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(This is the first of a 2-part series. The next article will discuss the spectrum nature of treatment decisions and how this can improve the process of shared decision-making with patients—Ed.)

Bipolar disorder (BD) is a categorical diagnosis according to the DSM—

. But bipolarity is increasingly recognized to be a spectrum phenomenon that warrants dimensional diagnosis—eg, per the chairman of the DSM-5,

 the patient has bipolar disorder, the head of the STEP-BD research program suggested in 2005 that we should ask, “

 Why then are we still using the DSM as though it were the only way to think diagnostically? Here is 1 reason: categorization bias.

 presents an example of bipolarity as a spectrum phenomenon. It includes structured interview results from 641 primary care patients referred for psychiatric consultation,

 using the CIDI 3.0—a bipolar assessment tool

 from the World Health Organization that has been used in primary care research.

The CIDI asks 2 questions about euphoria and irritability. If either is endorsed, another screening question asks whether this is episodic. If that too is endorsed, the full questionnaire

 is administered, containing additional questions about manic symptoms. The 

 shows the frequency of each score, from 0 to 9.

As you can see, among these patients—who were referred primarily for depression or anxiety problems—most scored 0 on the CIDI. But among the rest of the patients, scores created a bell-shaped curve. In this study, the same phenomenon was seen

 with additional questions about bipolar markers: family history, age of onset of depression, course of illness, and response to previous treatments. All these indicators of bipolarity lie on a spectrum from absent to fully present. There is no step-up—no obvious place to put a categorical diagnostic cut-off (including at 7 

 responses, which is the criterion used in previous research

Likewise, in clinical experience, hypomania/mania is also dimensional. Manic symptoms can present at any intensity. Some patients have the full experience, for which DSM criteria work well: That is bipolar I. Some patients have obvious hypomania that is observable to others: That is DSM-level bipolar II. But patients describe myriad variations of “up” symptoms.

If you have seen lots of patients with depression, you will have also observed the subtle forms of hypomania: a little more talkative than usual, a little more flamboyant, enthusiastic, confident. Needing less sleep, more motivated, energized. More willing to spend money. This state can accelerate into overt hypomania or mania, or just subside—or collapse into depression or become admixed with it. There are no cut-offs between such states in clinical experience—nor in patients’ experience. A brilliant example is presented in a newly published memoir, 

BrainStorm: From Broken to Blessed on the Bipolar Spectrum

 a bipolar II parallel to Kay Jamison, PhD’s, descriptions of the full manic-depressive experience.

If bipolarity is a dimensional phenomenon, why is the DSM still our primary diagnostic approach to mood disorders? Categorical and dimensional approaches can be used simultaneously,

 but multiple cognitive biases incline psychiatry toward the DSM (

recently examined another that is relevant to psychiatric diagnosis: categorization bias.

 (This analysis is replete with examples of the serious costs associated with this bias in the financial world.)

According to 2 marketing professors, our natural tendency to draw lines and create categories has 4 downsides:

1. Compression: One can lose sight of the many variations that exist within the category.

2. Amplification: One can exaggerate differences across category boundaries.

3. Discrimination: One can favor certain categories over others, insufficiently attending to other categories.

4. Fossilization: To quote John Maynard Keynes, “The difficulty lies not in the new ideas, but in escaping from the old ones.”

To these we should add 1 more crucial downside of categorization bias: 

, or the tendency to make a thing out of a label. As Kenneth S. Kendler, MD, a scholar of psychiatric diagnosis, put it, “our field has undergone a ‘conceptual creep’ in which our criteria have mistakenly become our disorder.”

 In his article entitled “The Problem of Reification,” former National Institute of Mental Health (NIMH) Director Steven E. Hyman, MD, suggested that categorization creates “epistemic blinders” that impede progress toward valid diagnoses.

An article in the American Medical Association’s 

 asserts that, like all humans, health professionals are subject to cognitive biases, and we must recognize the costs of these cognitive biases and the potential benefits of combating them.

