. Wordsworth does not mention it, but we know that daffodils are an early sign of spring. They signal the end of winter. Sometimes, they sprout even when snow still covers the ground. Perhaps he incorrectly credited daffodils for the spontaneous remission of his winter depression. After all, he did name his poem “I Wandered Lonely as a Cloud,” suggesting that he was very, very sad at the start. Only afterward did his verse come to be called “Daffodils.” Some speculate that he showed signs of bipolar disorder, and that his springtime switch to ecstasy and poetry, with increased exercise (through hills of daffodils), signaled the start of mild hypomania.

But what difference does his diagnosis make, when we can identify the same stressors in more ordinary souls, who might be suffering as much as Wordsworth did, before he saw the daffodils? While this explanation is possible, maybe even probable, we must ask ourselves, “Is it important?” Given that we practice in an era of “evidence-based medicine,” when anecdotal reports have less credibility than case-controlled studies, we cannot automatically accept Wordsworth’s words at face value (in theory, at least). Or can we? Perhaps Wordsworth’s “Daffodils” should be grandfathered into our psychotherapeutic armamentarium, since his insights have withstood the test of time. Plus, no adverse effects have been reported.

And as for the emeralds of the fabled Emerald City, which I mentioned at the start of this article, I ask you: can those fanciful jewels and factitious wisdom that Dorothy sought possibly compete with the real life green of spring, and with the insights that Wordsworth invites? I think not.

is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY. A condensed version of this article appeared in 

Cheerful prospects and tranquil restoration: the visual experience of landscape as part of the therapeutic regime of the British asylum

. New York: WW Norton and Company, Inc; 1971.
	3. Eriksson AH, Ronsted N, Guler S, et al. 

In-vitro evaluation of the P-glycoprotein interaction of a series of potentially CNS-active Amaryllidaceae alkaloids

. 1981;245:1871.
	5. Jeste DV, Lee EE, Cacioppo S. 

Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions

It’s been tornados, volcanoes, epidemics, and more. Now we have COVID-19; is the coronavirus here to stay?

 (SAD), but we don’t talk much about “winter woes.” In fact, we don’t yet have a precise term for the lull that follows winter solstice, when the days are slowly getting longer and when SAD sufferers theoretically should feel better, but don't necessarily do better.

For now, let’s call this decrescendo “winter woes,” when the depression isn’t necessarily bad enough to demand more medical care or increased psychotropics. Yet all too many people simply drag and droop, unable to enjoy life fully during those dark cold winter months.

By now, we all know that a mere 20 minutes of morning or noon exposure to 10,000 lux full-spectrum lights helps to offset the dips in energy and drops in mood that plague many people in the autumn. But what about the next few months, when many hole up indoors, wrapped in blankets, not necessarily enjoying the warmth of the hearth-as 

’s iconic American images suggest-but are immobilized (although not catatonic), more like hibernating bears than happy campers?

For sure, some folks crave winter sports and are agile enough and affluent enough to ski and snowboard and are not deterred by cold windy weather. Those people spend time on the slopes, exposed to extra sunlight reflected off snow and benefit even more from the physical activity.

What about those who do not spend time outdoors, because they are cold adverse or more frail than agile, or sun-sensitive. . . for whatever the season. Or they may be more urban than rural, without access to ski slopes or snowboarding trails. Is there hope for overcoming winter doldrums without upping antidepressant doses? Better yet, are there any natural treatments that bypass medications altogether, and may be more affordable than pricey (and often ugly) industrial-style FS lights?

I have a suggestion, but I also have a confession. While I heartily recommend the “amaryllis antidote” to winter woes, I cannot cite double-blind studies about this, nor do I know of any scientific studies on this subject. I have only anecdotal information to share.

 bulbs indoors in the fall is an amazingly easy way to ease the ennui and break the boredom of the cold winter months that linger after solstice and persist until spring. Ordering bulbs in early autumn, before the days grow shorter, is another way to boost spirits months earlier-but even those who do not plan ahead often find after-Christmas super-sales on amaryllis bulbs or potted plants.

