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Read my newest article on Personality Disorders here: https://www.drmichaelperrotti.com/wp-content/uploads/2020/10/Personality-Disorders-Article-1.pdf
Listen to the Podcast https://drmichaelperrotti.buzzsprout.com/1022650/3761813-finding-sanity-in-an-insane-world-dr-michael-perrotti
Dr. Perrotti is a Clinical and Forensic Neuropsychologist and Expert Witness with extensive court experience in Civil, Criminal and Family Law matters. He currently maintains a private clinical and forensic neuropsychology practice and is currently a fieldwork supervisor for UCLA interns in the psychology program. He has coordinated hundreds of evaluations for the courts, plaintiffs, and defense counsel in personal injury, assessment of pain and suffering, workplace issues, Traumatic Brain Injury, assessment of child sexual abuse accusations, PTSD, false confession, and eyewitness ID. Dr. Perrotti is an Independent Medical Examiner for the State of California and routinely conducts (Independent Medical Examinations) IMEs for the plaintiff and defense. Central to his evaluations are objectivity, adherence to ethical guidelines, and best practice standards and findings based on evidence-based research. He is a regular presenter of Peer-Reviewed papers to forensic psychologists at the American College of Forensic Psychology. He has also served as an expert witness for the Attorney General of the State of California in Standard of Care cases as well as administrative law matters. He is able to assist in detecting malingering and suboptimal effort on psychological tests taken by litigants.
He also has testified in child sexual abuse cases wherein Gold Standard child investigative interview protocols are not followed. He has presented testimony to juries on childhood memory and false memory syndrome. He has served as a rebuttal witness and has testified on other neuropsychologist’s assessments and reports. He has presented research to juries on false memory, suggestibility, child memory, and child investigative interview protocols best practice standards. He is certified by LA County Superior Court in neuropsychology, false confessions and eyewitness ID. He has conducted neuropsychological assessments on veterans for the US Military Command. He also is an Expert Medical Reviewer and opines on the employability of litigants as well as functional capacity.
Dr. Perrotti is also a neuropsychologist. He conducts comprehensive neuropsychological assessments including brain injury, neurodegenerative diseases, and assessment of functional capacity. In other words, he’s a big deal.
The title for today’s podcast is: Finding a sane space in an insane world.
Today’s Podcast is on managing stress, anxiety, and depression with COVID-19. New research on neuropsychology.
“Hello Dr. Perrotti, how are you doing today?”
“Doing well, thank you.”
“So today, a lot of people are dealing stress with anxiety, as well as depression due to COVID-19 and you are in the process of writing a paper/article on the topic, can you give us an update of what you are working on right now?”
“Well right now I’m working on and really concerned about the effects, specifically the psychological effects on people during the stay at home orders in place. Of course, stress affects physical health, such as causing cardiac arrest and other physical problems. However, on the bright side, the governor is moving step-by-step towards a healthy point and move towards opening up offices and other retail businesses, which in turn is good since this has been terrible for the economy. I think the governor is a very cautious person, which is a good thing, in terms of health and safety. Unfortunately, there’s a lot of people who are great office workers and great at working in a team and now are currently at home working in fear, saying “We can’t go back to the office.” While some people are saying, “I love working at home.” I think what we’re talking about here is understandable that COVID-19 is causing a lot of this fear, and I think some of it is has been exaggerated by the media and of course, when you’re afraid or anxious about something, it’s more reinforcing to avoid approaching what you’re anxious about.”
“The first step is recognizing the paralyzing effects of fear increases isolation, so for some people it’s more comfortable for them to stay at home. So the answer to this is to embrace safety guidelines and good sense and good judgment, to embrace CDC guidelines such as social distancing, sanitizing surfaces, and screening patients for symptoms. I also find it interesting that some professionals in these medical professions are doing everything remotely and avoiding face-to-face visits. There’s nothing that the government says that indicates the need for this. Governor Newsom in the very beginning, for example, designated medical health providers as essential workers, meaning they could go into the office. Yet, there are some providers doing remote therapy, remote assessment, which sounds horrible, because some of it is not standardized. So, people should stay in step with what we are seeing, which is taking gradual steps, and that’s the only way for this to work in beating this fear.”
“Thank you for that Dr. Perrotti, you mentioned that employees are gradually going back to work in the office, are your employees currently working in the office at this moment?”
“How was that transitioning from the non-COVID era to the COVID era with your employees?”
“Well it’s working out well, we use social distancing protocols, sanitizing surfaces, and we only have one patient at a time waiting, screening for symptoms, and this has been currently working quite well. Actually, the majority of patients prefer to come for a face-to-face visit, and probably less than 1% do not feel comfortable doing that, and I tell those people they need to do what they are comfortable with and tell those people that it’s fine.”
“You said the title of the podcast today was “Finding a Sane Space in an Insane World” can you elaborate on that?”
“Well, I think a sane world is a place where you’re keeping step with what the government is doing. The governor is doing things step-by-step in phases, he’s opening beaches, he’s eventually going to be opening up offices so office workers can come back. That is, dealing with reality, which is being sane. Insanity is, well there are some people that I know, who told me that they haven’t left the house in two months other than two times, and actually that is increasing your vulnerability for COVID-19 more than anything. This is because you are inactive, therefore, your resistance is going to drop since you are not getting anything physical exercise, you are not going out with your peers, isolation increases which increases depression, and your self-worth is decreased since people have great impressment in their jobs. I think when you’re isolating to the extent that you aren’t even going out and getting exercise, it’s not a healthy thing.”
“You said to find a sane space, can you elaborate on ‘space’?”
“Well, humans are social animals, and I think isolating is not a good thing. I think people should get out, but follow social distancing, of course. They could even go out by themselves, like take a walk on the beach. There’s nothing prohibiting that, as long as it’s active, as long as you are active. However, there are some things that I’ve seen that I didn’t understand, like a man sitting by himself on the beach with an umbrella, and there were three police officers there. I didn’t understand why they were around him. I think also getting out and being active, and although many businesses are closed down, many of them have curbside services so you’re not exposed to the same isolation at home. It’s essential to break the chain of isolation since it causes people to lose hope; it causes people to feel helpless. So, staying active, meeting with friends, and practicing social distancing is important and that’s what we call self-care. Self-care is very important.”