 The article cites a clinical decision-making specialist who has suggested using “cognitive forcing” to reduce errors.

 means conscious consideration of an alternative diagnosis—or, in this context, an alternative diagnostic perspective (eg, dimensional in addition to categorical).

For example, suppose your next patient, Ms Smith, presents with depression, anxiety, and a history of trauma. Posttraumatic stress disorder (PTSD) is an obvious potential diagnosis. Diagnostic forcing would entail consideration of alternative diagnoses, such as major depression with mixed features. Nosologic forcing would invite letting go of distinctions between trauma, mood, and anxiety disorders. 

Does this mean “farewell to differential diagnosis,” as one expert lamented

 following a description of the complexity of mixed states?

 Not entirely. One can think both categorically 

dimensionally (perhaps not at the same moment):

a) What is the diagnosis? Does the patient meet DSM criteria for PTSD?

b) How mixed is this depression? How traumatic was the experience?

Perhaps the latter questions will not help a busy clinician. Aren’t categories better for guiding clinical decisions? As a clinician myself, I strongly disagree, but we can all easily agree that we want what is best for Ms Smith. If it helps her to say yes or no to a diagnosis of PTSD, fine. For example, a formal diagnosis might make it easier to strongly recommend psychotherapy as first-line treatment for PTSD, rather than an antidepressant. On the other hand, if Ms Smith struggles with the label; if her trauma was not profound and she does not have pronounced avoidance and intrusive recall; and if she has a first-degree relative with a clearly established diagnosis of bipolar I—then perhaps then perhaps inviting her to learn more about subthreshold bipolarity and its treatment options is the next step. I created a series of 6 5-minute videos for this purpose.

In the next segment of this 2-part series on psychiatric diagnosis, I will suggest that treatment decisions lie on a continuum just as psychiatric diagnoses do. Contriving diagnostic cut-offs does not facilitate these decisions—indeed, it can interfere with them. Instead, acknowledging the spectrum nature of treatment decisions can improve the process of shared decision-making with patients. I suspect this is what many of us are really doing even while operating under the DSM roof.

is research editor at the Psychopharmacology Institute; emeritus faculty at Samaritan Mental Health in Corvallis, Oregon; and founder of 

. He is the bipolar disorder section editor for 

Bipolar disorder diagnosis: challenges and future directions

2. Angst J, Merikangas KR, Cui L, et al. 

Bipolar spectrum in major depressive disorders

Bipolar spectrum disorder masquerading as treatment resistant unipolar depression

The Bipolarity Index as a tool for assessment and creating rapport: an expert interview with Gary Sachs, MD

5. Phelps J, Bale J, Squires III K, et al. 

Bipolarity in a collaborative care model variation: detection, prevalence, and outcomes

6. Kessler RC, Akiskal HS, Angst J, et al. 

Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0

7. Cerimele JM, Chan YF, Chwastiak LA, et al. 

Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder

ased Screening Scale for Bipolar Spectrum Disorders

. University of Washington Advancing Integrated Mental Health Solutions Center.

Brainstorm: From Broken to Blessed on the Bipolar Spectrum

12. The psychiatrist’s list of cognitive biases. Psych Scene. Accessed January 26, 2022. 

https://psychscene.com/psychiatrists-list-cognitive-biases/

13. de Langhe B, Fernbach P. The dangers of categorical thinking. 

https://hbr.org/2019/09/the-dangers-of-categorical-thinking

The phenomenology of major depression and the representativeness and nature of DSM criteria

The diagnosis of mental disorders: the problem of reification

The importance of cognitive errors in diagnosis and strategies to minimize them

Mixed depression: a farewell to differential diagnosis?

19. Perugi G, Angst J, Azorin JM, et al. 

Mixed features in patients with a major depressive episode: the BRIDGE-II-MIX study

https://www.youtube.com/playlist?list=PL1lTWq-FqdPIBYwhJb8j5NCMMTg0lxTVI

Exploring cognitive biases toward the DSM and their avoidable effects on treatment decisions.