Unlike daffodil bulbs or even early blooming crocuses, amaryllis does not demand that we wait until April to see the fruits-or I should say blooms-of our labors. In fact, it’s not laborious at all to place an amaryllis bulb in what’s called a “cozy pot,” which is simply a small pot, large enough to hold an inch of soil surrounding the bulb, but no more. The bulbous bulb-and that descriptive is not rhetorical-is sunk into the soil, two-thirds of the way down, with the top third of the bulb-the so-called “shoulders”-peeking through the dirt. Except for the very first day, when the bulb is planted in the pot, amaryllis doesn’t need water for weeks. Moreover, it doesn’t demand anything more elaborate than a windowsill.

When little leaves sprout a month later, a few stingy drops of weekly water, just enough to moisten the soil without making it soggy, will produce beautiful blooms in midwinter. Buds appear and then the flowers unfold, even when the landscape outside is frozen solid with icicles hanging from trees.

Many people, me included, associated amaryllis with Christmas celebrations and poinsettias. Like many assumptions, that one is not totally true. Amaryllis is truly nonsectarian. Most amaryllises are not even red, as are poinsettias. Amaryllis may be coral or peach or pink or white as well as red, with many hues in between. It may be striped or stippled, big or small, single or twins or quintuplets or more. Moreover, some amaryllis varieties bloom for Christmas and some bloom for solstice. More likely, Amaryllis flowers appear for Kwanzaa or Chanukah, for New Year’s Day, or Little Christmas, or Three Kings Day or Orthodox Christmas or lunar new year, as celebrated by Asians and Asian Americans. Flowers persist to Martin Luther King Day and Presidents day through Groundhog Day and Mardi Gras. Recently, pre-grown red amaryllises have been recommended for Valentine’s day.

There have been years when amaryllis blooms lasted through Purim and Passover and almost made it to Easter, when outdoor daffodils sing about the start of spring. In short, amaryllis offers something for everyone, for it encourages celebrations on many occasions, over as many months.

Even better than enjoying its lovely flowers, which for many is enough, planting amaryllis bulbs offers us the satisfaction of knowing that we grew this bulb ourselves with so little effort. Studies show that behavioral activation, which is a fancy way of saying that doing something instead of doing nothing, augments antidepressants even more reliably than cognitive behavioral therapy and far better than psychodynamic therapy.

 We also know that spending time in nature improves mood but who’s to say that nature must always be outdoors rather than indoors? Certainly, it’s nice to live near green space, save for those who suffer from hay fever, and it’s better to devote two hours weekly to nature, as studies recommend, but there is no reason not to bring nature inside, to enjoy its benefits today.

Perhaps someone will study the amaryllis antidote someday but right now I leave it to each of you readers to conduct your own case-control studies (

 newsletters post notices about nature-related studies concerning mood and medicine but have not yet mentioned amaryllis). What have you got to lose except $10, the price of the bulb coupled with a small dollar store plastic pot, filled with a little planting soil?

1. Park LT, Zarate CA Jr. Depression in the primary care setting. 

We often hear about seasonal affective disorder, but we don’t talk much about “winter woes.” Amaryllis offers something for everyone, for it encourages celebrations on many occasions, over as many months.

Amaryllis as an Antidote for Winter Woes

Mat was big, blonde, and a bully. She was also a Buddhist who didn’t eat meat or drink beer. She called herself Mat, short for Matilda, using a gender-neutral name long before it became fashionable.

Mat was the proverbial “Big Nurse” who bulldozed residents, attendings, and even ward chiefs. Her concern for patients distinguished her from the diabolical Nurse Ratched-although some med students compared her to Nurse Diesel from Mel Brooks’s spoof, 

Had Mat told me that she secretly called herself “Brunhild” rather than “Mat,” and dressed like a Valkyrie in private, and imagined herself leaving her day job and auditioning for an operatic role in the Ring Cycle, I would have believed her. But, to us, she was Mat, the head nurse. It is she who is the star of this story, more than I, and more than the unfortunate patient, the piccolo player, whose preliminary diagnosis surfaced through our combined efforts.