“As a Doctor yourself, what kind of precautions would you carry out?”
“Well, I think you should put yourself in situations where you have control, where you can walk away from people. For example, when you go to a grocery store, you can maintain social distancing. I think the areas that are at risk right now are areas where you don’t have control, such as flying in airports. You don’t know what’s going to happen when you are flying and don’t know who may or may not have the disease and just sit there. I think that avoiding crowds is important, as well as following the safety measures is enough. Basically, making sure you are in control of the situation, but I don’t think you should be paralyzed by fear and stay home without going out.”
“What would you advise to the general public in regards to managing stress [and depression]?”
“Well I think it’s important to realize thoughts cross feelings, and that you have to reset your thinking. Others have much more catastrophic thinking, everything’s horrible, I can’t go out, I might get sick, etc. This is catastrophic thinking and is a thought distortion that is caused by stress and depression. Resetting your thoughts is thinking, ‘Okay, today I’m going to set some goals. I’m going to the beach, I’m going to get some groceries, I’m going to call my boss and say I don’t necessarily have to work remotely. Basically, setting goals which then leads to making progress instead of catastrophic thinking, which is not a good thing.”
“How would we replace fear?”
“I think you replace fear by relaxation exercises and thinking positive thoughts. Fear is something you approach one step at a time, like calling your boss to see what office precautions are in place, finding out more what the government is saying, and the great thing about people is that when they face their fears, they do pretty well. You need to realize you’re going to have some anxiety, but after 2-3 times, the anxiety goes away and you come out more courageous and a stronger person.”
“What is some advice that you can give to the general public?”
“Well, I think you need to do a benefit-risk analysis with your decisions. I believe there’s a great risk of staying isolated throughout a longer period of time, with the effects on your health and stress. As opposed to embracing and going on with the progress on society, with the governor opening up businesses. Certainly, there are still risks with travel and crowds not maintaining social distancing, but there’s a lot of benefits to going out and being productive. If we don’t challenge our fears as a nation and move from isolation to embracing our careers and our jobs with the comfort of these safety measures, then it won’t do any good.”
“How about the news Dr. Perrotti?”
“Well people shouldn’t binge-watch the news because it only exacerbates anxiety, and really there’s a lot of the news that’s inaccurate. For example, someone told me that the death rate is inflated because the hospitals get paid for each case that is reported, and this was fact-checked. I also think there’s not enough attention to young people who have had COVID-19, and many, many of these people recovered in the majority of cases. The other thing is to be selective about what you watch. Instead of CNN, watch other reputable sources and organizations that follow the CDC, be aware of where the source material is from, and know that the content may not be regulated. Instead, watch a happy movie, read a book, and do something you enjoy, leaving any of your fears and anxiety. People have overreacted in trying to take control of their fear at the expense of other people. This includes guarding shelves and hoarding supplies. I think people need to be aware of is very, very much influenced by politics. It’s not good to oversaturate yourself with tv news, watch something else, or use your time to do something productive like work on a project or get back to work and think about ideas to contribute to the company.”
“So you are a neuropsychologist, not many people know what that means, what exactly is neuropsychology, and what does a neuropsychologist do?”
“A neuropsychologist is a person who’s an expert in diseases of the brain, whether neurocognitive diseases like dementia and Alzheimer’s, expert in the treatment of traumatic brain injuries, seizure disorders, and anything to do with the brain and behavior because the brain affects behavior. We do testing and assessment of problems that have to do with brain dysfunction.”
“What are some neuropsychological effects of COVID-19 that you’ve seen in patients that you’ve read about or like to share about?”
“Well, there’s been some early research, however, it’s not well-developed at all, but it has to do with COVID-19 causing problems with cognitive processing and causing serotonin deficits. One problem is that you have to factor out the individual’s premorbid history if they had these problems before then it might not necessarily be caused to COVID-19.”
“You said that we are social animals, can you elaborate on that?”
“Well, I think people do their best when they can interact with each other. That’s why you have teams in an office, that’s why in our practice we have a research team. People do best sharing ideas and supporting each other, and intermingling with each other. Social interaction is healthy, productive, and makes people feel better about themselves. Like people working on COVID-19, everyone is working together for a common goal. For example, there are researchers that are communicating with Chinese and Russian researchers around the world sharing their knowledge. You cannot do that alone, people need to work together.”
“As a practitioner and scientist yourself, what are some resources that people can go to that are reliable and science-evidence based.”
“I think National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) are reliable resources.”
“How about health care professionals, are they also reliable resources?”
“That’s an interesting question, I think health care professionals that are doing a lot of work remotely, in some sense, are reinforcing the fears of patients since the majority of patients want to come in the office. These professionals that are working remotely, there’s nothing that I know of that mandates that this is how it’s supposed to be. There’s nothing that I read of that says this, rather, we are deemed as essential workers and that we should go on to work.”
“How about alleviating the fears for children?”
“Well, we are models for children. If we are fearful, the child is going to be fearful. Actually, infants, they can sense the mother’s stress and sense a stressful environment. As we go, they go, so if we become frozen in fear, they’re going to be frozen in fear. There’s a lot of research that shows on infants and children, that if adults cannot handle stress, it increases cortisol levels on children and they take longer to recover from stress because the parents take longer to recover on stress. This is transmitted and there are studies on this.”
“Final advisement dealing with stress due to COVID-19?”
“My final advisement is not to be frozen with fear. Be cautious, use safety measures that are out there for everybody and also look at what is going on with California and see the gradual phases it’s going through. If you’re not in step with that, then you’re going to question yourself if you are paralyzed in fear, because if the government is going one way and safety measures are there, and you’re going the other way then maybe you should get support, talk to another health professional to address your anxiety and fears. Certainly, COVID-19 is a terrifying thing, but the answer is not to succumb to fear and paralysis. The answer is to utilize the safety measures in place and follow the guidelines of the gradual opening of our society.”
By Michael J. Perrotti, PhD.
(Zaleski and Klein, 2018) conducted research on classifying the non-consensual sharing of images as sexual assault. Zaleski conducted a qualitative analysis on issues focused on the intersection of sexual assault and other forms of sexual violence, including revenge porn. They do note that victims do feel trauma secondary to revenge porn, viz, shame, post-traumatic stress. They note that post-assault symptoms associated with a sexual assault such as shame, self-blame, psychophysiological symptom, and hypervigilance also pertain to an individual who has had sexual images shared in a non-consensual way. Researchers at USC School of Social Work note shared symptomatology effects shared by both revenge porn and sexual assault survivors, viz, loss of trust, self-blame, anxiety, depression, suicidal ideas, and PTSD.