Why Use the DSM When It Is Inaccurate? Cognitive Biases and Solutions

A study found that racial and ethnic minority children experienced increased rates of anxiety, depression, and social risks during the first year of the COVID-19 pandemic.

The study, led by researchers from Boston Medical Center (BMC),

 included 168 caregivers of racially and ethnically diverse children between ages 5 and 11 who had completed screenings for behavioral and emotional risks as part of a well visit at an urban, safety-net pediatric primary care practice before the onset of the pandemic. The pre-pandemic visits occurred between September 2019 and February 2020, and participants were reassessed mid-pandemic between August 2020 and January 2021.

 Of the participating caregivers, 54% identified as non-Hispanic Black and 29% as Hispanic, and 22% did not speak English. Study visits were conducted in 3 languages: English (79%), Haitian Creole (16%), and Spanish (5%). The Pediatric Symptom Checklist (PSC) was used to measure behavioral and emotional symptoms of anxiety and depression, including attention and internalization and externalization of symptoms. Results showed that the rate of both depression and anxiety rose from 5% pre-pandemic to 18% mid-pandemic.

According to the researchers, the aim of the study was to compare negative symptoms of mental health among urban, racially and ethnically diverse children before and during the pandemic.

 This study is also among the first to include both pre- and mid-pandemic data in research involving urban children.

 “Our fear is that the pandemic has led to a 

 for both caregivers and children following the incredible stressors that COVID-19 has put on families,” said Andrea Spencer, MD, lead author of the study, in a press release. “We specifically looked at our urban and diverse patient population who are already at higher psychosocial risk and also most susceptible to the impacts of the pandemic, therefore raising particular concern for their mental health.”

To this end, the study also analyzed the children and caregivers’ social risk and unmet social needs—including food and housing insecurity, unemployment, difficulty paying bills, and difficulty with dependent care and transportation—pre- and mid-pandemic using BMC’s THRIVE screening tool.

 Higher social risks were reported, with all THRIVE items except for difficulty with transportation being ranked as significantly more prevalent mid-pandemic compared to pre-pandemic. For example, 50% of participants reported food insecurity mid-pandemic compared to 16% pre-pandemic.

“These findings point to the critical need for public health efforts to mitigate the psychosocial effects of the pandemic on racial and ethnic minority children and communities while searching for solutions to support the increased demand,” said Spencer, who is also an adult, child, and adolescent psychiatrist at BMC and an assistant professor of psychiatry at Boston University School of Medicine, in a press release. “We need new or expanded community-based, school-based, family-based, and trauma-informed treatment and prevention programs to reach the most affected families.”

New study finds COVID-19 pandemic exacerbated anxiety and depression in racial and ethnic minority children

. News Release. Boston Medical Center. December 8, 2021. Accessed December 13, 2021.

2. Spencer AE, Oblath R, Dayal R, et al. 

Changes in psychosocial functioning among urban, school-age children during the COVID-19 pandemic

Research also shows increased prevalence of social risks and unmet social needs.

Higher Rates of Anxiety, Depression Reported Among Minority Children

According to a new nationally representative study, 1 in 4 adults aged 20 to 39 with attention deficit hyperactivity disorder (ADHD) have 

 (GAD), and individuals with ADHD are 4 times more likely to have GAD at some point in their life, when compared to those without 

Other relevant factors, such as sociodemographics, adverse childhood experiences, and a lifetime history of substance use disorders and major depressive disorders were controlled; individuals with ADHD were still more than twice as likely to have GAD.

“These findings underline how vulnerable adults with 

 are to generalized anxiety disorders. There are many studies linking adult ADHD to depression and suicidality, but less attention has been paid to generalized activity disorders and other adverse outcomes across the life course,” lead author Esme Fuller-Thomson said. Fuller-Thomson is a professor at the University of Toronto’s Factor-Inwentash Faculty of Social Work and Director of the Institute for Life Course & Aging.

