One of my patients told me a story that exists on the internet in a number of different versions of basically the same story.  The story revolves around a family going out to eat and the waitperson takes their orders and comes to the youngest child who says, "I'd like a hotdog and a coke."  Her parents then tell the waitperson that she is having chicken, broccoli and milk.  The waitperson then turns to the child and asks what she would like on her hotdog.  After the waitperson leaves to place their orders, the child looks at her parents and says, "She thinks that I am real." 

My first reaction was to feel sad that the child felt that since her parents did not allow her to make choices in her life, she felt like her thoughts, wishes, feelings didn't matter.  I wonder if this is what it feels like being bullied, only it will be harder for her to tell her parent's about it. So, does being bullied make us feel that we are not real, not worth anything, or that we don't matter?  Do we have to be listened to and then be encouraged to make decisions for ourselves, to feel that we are real and worthwhile?  Is it that simple?  

I have previously blogged about how children who are bullied are more likely to become depressed and to commit suicide as adolescents; ["Being bullied as a child and self-harm behavior as an adolescent".]  So it is clear that bullying is traumatic for those who are bullied. It is therefore very important to identify those who are being bullied and get help for them. It is also important to be aware of what constitutes bullying so we can confront it wherever we encounter it, even in ourselves. We must all be so careful to treat everyone that we meet as if they are real.

What do you think?




I have previously blogged about this quote from de Saint-Exupẻry's The Little Prince.  The full quote is, "It is only with the heart that one can see rightly, what is essential is invisible to the eye."  In the book, this quote is spoken by the fox and to the Little Prince after the fox has taught the Little Prince to tame the fox so that they are now friends.  The fox helps the Little Prince to understand that the Little Prince's rose that is back on the planet where the Little Prince lives is special because of their friendship [Even though the rose can be very irritating and demanding.]  This allows the Little Prince to see the rose with his heart and thus he is able to see his rose even when he is looking at hundreds of identical roses. 

So, what does any of this mean?  Does it mean that we need to be aware of ourselves and accepting of ourselves so that we know what is important and see with this awareness [our heart?].  Maybe seeing with the heart means seeing others [and ourselves] without judging or stereotyping or reacting based on our insecurities or giving advice or ...?  Is it true that if we choose to see ourselves more clearly and are then accepting of ourselves that we are less likely to judge or stereotype others?  So often what troubles us about others is really something about ourselves.  Thus, being self-aware has its advantages.  As Carl Jung is credited with saying, "Everything that irritates us about others can lead us to an understanding of ourselves."  That certainly would dampen down our tendencies to be critical of others.  

What do you think?



I continue to be amazed by all the different ways that post traumatic stress disorder [PTSD] symptoms can present themselves as my patients cope with the fears related to past traumatic experiences.  I have witnessed manic and psychotic symptoms, conversations with angels inside their head, hearing music coming from outside their brain, paranoid thoughts and overwhelming feelings of shame and guilt.  Very frequently people who have been traumatized will act or feel responsible for others, as a way of preventing something worse happening. This keeps their brains on high alert.  

I have known that PTSD occurs in people who have experienced a wide range of traumatic events. More recently I have seen people with chronic stress related to the impact of untreated or poorly treated ADD/ADHD.  The impact of concentration and attention problems is often connected with traumatic type interactions that can lead to a post traumatic stress disorder [PTSD].  Others have experienced stress in relationships that also leads to PTSD.  Very often the people who I am helping are not aware that they have PTSD although they are aware that they have frequent anxiety symptoms. Diagnosing PTSD is important for a person’s ability to successfully reduce and even eliminate their anxiety symptoms.



I have recently been reacquainted with the long term impact of bullying by someone who sees me who had experienced severe depressions, some anxiety and negative views of herself.  Her mood improved considerably with medication and interpersonal therapy and yet there was a residual anxiety that responded to lorazepam [ativan] taken every few days and yet for no clear reason the anxiety continued with episodic increases when she was preoccupied with the necessity of change in her life.  She would hesitate and feel like she had to wait until it was ok with other people.  She wanted to make changes but couldn't make herself take the steps needed.  In talking with her she revealed that she was made fun of at school and teased for a few years but she was sure that this was not an issue now.  However, in exploring why she couldn't make changes in her life she realized that she was afraid to make things worse by doing something for herself. She was able to see how this might be connected to how she coped with bullying as a child and adolescent.  We discussed how her deferring to others told her brain to still be on guard for bullying and that things would be worse [much more stressful] if she asserted herself and did things that she wanted to for herself. She continued to hesitate to change this pattern until she was able to experience less anxiety when she thought about making changes in her life after she started taking propranolol. She was then able to directly tell herself that she did not have to fear doing things for herself and that nothing worse was going to happen.Her anxiety was significantly lower and she started making positive changes in her life.