This author has conducted forensic and clinical assessments on patients who are victims of non-consensual sharing of sexual images. In the cases of these patients, although the target events for PTSD, viz, a victim of a violent event or witnessing a violent event are not met, these patients display many of the symptoms of PTSD, viz, hypervigilance, intrusive, repetitive thoughts, triggering of events in the environment by a discriminative stimuli. Moreover, this author posits that non-consensual sharing of intimate images is a violent act, viz, an individual’s privacy and boundaries are taken from them and distributed to others.
The author posits that this lack of fit between the DSM-V criteria for PTSD and symptomatology of victims of non-consensual image sharing and cyberbullying is due to problems with the construct validity of PTSD. (Hermosilla, 2018) relates that reliability and accurate conceptualization of the structure of PTSD is essential to the development of effective assessment and treatment. Her study on the 2010 Haiti earthquake survivors noted a lack of congruence of the DSM-V construct to a culturally diverse sample. Her study also found that the DSM-V model had the poorest relative fit for her sample compared to the anhedonia model. Similarly, there are problems with the DSM-V model of PTSD lack of capturing of the population of victims of cyberbullying and non-consensual image sharing.
(Klein, 2018) at USC posits that victims of non-consensual image sharing and cyberbullying display symptomology similar to victims of sexual assault. This author has found this to be true in clinical practice. Victims of non-consensual image sharing and cyberbullying, display symptoms of PTSD, viz, intrusive repetitive thoughts of the trauma, hypervigilance to the environment, psychophysiological symptoms, triggering of distress by discriminative stimuli in the environment, triggers of the traumatic event, shame, survivor guilt and distortion of body image. Assessment of these patients reveals similarities to sexual assault victims, viz, loss of control over the privacy of body boundaries, victimization, and exploitation. This is yet another example of a group of individuals who do not present an exact fit to the DSM-V consistent with PTSD. As with samples of refugees, and other diverse populations, the DSM-V construct of PTSD does not capture these important populations who are beset by trauma and victimization.
Practitioners are urged to consider the similarities of symptomatology and the trauma matrix between both groups of sexual assault victims and victims of cyberbullying and nonconsensual image sharing in their assessments and treatment plan. These individuals undergo significant suffering and emotional distress. First and foremost, treatment should provide support and address issues with self-esteem. Cognitive Behavioral Therapy (CBT) has been found to have positive outcomes with these populations
Hermosilla, S. (2015). Measuring Psychopathology: Exploring Construct Validity Evidence for
PTSD: A 2010 Haitian Earthquake Example (Doctoral dissertation, Columbia University Libraries).
Klein, J., & Zaleski, K. (2018). Non-Consensual Image Sharing: Revenge Pornography and Acts
of Sexual Assault. In Women’s Journey to Empowerment in the 21st Century: A
Transnational Feminist Analysis of Women’s Lives in Modern Times. Oxford University
The MSW@USC, the Online master of social work program at the University of Southern
California (January 30, 2018).
Anxiety Disorders take many forms:
Separation Anxiety Disorder
Social Anxiety Disorder (social phobia)
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Body Dysmorphic Disorder
Trichotillomania (hair pulling disorder)
Excoriation (skin- picking disorder)
Panic disorder is characterized by recurrent panic attacks that occur unexpectedly followed by worry and behavioral change, as well as avoidance. A helpful tool with this disorder is “move forward”. As an individual continues to avoid their fears, the avoidance intensifies and becomes more solidified as a coping technique.
Gabbard (2014) notes that selective serotonin reuptake inhibitors (SSRI’s) have been well established for treatment of panic disorder. Venlafaxine has been FDA approved for panic disorder as well as benzodiazepine monotherapy (alprazolam). These are effective when first line treatments such as SSRI’s and SNRI’s fail.
Cognitive Behavioral Therapy (CBT) is recommended as a first line treatment for panic disorders (American Psychiatric Association, 2009). Cognitive restructuring assists patients with identifying thoughts that contribute to panic episodes and to recognize common errors in thinking that accompany fear and anxiety. Patients then generate alternative beliefs. Thoughts cause feelings. Positive alternative thinking diminishes anxiety. Psychoeducation is useful, including facilitating a strong therapeutic alliance, providing patients with a sense of hope and self-efficiency.
As noted in DSM-V, symptoms of SAD include distress with facing or anticipating separation from home or attachment figures as well as persistent worry about being abandoned. Among children with SAD, school refusal is common. Anxious attachments stemming from dependency produced by parental figures who are overprotective or who use coercive control increase the risk of SAD. Moreover, maternal dependency is inversely correlated with academic achievement. Letting children take risks and recover from them increases resiliency and strengthens their independence and sense of mastery.
SAD, also known as social phobia, encompasses fear and avoidance of social or performance situations, with prominent fear of embarrassment or humiliation. This disorder is very common with a reported lifetime prevalence of 12% (Ruscio, et al 2008).
The best supported cognitive behavioral treatment practices for individuals with SAD involve the combination of correcting maladaptive thinking patterns (cognitive restructuring) and confronting feared stimuli, ie, exposure to social situations.
Individuals with SAD often display problematic thinking patterns (eg, “they will think I’m weak if my voice shakes”) and disbeliefs, eg, (“If people really knew me, they wouldn’t like me”). During cognitive restructuring the psychologist and patient collaboratively identify distorted or maladaptive cognitions and challenge them using such strategies as Socratic questioning, logical disputation and behavioral experiments.
Mindfulness treatments are less effective than CBT, but can be more cost effective.
A substantial body of evidence demonstrated the effectiveness of several regimens of medicines for SAD including SSRIs and SNRIs have been found effective in clinical trials. SSRI’s are a first line treatment for SAD. Sertraline, fluoxetine, and venlafloxine have received FDA approval for SAD. (Gabbard, 2014) notes that buspirone is effective at a dosage of ≥ 45 mg/ day.
CBT is noted by (Gabbard, 2015) to produce more enduring effects than medicines alone.