Investigators examined a nationally representative sample of 6898 respondents from the Canadian Community Health Survey-Mental Health aged 20 to 39. Of those surveyed, 272 had ADHD and 682 had GAD. They found female respondents with ADHD had nearly 5 times higher odds of GAD, even after controlling for other covariates.

“ADHD has been severely underdiagnosed and undertreated in girls and women,” said coauthor Andie MacNeil, a Master of Social Work graduate from the University of Toronto. “These findings suggest that women with ADHD may also be more susceptible to experiencing anxiety, emphasizing the need for greater support for women with ADHD.”

Additionally, adults who had experienced adverse childhood experiences such as childhood sexual or physical abuse or chronic parental 

 were 3 times more likely to have GAD, and 60% of those with ADHD who had anxiety disorders had experienced at least 1 of these adverse childhood experiences.

Having an income below $40,000, having fewer close relationships, and having a lifetime history of major depressive disorder were amongst the other factors associated with GAD among adults with ADHD. The odds of GAD for individuals with ADHD were 6-fold if they had a lifetime history of major depressive disorder.

“These results highlight the importance of screening for mental illness and addressing depressive symptoms when providing support to those with ADHD,” said Lauren Carrique, a recent graduate of University of Toronto's MSW program who is a social worker at Toronto General Hospital. “Individuals experiencing ADHD, GAD, and depression are a particularly vulnerable subgroup that may need targeted outreach by health professionals.”

1. Fuller-Thomson E, Carrique L, MacNeil A. 

Generalized anxiety disorder among adults with attention deficit hyperactivity disorder.

2. University of Toronto. Adults with ADHD four times more likely to have generalized anxiety disorder. News release. November 18, 2021. Accessed December 13, 2021. 

https://www.eurekalert.org/news-releases/935302

Individuals with ADHD are 4 times more likely to have generalized anxiety disorder at some point in their life. 

ADHD and Generalized Anxiety Disorder: Hand in Hand? 

From seasonal affective disorder to 24/7 contact with visiting family to finding the perfect gifts, the holidays can be a minefield of stressful situations for patients! The following are 10 tips to share with patients so they not only survive the holidays, but remember to thrive during this hectic time.

For patients to get the most out of their interactions with family this year, encourage them to share specific stories from their lives. For instance, advise them that instead of saying, “life is good,” patients should tell family and friends about how a walk in the snow reminded them of peace and beauty, or how they felt relief after finding a meaningful gift for their partner after weeks of searching. Encourage them to use emotional words to help them tune into what is going on in their world and to build connections.

Post-pandemic interactions can be difficult and maybe even awkward, especially for patients with social anxiety disorder. Have your patient think of someone with whom they want to connect, and then reach out to that person to ask for advice: perhaps about cooking, ideas for gifts, outfits for certain occasions, etc. The next step for your patient is for them to bring their advisor along on the journey with follow-up conversations. Have your patient tell their advisors how the cooking experiment went, what the gift recipients thought, how the outfit looked, etc.

Help patients truly connect with others by giving their full attention and engaging. Have them ask specific questions. For instance, encourage patients to use open-ended questions such as “how do you decide what to buy people for gifts?” Or even something silly like “what do you think about the new Starbucks Christmas cup patterns? Which is your favorite?” Show them how asking specific open-ended questions is better than asking “how’s it going?” A quick internet search for “open-ended conversation starters” might be helpful for them.

If patients need a break from family, yet have nowhere to take such a break, encourage them to engage in “parallel play.” Parallel play is commonly employed when children engage in activities near each other, but not in direct contact or with each other, and this strategy can also be used by adults. An example might be reading a book in the kitchen while their family member is cooking. Advise patients that spending time with family can be a balance of direct interaction and parallel play to help patients limit social burnout. Read more about different types of play 

Do some of your patients tend to get into difficult situations more when they have had some drinks? Are tired? Have not exercised? Are hungry? Ask patients to think about these vulnerability factors and how they can do their best to mitigate them. By considering these factors, patients will be set up for success and be able to handle situations more peacefully and with ease. Read more about vulnerability factors 

After patients have taken time to mitigate vulnerability factors, ask them what they can do to add strengthening factors to their holiday plans. Have patients think about what they can realistically take care of themselves when their regular schedule is not in effect, and then choose to do a meditation challenge, go for a walk a few times per week, or something similar. Advise them to pick something easy that they know they can achieve.