Nick, as I shall call him, was a youngish male who was sent “upstairs” from the emergency department (ED). The ED doc called, and said, “it’s probably just drugs. You know how they are . . . I couldn’t send him home in his condition, so I sent him upstairs to psych. At least he’ll be safe there, till everything wears off.” Nick had started sobbing uncontrollably in an all-male dance hall near the hospital. “He should have been happy,” said the ER doc, who parroted the words of Nick’s friend, who said that Nick was thrilled by his Lincoln Center audition and would soon graduate from a conservatory upstate.

We assumed that Nick had been medically cleared in the ED. But there’s a reason why we should never assume, and there is no need to repeat that reason here. The timing was also telling. It was the early eighties, before medicine knew much about the plague brewing in the West Village and in San Francisco. All we knew was that Nick was too inconsolable to relate a coherent story.

Unable to speak without sobbing, he pulled out his wallet, and showed his school ID. He was indeed about to become a professional piccolo player. He was not someone who set up shop on the subways, or street corners, waiting for tourists to drop tips into his hat. Hoping to learn more about him, I asked to speak with someone from home. He nodded “yes,” so I asked him to call his brother on the phone.

That’s when it became apparent that something much more was amiss. I slid the phone across the desk, near Nick’s hand. It was a push button model in an era that had not yet envisioned auto-dial cell phones, much less speech-activated Siri. But this conservatory-trained piccolo player couldn’t dial the phone. His fingers stumbled around the keypad. His digits didn’t flip fast enough, even though he presumably had far better fine movement control that almost anyone around, save for some select neurosurgeons.

His gait was unimpaired, and his speech was clear, without slurring. The common signs of intoxication were absent. This strange sign prompted me to perform some impromptu “bedside” neurological tests even before asking the standard mental status questions used to assess memory and cognition.

Instead, I asked him to touch each finger with the opposing thumb, and then flip their hands right side up and upside down, as I observed for speed. Not surprisingly, Nick could not perform these simple tests any better than he could dial a phone. He had “dysdiadochokinesia,” a neurological sign of cerebellar dysfunction. Whatever ailed him, it was not strictly psychiatric, and it probably was more than the recreational drugs that the ED resident suspected.

Dysdiadochokinesia was a hard word to remember-and an impossible one to forget. The differential diagnosis for dysdiachokinesia was ominous: MS for starters in someone his age. Cerebellar tumors occur in much younger persons, as well as more obscure disorders, and some newer diagnoses also.

I was still contemplating the significance of this unexpected neurological sign, when Mat burst into the room, yelling, “stop.” She was a bully, for sure, but she was not an alarmist. In her hands were plastic gloves and a blue paper surgical gown, the kind that would pop up throughout hospitals soon enough. “Don’t draw bloods before you put this on,” she said, eyeing the syringe and tubes that I had lined up on a crash cart, expecting to order more laboratory tests than the ones done at Nick’s short ED encounter.

Having commandeered my attention, Mat beckoned me to exit the exam room. I pushed the cart ahead. With the patient still in sight, but outside of ear range, she whispered that she saw “thick white stuff” in his throat when she inserted the thermometer to take his temperature. She thought it was thrush.

The ED staff made no mention of this finding and recorded “WNL” in the HEENT section. Yet Mat was unmoved. A throat swab was already on the way. For someone who was ordinarily so persuasive, Mat nevertheless needed some persuasion to support her suspicions. Mat flinched when I told her about the dysdiadochokinesia that was evident during ordinary activity, even before a formal neurological exam.

Thrush had many meanings to the medical eye and ear, but in this case, where it appeared in a young previously healthy (and probably gay) adult male, who was not on corticosteroids and was not diabetic and was not receiving chemotherapy, it said “AIDS.” And AIDS meant blood-born transmission, and a need for extreme caution to avoid acquiring or transmitting the still-deadly and ill-understood infection.

The HIV test had not yet been born. We did not yet know that the retrovirus could affect the CNS system directly. We knew that systemic candida could afflict immunocompromised individuals or cancer patients or persons on complicated antibiotic regimens that wiped out less pernicious organisms. And now it seemed likely that Nick would be the next unfortunate recipient of this diagnosis.

A few phone calls later, Nick was on his way to a medical ward, which offered a more targeted work-up and more nursing attention, at least in the short run. Over the next few months, more “Nicks” would arrive in the ER, some with neuropsychiatric symptoms and nothing but, and some who were sick enough to enter ICU immediately. Over the next few weeks, white splotches surfaced on Nick’s skin.