GAD is a chronic and highly comorbid illness characterized by excessive and uncontrollable worry (Hecher, et al. 2005) and is associated with fluctuations in symptom severity and impairment (Witchen, et al. 2000). Recovery rates range from 32-58% and recurrence rate is 45-52% (Rodriguez, et al 2006) over a 2 year period. Patients with GAD anticipate negative outcomes or worst case scenarios. Cognitive behavioral therapy (CBT) is helpful and acts on restructuring thought processes and “resetting” negative thought patterns. CBT is the best established psychotherapeutic treatment for GAD. CBT promotes changes in patients via early anxiety triggers, challenging negative thought patterns, recurring avoidance behaviors and improving skills to manage worry and anxiety. Relaxation techniques are used to address elevated anxiety.
GAD is a chronic and highly comorbid illness marked by excessive and uncontrollable worry. GAD is typified by a later onset than other anxiety disorders. There is a low probability of recovery (32%-58%) and a likelihood of recurrence (45%-52%) (Rodriguez et al. 2006) over a 2 to 12 year period. GAD can be more debilitating than substance abuse disorders and personality disorder. Patients with GAD are vigilant in their environment for potential danger and negatively interpret neutral stimuli as threatening (Mathews & Mac Lord 1994). GAD is associated with restlessness, fatigue, irritability, concentration difficulties, muscle tension and sleep disturbance. Targeted interventions are necessary to address core symptoms.
(Gabbard, 2014) reports that CBT is currently the best established psychotherapeutic treatment for GAD. CBT is effective in identifying early anxiety triggers, challenging and disrupting patient’s misconceptions and factors producing worry, and anxiety and encourage developmental adaptive modes of responding to situations (Newman, et al. 2006). Patients are asked to engage in self-monitoring to identify anxiety triggers. Relaxation training and guided visual imagery are quite helpful in alleviating anxiety. Cognitive restructuring assists in replacing thought distortions with more accurate thoughts.
Relaxation techniques assist patients in relaxing a series of muscle groups and engaging in breathing exercises. Patients are asked to simultaneously “let go” of their worries while they relax. Once relaxation is established patients are asked to use relaxation techniques to challenge anxiety arousing thoughts:
(Gabbard, 2014) notes that individuals with GAD are more likely to be in enmeshed relationships, eg child or adolescent being parentified (Przeworski et al. 2011). GAD is more commonly associated with mental conflict or dissociation than any other anxiety disorder (Ahriman, 1999).
Attachment conflict and difficulties with early attachments are said to play a role in development and manifestation of GAD. In the absence of secure attachment, patients may view the world as threatening, and unpredictable. To build their source of control, patients may become perfectionists, be people pleasers, and require frequent reassurance concerning their worries.
(Crits-Christoph 1995) developed the model of supportive- expressive therapy (SET). In this model, traumatic events are seen as putting schemas in place as representations of self, others and the world that reflects uncertainty involving love, stability, security and practicum. SET assists patients to cope as well as express their needs and responding to others. SET was found to result in significant improvement in GAD symptoms and interpersonal problems.
OCD is characterized by recurrent and persistent thoughts, urges or images (obsessions) that are experienced, at some time during the disturbance, as intrusive or unwanted repetitive behaviors or mental acts (rituals or compulsions) that the person feels compelled to perform to lessen anxiety or discomfort (Rasmussen and Eissen, 1989). Investigations have shown that 75% of patients with OCD will engage in behavioral therapy and that most patients who do so faithfully show both immediate and sustained improvement. Griest and Jefferson (2014) report that effective behavioral therapy for OCD consists of exposure and ritual prevention. A critical phase of behavioral therapy for OCD is psychoeducation because patients vary in their willingness to directly confront their fears in therapy. Patients should be informed that their anxiety level may increase initially during exposure sessions. However, if a patient can tolerate the short term costs of behavior therapy, long term gain will be forthcoming.
SSRI’s have been seen as first line pharmacological treatment. A substantial body of evidence has demonstrated the effectiveness of several classes of medicines for SAD, viz, SSRIs, SNRIs and MAOI’s. SSRIs have emerged as first line medicines for SAD. The disorder effects include comorbid depression, risk of abuse, potential adverse effects on cognition, coordination and development of psychological disorders. Several studies have examined the effectiveness of CBT and medicines for CBT.
These modalities add external and interpersonal techniques to conventional CBT. Acute active therapy has been reported by (Gabbard, 2014) for GAD which has been reported to be more successful in reducing anxiety symptoms.
There are subtypes of specific phobia, viz, fears related to the clinical natural environment (heights, water), situational (dogs, cats), and others which include such phobias as fear of choking and vomiting.
Exposure therapy (ET) teaches patients to confront increasingly threatening situations in gradual steps. Initially ET is conducted with the psychologist and then at home in the form of homework. A fear hierarchy is created jointly by the therapist and patient involving confronting situations in the form of increasing severity. Exposure therapy enjoys a significant success rate (80-90%). (Choy et al 2007) found that brief psychological treatment can be sustained over time. Cognitive factors play a role in etiology and maintenance of phobias (Thorpe and Salkovskis, 1995).
Medicines have been shown to be of limited benefit in the treatment of specific phobias.
ET is the treatment of choice for specific phobia. This treatment can also be conducted with a supportive partner. Experts agree that at least 10 weeks of behavior therapy must be completed before concluding that SRI is ineffective. Patients in medication trials typically had a decrease in time spent with rituals and obsessions of at least 2 hours per day.
(Gabbard 2014) reports that adult (Foa et al 2005) and pediatric (Pediatric OCD Treatment Study) [POTS] trials found that behavioral therapy (exposure and ritual prevention for adults and children plus cognitive impairments for children) reduced severity in the Yale-Brown Obsessive Compulsive scale (y-BOCS) scores more than twice as much as clonipramine in adults and sertraline in children. Combining CBT and medicine added little benefit to behavioral therapy itself. (Gabbard, 2014) notes that medicine treats underlying depression and anxiety and may improve compliance with behavioral therapy which in turn improves the prospect of discontinuing medicine without rapid and substantial relapse of OCD.
Inositol is a second messenger precursor available in health food stores. In cross over designs, inositol was significantly more effective than placebo as behavior therapy for OCD (Fox et al 1996), but found effective as an augmentation for patient SRT’s (Fox et al 1999). (Gabbard, 2014) reports that trials of SRI augmentation in severe OCD with relazole, a glutamate antagonist, yielded a y-BOC reduction of 42%.