Sometimes it is difficult, or impossible, for individuals to understand a perspective or feeling that differs from their own, and patients may be especially reminded of this during the holidays. If patients are interacting with people who are not able or willing to listen to, understand, or validate their feelings, advise them to plan to satiate those needs elsewhere by talking to you, a friend, or a family member who will validate. Remind patients that writing in a journal may be useful.

8) Give yourself credit for the small things

When life is stressful, even the little things can be difficult, particularly for patients with anxiety and stress disorders. Encourage patients to take time to personally acknowledge themselves for all the things they have accomplished, no matter how big or small. Tell them that this is a self-gratitude practice, and it can change their outlook immensely and help them build self-esteem.

9)Plan some real vacation time in the future

The December holiday season might present with time off work, but is it really rest for a lot of patients? Encourage patients to plan a vacation for January or February: a short weekend getaway, or a staycation in bed with some good TV shows. Knowing there is time to actually relax right around the corner can help patients get through the hustle and bustle of December.

Remind patients that they cannot control if their flight home is delayed, or if their family members hound them about their love life. When patients feel like so many things in life are up in the air, advise them to focus on what they can control: their reaction and their attitude. A good example of this is Viktor Frankl, MD, PhD, whose discussion on how he believes his attitude helped him survive concentration camps during World War II appears in 

 is an author, counsellor, and teacher. Her book, 

The Conversation Guide: How to Communicate, Set Boundaries, and Be Understood

Are your patients feeling stressed out? Here are 10 tips to share with them for a less stressful holiday season.

Helping Patients Thrive This Holiday Season

Tales From the Clinic: The Art of Psychiatry

 in a young man who otherwise presents as the perfect patient who is treatment adherent. Individuals with anxiety suffer pervasive impairment in everyday life, and treatment is often not fully effective. Somatic and physical comorbidities typically complicate clinical anxiety presentation, but there are exciting conceptual and treatment considerations in this field worth highlighting, including novel concepts such as gut microbiome influence on anxiety disorders, high body awareness, and somatosensory amplification dimensions.

“Mr West,” aged 30 years, is a well-groomed, soft-spoken man who presents to the clinic for anxiety. He gives you access to extensive medical records spanning the past 8 years, during which time he has received treatment for generalized anxiety. He complains of intense anxiety, fatigue, and hopelessness on a daily basis. According to the patient, his symptoms are comparable with a “living hell on earth.” Mr West had a history of illicit drug use—stimulant use—for a brief period in his early 20s but has not relapsed since. He describes a rich cultural background with life in different countries (accompanying his family as they moved), as well as medications and illicit substance use that are unfamiliar to you, prompting some frantic internet searching. At one point, he mentions fenethylline, which he felt had helped him “fight being tired,” but says he has not used it in about 7 years.

To tackle anxiety symptoms, he has been on a plethora of medications, all of which had adverse effects (AEs) and were discontinued. He has been fully adherent to all treatment recommendations, has never missed any of his appointments, and produces multiple negative urine drug screens. He is diligent in attending all of his psychotherapy sessions as well. Despite his symptoms, he maintains a job, pays his bills with no issues, and dedicates a lot of attention to his ailing mother. However, you note upon history-taking that he has no close friends and has not had romantic involvements, which he attributes to his symptoms: “I’m just not OK, doc, I tell you.” The patient is followed for 6 years.