If only Nick’s story ended as nicely as Mozart’s 

, where Papageno the bird catcher meets his partner. But that was not meant to be. It was painful to imagine Nick’s last act. At very best, he entered Valhalla as heroically as the deities who died in Wagner’s opera, after the skies blazed red like fire. Happy endings were not available to people like Nick in the early 1980s, but times changed by the year 2000. On the other hand, I could easily imagine how badly things might have turned out for more people on the ward, myself included, had Mat not been so astute-and had I not been a physician first, who noticed subtle neurological signs as much as straightforward psychiatric symptoms.

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

Dysdiadochokinesia was a hard word to remember-and an impossible one to forget.

The Piccolo Player and His Last Tragic Tune

As Gilbert and Sullivan wrote, “Things are seldom what they seem, skim milk masquerades as cream.” Medical disorders may also masquerade, not as cream but as psychiatric disorders, as occurred in Maureen’s case.

Maureen had every reason to be depressed. Her live-in boyfriend left after 5 fitful years. Since then, her energy waned. She rarely slept through the night and couldn’t make it to morning team meetings.

Not surprisingly, her job was in jeopardy. Worse yet, her company was also in jeopardy, for the fashion industry had been floundering ever since “fast fashion” priced out their designer dresses. Her once-prestigious brand would be “cutting the fat” to stay afloat. They hinted at lay-offs to come.

Even when she was in time for the morning meetings, Maureen couldn’t concentrate. She made careless and costly errors. She received a formal warning from her boss, who said that her “presenteeism” was worse than her absenteeism. He referred her to HR, expecting them to do the dirty work of dismissing her.

Maureen left a voice message for me, saying that she had explained her situation to Eileen, the head of HR, who suggested a medical leave of absence, rather than the immediate termination recommended by her supervisor. She received my name from the company’s Employee Assistance Program (EAP). To me, this sounded like a generous offer, especially since it came with short-term disability benefits; however, there was one caveat. Maureen needed to seek psychiatric treatment while on leave. Maureen was told in no uncertain terms that she needed a psychiatrist to “sign off” on the disability and to prescribe medications as needed. HR would not accept a note from the texting therapist whom Maureen had found through a subway ad.

I knew from the get-go that there would be plenty of papers to sign, and annoying insurance forms to complete, along with regular clinical care, should I schedule her appointment. The EAP staff knew that I would not endorse questionable disability papers, and I made sure that Maureen knew that I could promise her an evaluation but could not promise anything more before completing that evaluation.

Maureen arrived at her appointment, looking pale and haggard for someone so young. She had neglected her grooming, which didn’t go unnoticed in the fashion industry. Her nails were chipped. Three inches of dark roots told me that her self-care had lapsed 6 months earlier, since hair grows half an inch a month.

Her speech was slow and monotone. Luckily, she was not and never had been suicidal. I could count on the EAP to catch those serious symptoms before referring patients to an office setting.

Maureen’s psychiatric history was straightforward. She had one previous depressive episode in college, also after a break-up. Symptoms were milder and remitted with therapy that she received from student health services. Her family history included uncles with alcohol use disorders and early deaths from cirrhosis but no other serious psychiatric disease. Maureen had the good sense to avoid alcohol because of this family history.

It would have been easy enough to diagnose MDD, recurrent, fill out her forms, start an SSRI, set up follow-up appointments, touch bases with her therapist, and leave it at that. But there was no way that she would leave my office without reviewing her medical history as much as her psychiatric and social history. A “review of systems” is a standard part of any initial evaluation. Obliging psychiatrists to apply the same “E & M” (“evaluation and management”) codes used by all other physicians (rather than unique behavioral health codes of the past) drives that point home even more.

On her intake forms, Maureen noted that she had anemia back in college-which remitted 5 years ago. In the section about exercise she wrote that she had stopped exercising when she felt too weak to walk to the gym. As always, intake questions included LMP (last menstrual period), since it is imperative to avoid certain medications in potentially pregnant patients. She scribbled a series of question marks after that question. I asked her to elaborate.