Evidence strongly supports the findings that Behavior Therapy is more effective than medicines in the acute phase and long term. Patients compliant with Behavioral Therapy and SRI’s have a positive outcome (50% reduction in obsessions and rituals).
(Phillips, 2014) reports that BDD is a common and often severe disorder whose core feature is preoccupation with one or more non-existent slight deficits in one’s physical appearance. The preoccupation causes clinically significant distress in impairment in psychosocial functioning and is not better explained by concerns with body fat or weight in an individual who meets diagnostic criteria for an eating disorder. Insight into the perceived flaws (eg, I look ugly) is usually absent or nil. Most patients are concerned that their view of their perceived deformities is accurate. All patients with BDD engage in compulsive behaviors with the goal of checking, fixing, hiding or obtaining reassurance about the perceived deficits. Poor psychosocial functioning and high rates of suicidality are characteristics of the disorder. These patients, believing that they are ugly or abnormal seek cosmetic treatment. Studies from mental health settings found that ⅔’s of patients with BDD receive surgery and dermatological, dental or other cosmetic treatment for their perceived flaws (Crernal, et al, 2005). In one study (n = 250) only 7% of such treatments led to overall improvement in BDD. (Phillips et al, 2004) and in another study (n = 200) only 4% of procedures improved overall BDD symptomatology. ( Crevard, et al, 2005). Due to most patients having poor or absent insight, they may be dubious that they have BDD and that psychiatric treatment can be of assistance. Patients may benefit from reading about BDD (e.g Phillips, 2009). Attempting to convince patients whose insight is poor that they look normal is usually ineffective and patients misinterpret comments, even if reassuring, in a negative light. On the other hand (Phillips, 2004) notes that it is of importance not to agree with patients negative view of their appearance as this may be devastating to them. Mental health professionals need to embrace the patient’s view of the world and provide understanding and support. This is essential to forming a therapeutic alliance.
Although no medicines are FDA approved for the treatment of BDD, serotonin uptake inhibitors (SRIs) are currently considered medicines of choice (Phillips, 2014). (Phillips, 2014) reports that all previous studies advocate that SRI’s are effective for BDD. Patients with delusional BDD beliefs often respond to SRI monotherapy. Cognitive Behavioral Therapy (CBT) is tailored to BDD’s unique symptoms.
Cognitive restructuring assists patients in identifying and evaluating negative appearance related thoughts and beliefs and identifying cognitive errors, e.g, all or none thinking. Patients learn to develop more helpful appearance related beliefs. Core beliefs (eg, being unloved, worthless or inadequate) needs to be addressed with more advanced cognitive techniques.
Response (ritual) prevention helps patients cut down on compulsive behaviors (mirror checking).
Exposure combined with behavioral experiments assist patients to gradually face avoided situations. (Phillips, 2014) relates that exposure is combined with behavioral experiments in which patients design and carry out experiments to test the accuracy of their beliefs, eg, going into a bookstore to test the hypothesis that 20% of people within a few feet of the patient will move away from them.
By: Michael J. Perrotti, PhD.
Schmidt (1983; 1992) published two articles describing Child Sexual Abuse Accomodation Syndrome (CSAAS). In his first article he asserted that CAAS consisted of five main components 1) Secrecy 2) Helplessness 3) Entrapment and Accomodation 4) Delayed Unconvincing Disclosure 5) Retraction. In his second article, Schmidt (1982) described what he saw as abuses of the CSAAS. He was particularly concerned that the CAAS was being misused in court to “diagnose” whether or not abuse has occurred. This writer frequently sees “experts” for the prosecution equating CSAAS with a defendant alleged to have committed child sexual abuse. In particular, delayed disclosure is equated with validity of child sexual abuse claims. While the syndrome has received high rates of attention in legal settings, including two highly critical reviews, the entirety of its issues have not been expanded upon. (Coden, Bruell, Ceci + Shwan, 2005; Coden, Bruell, Wright, Ceci, 2008). Bento (2012) went so far as to state CAAS should be considered as an example of “junk science” and should not be used in legal settings. Juries are misled by only a part of the true picture of CAAS being presented. Schmidt (1983) introduced CSAAS by claiming that accusers feel secondary trauma when their disclosure is viewed by significant individuals in their lives as a lie. Hunt asserts that secrecy creates fear in the child and the false promise of safety. In the secondary category of helplessness, Schmidt related that children are required to be obedient and appropriate with any adult entrusted with their care. His assertion is that perpetrators are often known to their victims. Thus, children are helpless against allegedly trustworthy adults. In entrapment and accomodation, Hunt represents that children hold themselves at fault for painful sexual events and that the child feels obligated to perpetrators. Schmidt argues that most ongoing sexual abuse is never disclosed and if family conflict triggers disclosure it is usually after years of continuing sexual abuse. This completely neglects to note that cumulative traumatic events in the form of PTSD result in acute anxiety impairing daily functioning. Schmidt notes that even when a child discloses child sexual abuse, he or she is likely to recant due to family dynamics such as seeing the family disrupted.
Ten years later, Schmidt (1993) published a response to what he described as distortion and misuse of CSAAS in the Courts. (Drohan and Bento, 2002) notes that Schmidt attested that CSAAS posed a threat to defense arguments that legitimate victims would fight back and that there are false complaints of sexual abuse.
As with any “syndrome” used to support child sexual abuse complaints in the courts, there are problems with experimental design. Lordn, Buuck, Wright and Ceci (2008) argued against research used in support of CSAAS. They questioned the representations of samples of children in forensic interviews, reliability of memory recall data and questionable abuse status. Evidence based interview protocols that lack leading questions yield high rates of disclosure (85%) lending support to the notion that denial is not common in substantiated abuse cases. (London et al, 2008). These same authors note that misinformation may stem from false disclosure elicited by highly suggestive interviewing techniques. Drohan and Bento (2012) note that Brodley and Wood (1996) noted disclosures of sexual abuse in 234 sexual abuse cases in CPS and observed recantation in only 4% of cases. Of the 4%, only ½ who recanted did so in response to pressure from a caretaker.
