Today’s blog will take a much more editorial and conversational tone than some of my previous posts. I recently had the opportunity to be interviewed for the Manhattan Uranus, a tongue-in-cheek Facebook page. If you haven’t heard of it, it might be worth a look, as they seem to be quite popular and their page has a variety of informational and entertaining posts. One of the questions asked during their interview got me thinking about a theme that has often been on my mind throughout my life. To paraphrase the question, essentially asked how does one utilize open-ended questioning and exploration in the case where it seems like everything in one’s life, or more globally, is going poorly. The question cited multiple alarming events in the world and recent news and overall read as someone who may be feeling a lot of despair or hopelessness at the current state of the world.
 
To get a bit personal, I have at times struggled with depression and fought against an inclination towards being pessimistic. For a long part of my life, I struggled with always seeing the bad side of things or assuming that others had ill intentions or were malicious. I think what has helped me to become more positive and indeed hopeful is to get some perspective and to give myself permission to step back. Throughout history, there have been periods of social upheaval that have often coincided with technological or ecological change. There have also been periods of great prosperity and stability where “everything” appears to be going well (rarely are these periods truly great for everyone in society). As individuals, few of us can directly impact these broader trends, and this can be difficult to accept. What we can do is to choose how involved we want to be and how we would like our voice to be heard.
 
For example, we can choose to participate in organizing or meeting with like-minded individuals to discuss the issues we find important or meaningful to us. We can choose (in the United States of America), to some degree, who we vote for and if these people match our own values. We can choose if we need to make changes in our lives that might make us feel more satisfied or help us stay in touch with what is important to us. We can also choose to feel hopeful and make more realistic appraisals of our situation and take action, rather than succumb to despair. Allowing ourselves to reflect on one more instance of joy and connection than the day before is a victory. Deciding to try something new and seeing if it helps is a victory. Our brains and hearts are a part of us, and we get a say in how we think and feel.
 
Additionally, it is okay to take a step back and say, “I need some time for myself” or “I need a vacation from the news.” We might benefit from exploring new hobbies or reconnecting with old ones. If you have some healthy connections in your life, spend more time with those people or animals. Even if you skew on the introverted side of the continuum, step outside of your comfort zone and meet new people, or enter a social space even if you aren’t directly interacting, but instead soaking up the time around people. Go on an adventure and explore a part of town or your neighborhood that you have not been to before.
 
Spending all of one’s time worrying about the world and ruminating on misery will likely not benefit us or result in change that could improve our situation. Hope is something that must be cared for and nurtured if it is to bloom, and so creating the conditions in your life to feel hopeful is important. Feeling hopeful can, admittedly, be scary at times because it suggests that things can get better.  This is different from the potential safety of stagnation that suggests there is nothing one can do (cynicism). I genuinely believe that taking the risk of hope and making changes is worth it in the end.
 
I do not want this blog to come across as patronizing or dismissive of the difficulties of the current time. It is valid to feel worried, scared, angry, or disheartened about the direction of your life. I merely encourage you to ask yourself: “Is this helpful for me to be focused on right now, or is there something else I can do that would be more helpful and would feel better?” Perhaps instead of stewing in despair, we try steeping ourselves in hope.

By Gabriel Macfee, LCP, LMLP

Gabriel believes firmly that therapy should promote growth in both the client and practitioner, so he is always focused on learning and working.

Internet and Video Gaming Disorder
 
Although not currently an official diagnosis recognized by the APA’s DSM 5 TR, internet gaming disorder (video gaming addiction) is included in the section: Conditions for Further Study. The proposed features of internet gaming disorder include a preoccupation with internet or video games, withdrawal symptoms when internet gaming is not available, observable tolerance to gaming (the amount of time needed to feel pleasure from gaming increases, leading to longer gaming sessions), and difficulty controlling the amount of time spent gaming (APA, 2022, p. 913). Additional features include loss of interest in other activities, excessive use of gaming despite being aware that it is an issue, lying about the amount of time spent gaming, using gaming to escape negative feelings, and gaming damaging relationships, jobs, or education/career (APA, 2022, p. 913-914).
 
While much of the research on this potential disorder comes from Asian countries (South Korea has declared this issue a public health threat), recent research supports that video gaming addiction is a significant concern in America and other Western countries as well (APA, 2022, p. 914). The estimated mean prevalence of internet gaming disorder in the United States over 12 months is approximately 1%. Meaning that, on average, nearly 3.5 million people in the US would meet criteria for internet gaming disorder (APA, 2022, p. 915). This proposed disorder appears to be more prevalent among adolescent and young adult men, and the data also suggest that young men are more likely to play games with a higher potential for addiction (APA, 2022, p. 914). This author would like to note that these numbers may be skewed because gaming has traditionally been marketed more heavily towards young men.
 
Since internet gaming disorder is not an official diagnosis, this section will not focus on the best treatments or tips. Instead, the author will offer reflections and anecdotes as a clinician who also enjoys online gaming. I believe it is likely that internet gaming and non-internet gaming addiction will continue to increase in prominence for several reasons. Firstly, the male loneliness epidemic seems to be increasingly driving young men to withdraw from social relationships and to spend more time isolated online. This can be seen in the rise of incel culture and, more broadly, the “manosphere” – that is a topic worthy of its own blog/discussion.
 