Upon questioning, Maureen mentioned that her periods often lasted so long that she wasn’t sure when they began or ended. She recalled that her college gynecologist attributed her anemia to heavy periods but did not recommend treatment or further work-up. Maureen added that her previously mild menstrual pain had become major pain. When asked about her last primary care or gynecology visit or recent laboratory tests, she looked up sheepishly and said that she hadn’t seen a doctor for 2 or 3 years.

I needed more data about Maureen’s medical status, since any number of medical conditions can affect mood and cognition, even when someone has obvious social stressors that can precipitate depressive symptoms. So, I bargained with Maureen and told her that I would sign her disability papers a week at a time, with the proviso that she consult a primary care physician and a gynecologist in the interim. Again, the ever-efficient EAP head had those doctors on direct-dial. To expedite matters, I handed Maureen a lab slip, knowing that basic lab results would return electronically the following day, but thyroid functions would follow in a few days. Those tests would be ready by the time she scheduled her PCP appointment.

Maureen was started on sertraline, but I emphasized that her unexplained medical problems could also cause lassitude. Her gynecology appointment was arranged quickly, and the gynecologist took the time to call and say that she felt large masses during the office examination. She suspected fibroids but needed imaging studies and a biopsy to support her suspicions and to rule out something more serious. In the meantime, Maureen’s lab tests returned with strikingly low hemoglobin levels. The repeat lab test ordered by the gynecologist later that week showed even lower levels. The gynecologist recommended iron supplements in the interim and explained the treatment options to Maureen.

The biopsy report came in. Luckily, there were no cancerous cells. Unwilling to wait for a response to medical treatment when her hemoglobin was dropping, the gynecologist scheduled a myomectomy. By then, Maureen’s stomach pain had increased and interfered with traveling to our appointments. We decided to make do with telepsychiatry appointments until she recovered from surgery.

It was late in the day when Maureen telephoned me to say that her surgery took far longer than expected. The gynecologist called in a GI surgeon to assist with dissection of a bowel loop wrapped around the 5-pound fibroid. Maureen wasn’t sure of the specifics. What was certain is that Maureen’s worsening stomach pains were something other than the vague aches and pains of depression. The gynecologist warned her that she could have developed gangrene that required a bowel resection, or might even have died from sepsis, had the mucosal membrane ruptured, and had they not acted so quickly.

While she recovered, Maureen’s surgeon assumed responsibility for documenting her disability and our telepsychiatry appointments revolved around titrating her dose of antidepressants. I half-expected her to transfer all treatment to her PCP, but a few months later, Maureen scheduled an office appointment.

She bounced into the room, looking like a different person. Her cheeks were rosy; she had “pep in her step” or so she said. There were no signs or symptoms of depression. She said that this near brush with death made her appreciate life. I asked about the insurance paperwork, since insurance paperwork prompted her first appointment with me. Maureen said it was moot: her company collapsed since she left on leave, and her disability benefits disappeared. Yet she seemed happy. She received a severance package and paid COBRA benefits and now had renewed energy and enthusiasm to seek new work.

I, too, had renewed enthusiasm about the importance of medical training to the practice of psychiatry. I confess that I cringe when I hear people say that “psychiatrists prescribe medications” without considering the need for a differential diagnosis and the significance of the “big picture.” Maureen’s life was at stake; this was more than a matter of mood. Doing a review of systems was a rather simple matter and putting those pieces together could be done by any doctor. It wasn’t “rocket science,” as they say-but it was a classic example of medical science and of why psychiatrists are physicians first.

That’s all well and good-but what happens when psychiatric physicians are not available? The supply is dwindling. There are some innovative solutions on the table, including “integrated care.” But that approach presupposes that patients already have PCPs in place-and many younger people consult urgent care for minor problems without forging relationships with PCPs. Curiously, as per Peggy Drexler’s 

 millennials are more comfortable with therapy, even texting therapy, and may bypass psychiatric assessment as well, as happened with Maureen.

Currently, pediatricians can fast-track into child psychiatry fellowships, but I don’t know of plans to fast-track PCPs into general psychiatry training. Perhaps that’s something to consider, especially for PCPs who miss the doctor-patient relationships that get lost in an increasingly impersonal and corporatized health care delivery system. Perhaps there is a solution in sight-but dismissing the value of medical training in providing psychiatric treatment is not the solution.