The first year is spent establishing rapport and getting to know the patient. Monthly visits follow the same pattern: The patient profusely describes beliefs of having “something wrong” that is not properly diagnosed. He asks for brain imaging and cortisol levels, and he brings literature showing sustained brain damage from substance use. Attempts at reassurance often fall flat and are of limited effectiveness, but, as he is a model patient otherwise, you keep trying. Attempts at cognitive behavioral therapy produce limited positive effects, and the patient frequently comments, “This is too simple for me.”

You believe, based on his description, that he has irritable bowel syndrome (IBS), but he has not received specialized care. He reports that the fatigue and anxiety correlate with his gastrointestinal (GI) symptoms. He does slightly better when he is able to wake up between 9 and 10 AM; when he has to awaken earlier (ie, for work), he experiences loose bowels, burping, indigestion, and nausea.

At the end of year 1, Mr West tells you he has to seek “more care. I have to get answers—something is wrong with me.” He moves to another country in the hopes of more thorough treatment. He returns in 2 years, and you are surprised to see his name appear on your clinic roster.

Out of the blue, Mr West returns, bringing with him a panoply of medical test results, all of which are negative, as expected. He continues to report that he feels he has a terrible missed diagnosis, but he is less forceful in that statement and more amenable to reassurance. He continues to report daily GI symptoms and fatigue that severely limit his social interactions. Mr West mentions 2 medications that have been somewhat helpful, both of which you had to Google: Motival (fluphenazine and nortriptyline) and Deanxit (melitracen and flupentixol). He continues to take fluoxetine, as he has done for years.

In year 5, Mr West agrees to go to a GI specialty clinic. As a result, he changes his diet drastically, with partial anxiety improvement. However, he continues to complain of daily tinnitus. He continues to use medications not available in the United States. As you look for alternatives available here, you start him on lisdexamfetamine, which he feels is helpful with fatigue. At most sessions, however, he still reports his life is hell.

Generalized anxiety disorder (GAD) is characterized by exaggerated tension, worrying, and nervousness about daily life events. GAD is often a lifelong disease, causing significant impairment.

 The prevalence of anxiety disorders in the United States is approximately 10% in adults

 Symptoms include restlessness, irritability, and fatigue, with overthinking and consideration of worst-case scenarios predominating cognitive schemas of GAD patients. Patients with anxiety frequently have GI symptoms (about 18% of individuals).

 Individuals with IBS are twice as likely to have physical fatigue, GI-specific anxiety, perceived stress, pain catastrophizing, and trait anxiety.

 More severe mental symptoms and distress are associated with IBS severity, and vice versa.

Computational modeling confirms what clinicians already know: Evidence suggests that individuals with psychiatric illness such as depression and anxiety misread and misinterpret visceral information compared with healthy controls.

 As a result, a patient with anxiety may feel a benign physical symptom very acutely and interpret the symptom in a catastrophizing way, instead of dismissing it as normal. A relevant concept is body awareness.

 Somatic internal perceptions—which are often preconscious—involve interoception and proprioception, and these neurological paths can be altered or damaged by disease processes. Those sensations arrive to consciousness and are interpreted by the individual, with an assigned explanation for the sensation in question. Thus, when dealing with patients who have anxiety and comorbid somatic symptomatology, the clinician may be faced with somatosensory amplification and potential exaggerated or maladaptive interpretation of bodily symptoms. This is a budding research field, with further definitions and clarification of terminology needed.

Patients with anxiety disorders have a tendency to avoid making changes to their medications, as trying new things and making alterations to their routine makes them apprehensive. This may make them more likely to report AEs after trying new treatment options, which could explain why this patient had low symptomatic tolerance to many of the attempted alternate treatments. It is important to give patients with anxiety disorders ample time to adapt to changes in their treatment regimens. Forcing change, or switching too rapidly, may be counterproductive and could create apprehension, possibly worsening anxiety and creating a barrier to adherence. Slow dosing and upward titration are essential to avoid AEs and a mental aversive reaction to treatment.

It is sometimes difficult to unravel all aspects of a clinical case within a few visits. Intrinsic personality aspects can underlie much of the behaviors we label as anxiety; this includes neuroticism.