The term “CSAAS syndrome” noted by (O’Dohne and Bento 2012) is an imprecise term. They acknowledge that there is no clinical methodology to assess typical “valid” claims from those that are invalid. Schmidt (1992) himself notes that the intent of CSAAS used in court testimony is not to prove but to refute his thesis which produced endorsement of delayed or incomplete disclosure. Drohan and Bento (2012) note that Schmidt failed to provide empirical evidence that there is an aggregate to be treated as a group.There is no operational definition of what is meant by a “delay” in reporting.
Schmidt does not specify if CSAAS appears to apply to all children who are sexually abused. To boys? Girls? What age range? None of the variables are specified by Schmidt.
Long-Term Memory in Adults Remembering Sexual Abuse 20 Years Later
Goldfarb et al (2019) state that recent research confirms the possibility of false memories of childhood sexual encounters (Badanz, Slaver & Goodman, 1990; Liddonfield, 2015; Loftus, 1996). Goldfarb et al (2019) state that memories of highly emotional events are less susceptible to forgetting. However, one must take into account that memories are a constructive process. Individuals make source errors, viz, erroneously recalling characteristics of another situation. Imagination inflation refers to a finding that imagining an event which never happened can increase confidence that it actually occurred. Goldfarb et al (2019) note that there is disagreement about the extent of forgetting and errors in recall of information. There is also the phenomenon of suggestibility, especially with children, and the effect of suggestion and leading and suggestive investigative interviews on memory. “Recovered” memories from sessions with therapists are yet another source of memory contamination. Singer and Wixtel (2006) note that as the time between an event and a memory increases, individual differences will be evident in an individual adopting a conservative as opposed to liberal response strategy, which may in turn increase suggestibility. Memories also decay over time and are reconstructed and subject to distortion.
Contribution of PTSD and Depression to Errors in Reporting Events
Some investigators report that maltreatment history and/or PTSD symptomology are associated with increased accuracy of recall of abuse (Alexander et al 2005; Eisen, Goodman, Gin, Davis, & Crayton, 2007). However, it has also been proposed that individuals with trauma-related psychopathology such as PTSD or depression are more likely to err in reporting events (Otgaar et al 2017, Windmann & Kruger, 1998).
What is not addressed by those who propose that trauma (PTSD) results in vivid images of abuse and greater accuracy of memory is the phenomenon of dissociation which co-exists with PTSD. Individuals in dissociative states are detached from their surroundings and report out of body experiences. There is a disconnect of awareness, consciousness, and orientation to the environment. Goldfarb et al (2019) reports that memory errors may be driven by mental health symptomatology resulting from trauma, rather than by maltreatment itself (Eisen, 2007; Goodman et al, 2016).
Gender differences in memory for emotional childhood events have been documented, with males recalling fewer emotional childhood experiences (Daniels, 1999) compared to females (Goldfarb et al, 2019) reports that such differences may be more likely for an emotional event that is sexual in nature. As a consequence, males may be more reluctant than females to remember and disclose sexual details thus increasing commission errors (Vlman and Filipas, 2005); (Widsom and Morris, 1997).
Effects of Repeated Interviews
Memory rehearsal via repeated interviews and conversations with others regarding an event may reinstate memory but can also lead to erroneous memories (Gordon et al 2004; O, et al 2006) (Peter and Sara 2015; Peterson, Pardy, Tizzard-Drover and Warren 2005).
(Goldfarb et al 2019) reports that children who had been exposed to violence were recovered from their homes and placed in a forensic hospital and had an anogenital examination as part of the standardized forensic medical procedure, recalled the examination 29 years later. However 30 of the subjects did not recall being at the hospital at all exhibiting a “lost memory”. They also reported that depression is associated with comparatively accurate memory of negative childhood occurrences at least at 20 years later. Adult males were found to recall less than adult females (Denis, 1999) including childhood sexual abuse. Males were reported as more likely to exhibit a “lost memory” for being at the hospital, were less likely to report genital contact and were more likely to make omission errors in answering specific questions. It was also found that specific and misleading questions did not count as memory reports after 20 years. “False memory” was not able to be investigated.
(Goldfarb’s 2019) study has limited statistical power due to a small sample size (n = 30).
Court Limitation on Long-Accepted Child Abuse Theory
The New Jersey Supreme Court (August 2018) agreed with a lower court that until aspects of the CAAS theory are well-defined and scientifically proven, that expert testimony about these aspects should not be introduced as evidence. The Supreme Court noted a number of shortcomings about the concepts of CAAS including labeling the theory as a syndrome, defining the five behaviors with precision and defining how the behaviors related to each other. Chief Justice Stuart Rabner wrote “based on the record before the Court, we conclude that the CSAAS (the Syndrome) does not satisfy a basic standard of admissibility – reliability – because it is not generally accepted by the scientific community”.
There are many problems with reliability and validity of the concepts of CSAAS. Unfortunately it has been misused and misrepresented by some prosecutors and prosecution experts and has been represented as being “associated” with the validity of claims of accusers. However, this assessment is problematic. This is at the expense of defendants. The courts are in the forefront of adversarial conflict and are entitled to evidence based research examining all sides of issues rather than “junk science”. Our justice system and a defendant’s presumption of innocence and civil rights under due process deserves no less.
Celik, Tahiroglu, and Avci (2008) relate that false allegations may occur because of memory distortions or contamination. The phenomenon of imagination inflation occurs when an individual commits a source error, viz, is erroneous in identifying the situation and circumstances of what they are recalling. The individual then embellishes and adds on to the erroneous source and attendant memory and believes that it is true. Celik, et al (2008) also note that recurrent and close-ended questions may result in recantations and/or false allegations, especially those made to the police and the Courts. The authors also note that all evaluations of psychosexual factors may be more valuable than examining any physical findings or psychiatric symptoms or disorders in children who have disclosed sexual abuse. In their research, they discovered that recanting cases must be followed for at least one year with multidisciplinary facilities such as social services, legal procedures, and child psychiatrists. They note that additionally recounting disclosure rates mostly focus on forensic samples rather than general population. Recanting disclosure rates, they note, are still a controversial issue. They recommend that further studies should evaluate recantation rates in high risk populations as follow up.