Drexler P. Millennials are the therapy generation. 

https://www.wsj.com/articles/millennials-are-the-therapy-generation-11551452286

Doing a review of systems wasn’t “rocket science,” as they say-but it was a classic example of medical science and of why psychiatrists are physicians first.

Things Are Seldom What They Seem

Dr. Edrei recently completed his Ph.D. at Tel-Aviv University and currently teaches a course on gaming that university. His publications on interactive storytelling, video games, and virtual narrative appear in 

 (Brill). Dr. Packer is a psychiatrist and a frequent contributor to Psychiatric Times. She is the author of several books pertaining to psychiatry and popular culture.

Psychiatry and media have long been strange bedfellows. There are several reasons why. For one thing, psychoanalysis and cinema emerged within a year of one another as the 19

 century ended. That chronological correspondence allowed each to influence or interact with the other and increased one another’s awareness of such turn-of-the-century innovations. Much attention has been showered on psychiatry’s representation in cinema.

Video games now merit the attention of psychiatric practitioners as well as the public-and financial forecasters.

 Video games are currently three times as profitable as films. Earnings for youthful esports champions exceed their parents’ wildest expectations, according to the 

 The Entertainment Software Association (ESA) 

 notes that 42% of Americans (150 million people) devote at least three hours a week to video games.

 Over 91% of persons under age 17 years play video games regularly (and that number is increasing rather than decreasing). Yet over 

 making them less likely to have as much personal experience with video games as their younger patients, peers, or progeny, and making the profession in general in need of updated information on this medium.

When video games do attract the attention of psychiatrists, that attention often revolves around potential 

 or about premorbid psychopathology that 

 Occasionally, we hear about negative portrayals of psychiatric patients or practitioners in video games, such as 

Universe and today’s top-grossing video game). 

revolves around a bedlam-like asylum for the “criminally insane,” where psychotic or simply sociopathic psychiatrists are committed to the very same institutions they administer and are locked in wards with murderous and often infamous mental patients (eg, the Joker, Penguin, Mad Hatter, the Riddler). We find allusions to video game addiction in American psychiatric literature, and rehabilitation programs for such addictions have popped up. This is especially true in South Korea, where nationwide high-speed internet connectivity is conducive to gaming.

DSM-5 failed to add this proposed diagnosis to the standard nosology but instead listed it as “a condition for further study.” Yet as of 2018, World Health Organization (WHO) broke with the American Psychiatric Association’s lead and is set to include “

 International Classification of Disease (ICD-11).

At a time when other novel forms of media are being touted for treatment of psychiatric disorders (such as virtual reality [VR] treatment for phobias), it may be useful to revisit a new breed of video games that may have value as teaching tools, if not necessarily as treatment tools.

is one such example. Developed by Ninja Theory and published in August 2017, the game’s bombastic title belies its thoughtful, emotionally resonant narrative that stands out even in the age of increasingly cinematic game experiences. It relies on extensive neuroscience-related research for the project.

The player controls Celtic protagonist Senua, a warrior whose lover Dillion has been sacrificed to the Norse goddess Hela at the hands of Viking marauders. To reclaim his soul, Senua embarks on a solitary journey to Helheim, fighting through hordes of masked Northmen.

Taken in isolation, the plot offers little innovation: while some critics have praised the game for inverting the gender roles of the stereotypical revenge plot, and casting the avenging protagonist as female, the structure of the game’s story follows the expected route. However, the presentation of said plot is key to understanding the game’s appeal. The opening sequence, in which Senua quietly rows to the shores of outer Helheim, immediately distinguishes itself from its predecessors via three points of interest.

The first concerns the narrator who introduces herself as the camera closes in for its first look at the game’s protagonist. Unnamed, the voice addresses the player directly, speaking in a low whisper so as not to alert “the others.” A host of whispers immediately follow-some asking questions, some mocking Senua, some reiterating her mission statement and determination. The voices overlap, speak over each other, and at times argue with each other. As the cacophony continues, Senua looks around apprehensively, indicating to the player that she can hear every word. As the introduction winds to a close, just before the player gains control of Senua’s movements, the protagonist indicates that she can hear the narrator-and that she is aware of the player as well, just another voice in her head. Though these voices are referred to within the fictional world as Furies (a clear reference to the Greek tradition of conflating femininity and madness), the game is quick to demystify Senua’s condition: she suffers from schizophrenia, a condition later revealed to have been inherited from her mother.