 For example, the patient’s mother had possible paranoid traits, chronically thinking that the neighbors made noise to bother her. Therefore, paranoia in this patient may be part of the family’s disposition, further explaining response to agents containing low-dose antipsychotics. Anxiety and depression tend to be highly comorbid, so it should be a priority to screen for and treat both as part of the treatment plan.

For anxiety disorders, guidelines usually recommend a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor as first-line treatment,

 with augmenting agents such as the azapirones (like buspirone) and antihistamines (like hydroxyzine). Only 1 antipsychotic—trifluoperazine—is approved by the US Food and Drug Administration for use in treating anxiety, although off-label use of multiple antipsychotic agents is very prevalent in clinical practice.

 GABAergic agents are also profusely used with some success. Serotonergic mechanisms are important, given the presence of serotonin receptors throughout the gut and the known dysregulation of serotonergic afferent neural signals in functional GI disorders.

In terms of dosing, clinicians anecdotally note that some patients with anxiety seem to require multiple doses of medications, even for those agents that can be dosed once daily. This is another clinical correlate of anxiety that may be unrelated to treatment, but more linked to patient satisfaction, as systematic reviews show that most classes of psychotropics can be dosed once daily without a decrease in efficacy.

In this case, the patient did well on Deanxit and Motival, each of which combines an antipsychotic medication and an antidepressant medication. A positive response to Deanxit and sertraline vs sertraline alone has been shown in patients with chronic somatic diseases, so this could explain the success of the regimen in this patient.

 Mr West continued to be stressed about having to ask people to get his medication when they travel and wanted a substitute. He achieved the best results with chlorpromazine, which is chemically similar to the flupentixol in Deanxit.

Psychotherapeutic interventions are crucial in anxiety disorders in general, not just GAD. Symptomatic improvements of more than 50% can be achieved with cognitive-behavioral therapies, meta-cognitive therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy.

Lastly, lifestyle factors such as exercise (eg, running) are underemphasized and underused modalities of treatment that have shown to be helpful in decreasing depression and anxiety,

 and they should be strongly encouraged. Diet modification, whether the patient has GI symptoms or not, is also relevant, as multiple studies now highlight the role of gut microbiome in depression/anxiety disorders.

 is a volunteer research fellow in the Department of Psychiatry at the American University of Beirut. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

Symptoms of depression, anxiety, and post-traumatic stress disorder and their relationship to health-related behaviors in over 12,000 US military personnel: bi-directional associations

2. Ries Merikangas K, He J-P, Burstein M, et al. 

Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A)

3. Mussell M, Kroenke K, Spitzer RL, et al. 

Gastrointestinal symptoms in primary care: prevalence and association with depression and anxiety

4. Midenfjord I, Borg A, Törnblom H, Simrén M. 

Cumulative effect of psychological alterations on gastrointestinal symptom severity in irritable bowel syndrome

A cross-sectional study of gastrointestinal symptoms, depressive symptoms and trait anxiety in young adults

6. Smith R, Kuplicki R, Feinstein J, et al; Tulsa 1000 Investigators. 

A Bayesian computational model reveals a failure to adapt interoceptive precision estimates across depression, anxiety, eating, and substance use disorders

7. Mehling WE, Gopisetty V, Daubenmier J, et al. 

Body awareness: construct and self-report measures

Associations between facets and aspects of Big Five personality and affective disorders: a systematic review and best evidence synthesis

9. Penninx BWJH, Pine DS, Holmes EA, Reif A. 

10. Garakani A, Murrough JW, Freire RC, et al. 

Pharmacotherapy of anxiety disorders: current and emerging treatment options

11. Del Colle A, Israelyan N, Gross Margolis K. 

Novel aspects of enteric serotonergic signaling in health and brain-gut disease

12. Kikuchi Y, Shimomura Y, Suzuki T, et al. 

Single versus multiple daily dosing regimens of psychotropic drugs for psychiatric disorders: a systematic review and meta-analysis