This examiner has frequently encountered forensic interview techniques that do not adhere to the Gold Standard NICHD interview protocols articulated by Michael Lamb, PhD. close ended interview techniques such as, “Where did he touch you?”, “What else did he do to you?”, are suggestive, tainted and the research reveals high rates of errors in information given. Moreover, children are very suggestive. Many individuals are acquiescent to authority and tell law enforcement what they think they want to hear. Another source of error is repetitive interviews. Information becomes increasingly distorted as accusers are interviewed by parents, investigators, law enforcement, etc. Celik et al (2008) also notes that experts need to be aware of children who may show a tendency to recant due to their psychosexual backgrounds.
“Sex Offenders!” Do they all need GPS tracking.
By: Michael J Perrotti, PhD.
Clinical and Forensic Neuropsychology
The other day, I was in a class with law enforcement and was stunned to hear the presenter, a “Sex Crimes Investigator”, state with reference to individuals convicted for sex offenders. “They all recidivate. They all go back to jail.” I told him that was incorrect. That this was not supported by the research literature on offense rates. For example, DOJ rates for reoffense with Incest offenders are in the area of two percent.
Individuals fall into many different categories with respect to sexual offenses. There are
Doubtful Offenders – accused but issues are in dispute; Situational Offenders. These are individuals who act out sexually due to extreme stressors such as divorce and substance abuse. This examiner has evaluated many of these individuals who seek treatment and have successful outcomes. Then there are preferential offenders, viz, offenders with a preference for children.
In reference to child pornography (non-contact) offenders, recidivism rates are low. Some individual’s behavior stems from deprivation of affectional needs in the family. Thus, one can not make a blanket statement that all sex offenders suffer from sexual deviation. A thorough and comprehensive forensic psychosexual assessment is needed.
The overcategorization of individuals in the category of sex offenders with need for monitoring and GPS tracking has resulted in personnel being overwhelmed in the system. It is incumbent upon psychological experts to educate the courts that sex offenders are not all pedophiles, but a complex mix of many other dynamic issues. Even with respect to individuals with elevated recidivism rates, relapse prevention groups are helpful in reducing reoffense rates. Individuals in the groups are asked to keep diaries with a daily log of triggers, and intensity of particular behaviors. Protective Factors such as family support, and motivation for treatment also reduce reoffense risk.
The Value of Weight Lifting and Cardiac Health
By: Michael J. Perrotti, PhD
Clinical and Forensic Neuropsychology; Sports Performance Enhancement
Mind-body dualism (mind and body interconnection) is our DNA. The gym is excellent as a stress management coping tool, a welcome time out from our busy schedules and a needed focus on self-care. Many gym goers focus on aerobics – bicycle, elliptical trainers, treadmill.
Recent research from the American Heart Association concludes that for healthy adults, a regular program of weight training not only increases muscle strength and endurance. It also improves heart and lung function, enhances glucose metabolism, reduces coronary disease risk factors, and enhances well-being.
A recent study followed 13,000 subjects who exercised on treadmills. Blood tests and follow up outcome measures were used. Of significance was that subjects who did weight training twice per week have been evidenced to have less cardiac events and lower risk factors for cardiac disease over time.
One can also obtain both cardio and cardiovascular fitness by elevating heart rate with regular cycle exercise, eg, circuit training. Several research studies have been conducted on the effect of high intensity, short rest weight training and its effects on cardiovascular health and fitness. Their findings are remarkable as strength training has not currently been thought to improve cardiovascular fitness. Aerobic activities that increase heart rate and make one breath harder – walking, biking, jogging – have typically been recommended for cardiovascular fitness. We are now learning that maximum increases in strength and cardiovascular fitness can be obtained from one type of exercise – strength training. Properly applied, strength training simultaneously engages both the muscular system and the cardiovascular system. Recommended intervals are three to five times per week for 20 to 30 minutes at moderate intensity level, or two to three times per week for 15 to 20 minutes at a high intensity level. One should check with their primary care physician prior to engaging in any exercise regimen.
The aforementioned fitness regimens improve the quality of life and are conducive to reducing stress.
Make the resolve to improve your fitness today. Fight on! Stay Strong! Plan for a fit and healthy 2019.
(Throckmorton, et al 2018) warns of shifting trends in the addiction landscape. They note that the Gabapentinoids (Gabapentin and Pregabalin) are approved in treatment of seizures and certain forms of neuropathic pain. However, US rates of Gabapentinoids use tripled between 2002-2015 and Pregabalin ranked as one of the 10 best selling drugs in 2017. Increased prescription rates have raised concerns about possible abuse of Gabapentinoids. Cannabinoids are linked to dependency in individuals. Cannabis use disorder has long been noted in DSMV. Gabapentinoids have been increasingly dispensed with opioid analgesics and benzodiazepines.
Kratom, a botanical substance is available via online commerce and retail outlets specializing in tobacco and cannabis paraphernalia. Although Kratom has no approved use in the United States, it has been widely discussed in the media as an alleged treatment for opioid use disorder and pain. Many lay coalitions advocate for its availability. Kratom has been widely used as a recreational drug. The CDC report calls to poison control centers citing Kratom exposure rose 10 fold between 2010- 2015. The FDA has expressed concerns. Recently, Kratom was found to have opioid pharmacological properties and being used in place of approved opioids. FDA researchers found that more than 20 specific compounds within Kratom are predicted to bind to the mu- opioid receptors. Analysis of data from social media shows the use of Kratom to treat pain, lessen opiate withdrawal symptoms and for recreational use often with no regard for its safety or addiction potential and despite the lack of clinical studies involving this substance. The same applies to Cannabis, a schedule II drug, not approved by the Institute of Medicine or the FDA. New disorders are emerging for Cannabis such as hyperemesis syndrome. Neuropsychological deficits in learning potential and executive function are related to cannabis use among teens.
An addiction trend is the dramatic increase in abuse of loperamide a common over- the – counter product. Loperamide in approved doses is noted to be a safe, effective treatment for diarrhea, but individuals are reported to be using Loperamide in overly high doses to self manage opioid withdrawal or achieve euphoric effects. Serious health concerns have been reported including Torsades de pointes and death in individuals taking high doses of Loperamide. The FDA recently has been working with the manufacturer of Loperamide to reduce the amount of the drug packaged.
(Throckmorton et al. 2018) reports a shift away from use of prescription opioids towards plant based materials containing unrecognized opioids in OTC products with potentially lethal opioid effects.