The second revelation becomes immediately apparent as the voices persist in speaking over the narrator’s exposition: in a behind-the-scenes feature, director Tameem Antoniades explains that the discordant voices were recorded using binaural audio. Thus, when the player hears these voices, they move from the left speaker/earphone to the right, alternating in volume and distance. This is meant to mimic the aural symptoms of schizophrenia, which has been frequently misrepresented in visual media such as film and television.

The third innovation becomes apparent during the game’s initial credits, as the first name listed is not Antoniades’ or a producer’s, but rather Paul Fletcher, a professor of Health Neuroscience from the University of Cambridge. The feature provides more details on Professor Fletcher’s role as Mental Health Advisor and elaborates on Antoniades’ determination in addressing the subject of mental illness from the rare position of factual accuracy rather than dramatic license. Indeed, the game goes so far as to differentiate the symptoms of Senua’s mental state: she has heard voices since early childhood, while the later-onset visual hallucinations that plague her in the present may be the by-product of another psychotic break or PTSD-type flashbacks from any of several traumatic events (including Dillion’s murder), sensory deprivation during her solitary journey or complicated bereavement or more. Psychiatrists will reflexively speculate about the differential diagnosis of new-onset visual hallucinosis, which could result from any number of medical etiologies, or may simply be an allusion to Celtic myth. The ambiguity adds to the game’s appeal.

As a narrative medium, video games have been alternatively praised and criticized for their attempts to discuss ‘serious’ subjects such as suicide, rape, trauma and mental illness. While some developers have grounded their fictional representations in a measure of emotional veracity, Ninja Theory’s effort here is remarkable for the extent to which the studio solicited, retained, and followed the advice of professionals in the field, and consulted advisors who suffered from similar conditions. Thus, the game aspires to a more faithful and honest depiction of an oft-stigmatized mental illness-a depiction that may yield positive effects as an educational experience, given the increasingly ubiquitous hold immersive video games have on the public. This game may also aid in the education of mental health professionals who strive to understand their patients’ perceptual, emotive and cognitive experiences as much as their neurochemistry.

Cinema’s Sinister Psychiatrists: From Caligari to Hannibal.

Psychiatry and the Cinema, Second Edition.

 Washington, DC: American Psychiatric Press, Inc.; 1999.

4. Needleman S. Video stars have fans, fortunes-and utterly baffled parents. 

https://www.wsj.com/articles/videogame-stars-have-fans-fortunesand-utterly-baffled-parents-1515085499

5. More than 150 million Americans play video games [press release]. Washington, DC: Entertainment Software Association; April 14, 2015. 

http://www.theesa.com/article/150-million-americans-play-video-games

6. Hawryluk M. Supply of psychiatrists shrinks. 

www.bendbulletin.com/home/4557462-151/supply-of-psychiatrists-shrinks

7. Young K. Video games: recreation or addiction? 

http://www.psychiatrictimes.com/adhd/adhd-associated-video-game-addiction

8. Fuerst ML. ADHD associated with video game addiction. 

. May 9, 2016. Accessed February 26, 2018.

9. Wakefield J. Gaming addiction classified as disorder by WHO. 

http://www.bbc.com/news/technology-42541404

A review of the video game Hellblade: Senua’s Sacrifice and implications for psychiatry.

Lessons Learned From Mental Health Portrayals in Video Games

Amy’s 5 years in New York City had been a success. She completed college and earned an internship in a prestigious publishing house before the economy collapsed. Her bachelor of arts degree with honors brought no job prospects, however, because no one was hiring. Fortunately, her recent mental health “report card” was as good as her college transcript.

She had bipolar disorder that was largely quiescent, so much so that it was barely on the radar as graduation rolled by. She kept appointments, always remembered her medications, and never needed hospitalizations, unlike family members whose severe symptoms reportedly worsened with alcohol overuse. Only 2 challenges remained: she needed a job and an income, and she wanted to tame her trichotillomania (TTM). Her TTM worsened under stress and never fully responded to behavioral techniques, such as habit reversal therapy recommended by experts.