Sertraline plus deanxit to treat patients with depression and anxiety in chronic somatic diseases: a randomized controlled trial

14. Apolinário-Hagen J, Drüge M, Fritsche L. 

Cognitive behavioral therapy, mindfulness-based cognitive therapy and acceptance commitment therapy for anxiety disorders: integrating traditional with digital treatment approaches

15. Vieira Pereira H, Labisa Palmeira A, Encantado J, et al. 

Systematic review of psychological and behavioral correlates of recreational running

16. Simpson CA, Diaz-Arteche C, Eliby D, et al. 

The gut microbiota in anxiety and depression – a systematic review

Why are psychotherapeutic interventions crucial in the treatment of GAD and anxiety disorders in general?

My Life is Hell, Doc. Please Help Me!

The stillbirth of twins at 7 months of pregnancy. The sudden loss of an infant 3 days before his first birthday to a freak accident at home. The loss of a 9-month-old to sudden infant death syndrome (SIDS). The fourth miscarriage after 3 months of pregnancy with no clear reason why.

These tragic and unimaginable losses can complicate ongoing psychiatric care, not only in terms of identifying what is normal grief versus an abnormal depressive disorder, but also in terms of the very normal human response we all have watching another human suffer a very significant loss. For many psychiatrists and mental health professionals, it is also unclear how to best manage these struggles and losses. We talk about grief and counseling; we talk about groups; and we make referrals. But do any of us really know what to expect and what approach is associated with the best outcomes? And what happens when these 

 again, as many do, often within months of their loss?

Miscarriage is defined as the loss of a pregnancy before 20 weeks, and stillbirth is the loss after 20 weeks. It is estimated that 11% to 16% of pregnancies end in 

 in women who knew they were pregnant, though this is likely an underestimate due to underreporting.

 Of women who experience a miscarriage, 50% to 80% will become pregnant again.

 Stillbirth occurs in 1 in 160 births, which amounts to 24,000 stillborn babies each year in the US.

 Infant mortality is the death of an infant before 1 year of age. In the US in 2019, the infant mortality rate was 5.6 deaths per 1000 live births.

Unlike postpartum depression, which the American College of Obstetricians and Gynecologists has identified as a pressing issue for pregnant women requiring a systematic and simple screening tool in the postpartum time period,

 no such protocol following miscarriage or stillbirth has been established. Because of this, epidemiological studies of psychological distress following perinatal loss are still in their infancy with small cohorts, and therefore firm conclusions regarding prevalence rates of psychiatric illness and symptoms are difficult to draw.

According to a small number of standardized studies, grief, depression, and/or anxiety are the most common psychological reactions following miscarriage.

 Grief is seen shortly after 40% of miscarriages and can represent a normal adaptive response, but it can also go on to develop into pathological grief characterized by despair, strong feelings of worthlessness, hopelessness, and difficulty engaging with normal life. In the early weeks of loss, 36% of women were found to have moderate to severe depressive symptoms and 10% to 50% go on to meet criteria for major depressive disorder. Risks for post-miscarriage emotional distress include later gestational age, miscarriage of planned pregnancy, prior struggles with infertility, having no living children, poor social support, and a history of poor coping.

Loss and suffering can be hard for both patient and provider. Here’s what we know, what we need to learn, and how to protect yourself as a clinician. 

Anxiety & Stress Disorders

Why Use the DSM When It Is Inaccurate? Cognitive Biases and Solutions

Higher Rates of Anxiety, Depression Reported Among Minority Children

ADHD and Generalized Anxiety Disorder: Hand in Hand?

Helping Patients Thrive This Holiday Season

My Life is Hell, Doc. Please Help Me!

The Unimaginable: Pregnancy and Infant Loss in Psychiatric Practice

New Investigational Social Anxiety Disorder Drug Differentiates Mechanism of Action

The Cognitive Benefits of Matcha

Tackling Reentry Anxiety: Strategies for Coping

5 Personality Traits of Olympic Athletes