New drugs of abuse can emerge (eg, tinneptine) and patterns of use and abuse can change, (eg, Gabapentinoids). (Throckmorton et al. 2018) notes that a system of pharmacovigilance is proposed along with new epidemiological data. The goal is to identify emerging trends earlier. However, this writer proposes greater education of the public in non-pharmacologic treatment of chronic pain and addiction, as well as increased access for patients to these treatment modalities. Cognitive behavioral therapy is the gold standard in non- pharmacological treatment of chronic pain. It assists patients with management of chronic pain and restructuring of thought processes to effectively manage anxiety and depression. Biofeedback teaches patients to increase skin temperature and thus reduce pain. Patients are taught to acquire voluntary control of normally automatic bodily functions.
A great starting place with treatment of chronic pain and addiction is a comprehensive assessment by a skilled, highly trained healthcare professional. An important distinction in deciding appropriate treatment is where one falls in the following categories:
Primary Addiction Dual Diagnosis
Primary problem is addiction to a Addictive Disorders co-occur with
Substance with Medical and depressive anxiety and bipolar
Psychological treatments applied disorders; treatment focuses on both
To Primary addictive disorder . disorders simultaneously and how
they reinforce each other.
It is puzzling as to why methadone clinics and maintenance treatment are mainstreamed but effective non-pharmacologic approaches are not.
UCLA dual diagnosis program emphasizes a comprehensive diagnostic assessment. An accurate diagnosis is challenging in the context of an addictive disorder and co-occurring psychological condition. Patients frequently are given conflicting and inaccurate diagnosis not informed by psychological testing. Many patients are seen in recovery programs and no psychological testing is conducted. Thus, an objective study of diagnostic issues is neglected at patient’s expense. The treatment plan subsequently is flawed. Medication management, education and cognitive behavioral group therapy are all part of a quality targeted dual diagnosis treatment program.
The FDA is currently convening a group of professionals to evaluate epidemiological signals that may preface new usage trends. The public needs protection from risks that may emerge as the nation’s opioid problem is confronted. Consumers need nothing less than this!
Throckmorton, Douglas, Gottlieb, Scott, & Woodcock, Janet (2018), The FDA and the next wave of Drug Abuse – Proactive Pharmacovigilance in New England Journal of Medicine, Vol. 379, No: 3
At the sentencing hearing of Larry Nassar, he told the Court that he was a “good doctor” and that the victims returned to him for more treatment. This externalization of blame, objectification of the victim and non-acceptance of responsibility for these actions is common with predatory sex offenders. Aside from Dr. Nassar's alleged actions with the victims, it has been reported that individuals at Michigan State University allegedly deleted information and enabled this scenario to continue as reported by Pardon the Interruption (PTI).
Sex offenders are dissociated from their feelings, intellectual and rationalize their actions (they are very much in their head). As we heard on PTI today, this cover up of egregious abuse is also seen with universities such as Baylor and Penn State. Perhaps as noted on PTI today, this is a larger problem in our culture related to treatment of women. The NCAA must demand accountability and mete out appropriate discipline. This type of enabling behavior results in harm to others much like failure to protect students. Congress needs to enact laws to codify these actions into crimes. Unfortunately, the healing process for the victims is only just beginning. ESPN’s Outside the Lines article determined an investigation that detailed incidents in the basketball and football programs at Michigan State University (MSU) in what is called “ a pattern of widespread denial, inaction and information suppression by officials”. Is over 100 courageous victims coming forward enough to stop this? Penn State, Baylor, etc., the list goes on. Image and revenue from college sports seem to trump safety of innocent victims. Accountability must be demanded. Enablers must be eliminated from universities and professional sporting programs. This will not happen until morality and protection of our children takes precedence over college sports programs and the attendant focus on money from the programs.
Christina Grimmie was a promising aspiring singer. She had been stalked by alleged perpetrator Kevin James Loible. He had traveled from St. Petersburg, Florida to Orlando, Florida where Miss Grimmie was performing. He walked up to her in an area where she was signing autographs. He was alleged to have walked into the area armed with two handguns. There were no threats or disturbances. Mr. Loible walked up to the area where Miss Grimmie was signing autographs. She had opened her arms to give him a hug. He then is alleged to have fired three rounds into Miss Grimmie fatally wounding her. He then killed himself. A note was also pinned to Mr. Loible’s family’s front door with condolences and concerns about Miss Grimmie’s death. The gunman was obsessed with Christina believing that she was his “soulmate.” As we often see with extreme, predatory violence, Mr. Loible was a “hermit” with poor social skills. He would cover the windows of his room with foil. These individuals always feel alienated and see themselves as on the outside looking in.
This situation and circumstances of Christina’s death cries out for an explanation. Somehow, someway we strive to make sense of these nonsensical events. The circumstances of the homicide of Christina Grimmie are strongly suggestive of the subtypes of stalking involving erotic delusion. There are numerous subtypes of stalking. In this case, the obsessive nature of the mind of a stalker is reflected in Mr. Loible traveling from St. Petersburg to Orlando to make contact with Miss Grimmie.
There are many subtypes of stalking. In this particular case, the alleged perpetrators behavior and fixation appears to be reflective of erotic delusions. These individuals pursue someone with whom they have little, or if any, relationship. They suffer from an erotic delusion in which they believe that they are loved by the victim. The stalking satisfies needs for contact and closeness while feeding fantasies of an eventual loving relationship. For this case, we see clear intentions of predatory behavior and control frequently seen in domestic violence.
High profile figures in our society live in glass houses fueled by social media. This writer has conducted forensic assessments in this area. Their lives are not easy and they are vulnerable to the irrational behaviors and acts of disordered minds. They need our prayers that they may be safe.
The alleged perpetrators family life was one of reported domestic violence. Those victimized go and victimize others. It is a vicious cycle of danger to other human beings. Unfortunately, Christina Grimmie was a target of this unreasonable violence. The family needs our support and prayers. Any abuse is life abuse!
Dr. Perrotti is dedicated to providing effective representation in forensic neuropsychological and clinical assessment in relation to legal counsel.
Michael J. Perrotti, Ph.D.
3 Pointe Drive, Suite #303
Brea, CA 92821
Office – (714) 528-0100
Fax – (714) 528-2575
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