An adolescent who is seeing me denied being bullied and yet was very anxious at school.  She felt physically sick each morning before school as well as physically ill at school.  She felt depressed and anxious and coped by avoidance, physical symptoms, compulsive behaviors and when these didn't help, she threatened self-harm. She also had been shy at a younger child in school and yet she was no longer feeling shy in school and instead felt at the mercy of her teachers who she was convinced hated her.  She dismissed the other students as boring.  Her mood improved after learning to be more positive about herself with antidepressant.  This worked until she was confronted by needing to go to school at which time her anxiety intensified and she experienced physical symptoms, etc. Over time, she was able to calm herself before and during school. She also was able to be more positive about herself while at school and to share some of her anxieties with a few other students and one teacher. She also learned to schedule specific things that she would do during the day that occupied her mind and helped her to not focus on worries and anxiety.  She realized that if she were really focused on an activity that could help her to feel calmer.  She had previously realized this when she would exercise intensely. Translating that into other ways of focusing without exercising was difficult but doable.  

An article by Karen Dineen Wagner, M.D., PhD in the February, 2016 Psychiatric Times summarizes the connection between bullying, depression and suicidal impulses in children and adolescents. Dr. Wagner reported that Hamm and colleagues [JAMA Pediatrics 2015;169] found that 23% of a large sample of 12-18 year olds reported being cyber bullied. The bullying took the form of name-calling, insults, circulating pictures, and spreading gossip and rumors.  They also found that relationship issues preceded the bullying.  The bullied adolescents reported being withdrawn, having lower self-esteem, problems with family relationships, poorer grades, more school behavior problems as well as increased rates of depression and suicidal impulses.  Dr. Wagner also summarized findings from Bowes et al. [BMJ2015;350] who looked at the relationship of being bullied at age 13 and depression at age 18 in a cohort of 6719 adolescents in the United Kingdom. 10% of these adolescents reported frequent bullying at age 13.  The more frequent the bullying the more depression with the rate being 14.8% for frequent bullying and 7.1% for occasional bullying and 5.5% for those who said they were not bullied.  Almost 1/3 of the risk of depression at age 18 was related to bullying.  

So, what can our adolescents do to cope with the impact of being bullied?  Sibold et al. [JAACAP 2015;54] evaluated the impact of exercising on rates of sadness, suicidal ideation and suicide attempts.  They found that bullied adolescents who reported exercising 4 or more days per week were 23% less likely to have suicidal ideation or attempts.  So it appears that frequent exercising lowers the stress associated with being bullied. It is possible that exercising helps by allowing the bullied person to stop thinking about being bullied as well as feel less stressed during the exercise [endorphins?] and likely for a period of time afterward.  It is one way to get away from the reminders of being bullied.  What else can help? Not continuing to be exposed to the bullying can help.  It may not be possible to remove the adolescent from the bullying and some professionals feel that it is better for the adolescent to face their abusers and learn to not take it personally. However, in my experience, the ability to manage this happens later in treatment.  I have found that it important for the bullied adolescent to have breaks from exposure to the bullying before they will be able to learn to face their abusers directly, without being re-traumatized.  It is also important for adolescents who are being bullied to give themselves permission to avoid the stress and not criticize themselves for avoiding stressful situations. Also, to reduce their stress reactions it is extremely important for the bullied adolescents not to allow themselves to feel responsible for others nor to judge themselves harshly. Feeling responsible for others is a message to their brains that things are dangerous and that they are taking on this impossible responsibility to avoid things getting worse.  For them to have the ability to be calm and to clear their mind of worries is an important skill to develop and one that is being taught as mindfulness practices to elementary age children in their schools across the country.  Being able to calm one's mind is critical to being able to choose to think about their abusers while remaining calm, reassuring themselves that they no longer need to fear their past traumatic experiences.  Finally, having a professional relationship where there is trust and support allows them to develop other coping skills and keeps alive the possibility of curing the adolescent's PTSD. 



An opinion piece in the New York Times [January 22, 2016] by Richard A. Friedman discussed recent brain research regarding memories and a medication that can help the brain let go of fears, with the example of being fearful of spiders, by blocking the activation of a fear conditioned response.  Merel Kindt and her colleagues at the University of Amsterdam reported that in the study, people were exposed to a spider and also given a medication called propranolol and they were no longer having fear responses to seeing spiders up to a year after the initial pairing up of the spider and propranolol.  There are also a number of studies showing that giving propranolol immediately after a traumatic event may mitigate the fear response and may prevent PTSD from developing.

So what is propranolol?  Propranolol is a non-selective beta blocker that blocks the action of epinephrine and norepinephrine on beta 1 and beta 2 adrenergic receptors.  Propranolol works in part by inhibiting the effects of norepinephrine in the brain.  Norepinephrine is a neurotransmitter that works by enhancing memory consolidation.  The inhibition of norepinephrine by propranolol may be related to its ability to reduce stress associated with PTSD and other fear conditioned experiences. It is possible that propranolol blocks some of the fear responses so that people can use their coping skills to demonstrate to themselves that they are no longer at the mercy of past stressful experiences.

I have found that propranolol can be helpful in reducing symptoms related to PTSD.  More recently, I have found that a long acting form of propranolol seems to work better to block some of the fear conditioned responses that people with PTSD have, compared to the immediate release type of propranolol.


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