Medications had little effect on her hair-pulling. Amy’s struggles were not surprising, considering the difficulty of treating TTM. A favorite symptom-substitution behavioral technique-plucking orthodontic rubber bands fitted to the fingertips-was no help. Nor was the hand-held rubber band ball sold by office supply stores. High doses of serotonin reuptake inhibitors or any dose of clomipramine or fluvoxamine brought more adverse effects than positive effects. Anticonvulsants that treated her bipolar disorder had no effect on her TTM, even though they kept her mood swings in check. Naltrexone helped a little but hurt her stomach a lot.

Drawing Venn diagrams to show how TTM symptoms overlap with OCD, impulse control disorder, anxiety, and even addiction explained her symptoms without offering relief. And Amy needed relief, especially if she returned to the family business while waiting out the financial storm. It was immaterial that there might be more than a chance association between bipolar disorder and TTM.

From experience, she knew that her TTM surged in response to her emotionally explosive family. Family dinners literally made her “pull her hair out,” as the saying goes. She had avoided visits home, until economic necessity left her little choice.

Superficially, Amy’s home sounded picture perfect. Flower gardens flourished, as often occurs in the South. Yet Amy insisted that the occupants of the picture-perfect house were far from perfect. She said that she came from a hybrid of Tennessee Williams and William Faulkner.

Her mention of gardens got me to thinking, not just about fragrant flowers but also about “symptom substitution,” an old-time favorite of behavioral psychologists. Which activities most resemble hair-pulling? Weeding, for one. I had heard anecdotal stories about persons with TTM who like to weed-while most people, dedicated gardeners included, dread this task. So, I suggested that Amy try weeding, adding disclaimers that I did not know of case-controlled studies to support this approach, but at least it might beautify the family’s flowerbeds.

Instead of laughing, Amy recollected her grandfather, the mild-mannered member of the clan who kept to himself. He tended his garden and avoided the arguments that consumed his siblings. Skeptical at first, she said that she would give it a try if for no other reason than to avoid more medication adverse effects or arguments with managed care companies about coverage.

Before moving home permanently, Amy returned for a weekend to attend her brother’s birthday celebration. She scheduled an extra appointment before she left, fearing that another family fight would send her reeling. Yet that did not happen this time around. On her return, she reported that she spent time weeding the garden and next to no time pulling out her hair.

Admittedly, retreating to the garden instead of sitting through suppertime shouting matches is a respite from stress, weeding or no weeding. She had a polite excuse to escape explosive sibs who lowered their lithium and upped their alcohol. Gardening with her grandfather, the most benign family member, also offered support. The “experiment” succeeded, perhaps for all the reasons mentioned above. With no time or money for case-controlled studies to “weed out” placebo effects or halo effects or other variables, we agreed to make do with what worked, especially since there seemed to be no downside to applying this approach while she transitioned treatment.

I subsequently found a surprising number of scholarly (and not so scholarly) reports on the subject. Amazon sells at least a dozen books about horticulture therapy. The history of medicine literature offers compelling centuries-old anecdotes. Benjamin Rush (1749-1813), the “Father of American Psychiatry,” signer of the Declaration of Independence, and namesake of Rush Medical College in Chicago, recommended “horticulture therapy” to his patients and to prison inmates.

 Rush wrote the first systematic textbook on mental diseases in America.

In addition to anecdotes, studies show that growing plants improves moods of nursing home and hospice residents. Of course, looking forward to just about anything improves mood, anywhere. Unfortunately, gardening does not guarantee 100% success, and grave disappointments may follow months of hard work.

Data documenting horticulture therapy’s benefits for persons with autism spectrum disorder are also impressive, but not entirely unexpected, since gardening employs non-verbal skills and circumvents direct human interaction. It seems that rehabilitation journals publish more articles on this subject than psychiatry journals.

Her mention of gardens got me to thinking, not just about fragrant flowers but also about “symptom substitution,” an old-time favorite of behavioral psychologists. Which activities most resemble hair-pulling? Weeding, for one.

Author | Sharon Packer, MD

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