In my experience as a clinician, I have encountered many isolated young men who very much desire more real-life relationships but either lack the skills or confidence to find them. It is much easier for these individuals to remain within the safety of their online worlds than to enter an unfamiliar and scary setting, such as a public space, and risk experiencing embarrassment or ridicule. Often, these young men spend so much time online interacting with other young men who may also have social skills deficits that the social interaction they do get leaves them unprepared to interact with others who are not terminally online or participants in “gamer culture”.
 
Lastly, I would like to highlight how some video game companies have intentionally introduced addicting elements into their games. “Loot boxes”, “battle passes”, and other features introduce gambling elements, FOMO (Fear of Missing Out), and other strong incentives to be spending as much of one’s time on a game as possible. In fact, some modern games essentially operate as glorified Skinner boxes (a box designed to administer rewards to reinforce a desired behavior) that shower the player with flashing lights and music for acquiring a rare item or leveling up. This can also create a social comparison aspect since players can show off their high-level or rare items to others, which further incentivizes spending more time in the game to obtain these rewards.
 
Similarly to what we’re already seeing in South Korea, I would not be surprised if internet gaming disorder is eventually declared a public health concern in the US. Even though it is not an official disorder… yet, I would highly encourage people who are worried about a loved one who spends too much time gaming to seek help through therapy. I would be happy to help you or a loved one navigate through these challenges in a supportive environment.
 
By Gabriel Macfee, LCP, LMLP

Gabriel believes firmly that therapy should promote growth in both the client and practitioner, so he is always focused on learning and working.
​
Works Cited
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association.

Photo by Alex from Calgary

​This is the second time this blog has covered depression, so if you are looking for information about depression in adults, feel free to check out the post titled: Accessible Steps in Fighting Depression. Today, I’ll focus on exploring how depression can present in children and adolescents, which sometimes appears differently than in adults. The DSM 5 TR by the American Psychiatric Association notes two diagnostic differences in children with depression. First, rather than having a down or depressed mood nearly every day, depressed children may instead present with frequent irritability (APA, 2022). An important caveat is that the irritable mood must be distinct from the child's observed pattern of becoming irritable when frustrated (APA, 2022).  Second, rather than noticeable weight loss or gain, children who are depressed may instead fall short of expected growth metrics as predicted by their doctor (APA, 2022).
 
Since children’s lives often revolve around play, school attendance, and social activity, early signs of depression to watch out for include a sudden drop in grades or a decreased interest in taking part in previously enjoyed activities (sports, spending time with friends, etc.). Other signs could be decreased energy and/or difficulty with thinking and concentration (APA, 2022). Childhood depression may also manifest as social withdrawal (APA, 2022).
 
Parents may feel overwhelmed upon learning that their child may be depressed and may be unsure of how to navigate this development. One helpful tip is to have patience in interactions with the child and model positive and healthy life practices. Good sleep, exercise, and eating can all help alleviate depression, and modeling an optimistic attitude can help children avoid slipping into despair. Encourage your child to spend more time with family and to avoid withdrawing from friends and social activities, as isolation can worsen depression.
 
If you have experience with depression yourself, don’t be afraid to share your own experiences and empathize with your child. Make sure to emphasize that depression is often temporary and that there is no stigma in feeling that way. If you are concerned that your child may be having suicidal thoughts, or if they confide in having suicidal thoughts, do not shame or stigmatize these thoughts. Suicidal thoughts are common in depression, do not indicate that a child will take their own life, and may be scary for a child to be vulnerable about these thoughts. In fact, it is much better for your child to feel comfortable sharing when they are having unsafe thoughts than it is for them to be scared and keep them secret. If your child does verbalize suicidal thoughts, it is recommended to seek out therapy or crisis services and take simple steps to maintain safety, such as locking up guns, removing unsupervised access to sharp objects, and making sure that pills and other potentially poisonous substances are accounted for. Crisis services are generally available at local community mental health centers or at local hospitals.

​By Gabriel Macfee, LCP, LMLP

Gabriel believes firmly that therapy should promote growth in both the client and practitioner, so he is always focused on learning and working. 
 
Works Cited
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association.
 

​Understanding OCD and OCPD
 
While people are familiar with obsessive-compulsive disorder (OCD), in my experience, it is often misunderstood. Some people might say, “Oh, I am just a bit OCD about this,” or suggest that they have OCD because they often clean their house. These types of statements often refer to behavior that could be more closely associated with obsessive-compulsive personality disorder (OCPD).
 
To help distinguish between OCD and OCPD, and to increase understanding of OCD in general, I will share some passages directly from the DSM-5-TR from the American Psychiatric Association. “OCD is characterized by the presence of and/or compulsions” (APA, 2022, p. 263). “Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly” (APA, 2022, p. 263). It is important to note that while most cases of OCD have both obsessions and compulsions, it is possible to have just obsessions or just compulsions (APA, 2022).
 
Here, I will provide a few examples and explain how obsessions and compulsions differ from typical preoccupations. Take the example of a person touching a potentially dirty public surface. Someone without OCD would likely wash their hands or use hand sanitizer and then proceed with their day. However, for someone who does have OCD, they will feel extreme anxiety, and their obsession might be the idea that there are deadly germs on one’s hand after touching that dirty surface, and that death is the likely outcome if nothing is done. Not only will a person with OCD experience distress about this possibility, but they will also attempt to suppress the obsession or resolve it by performing a compulsion (APA, 2022). In this case, a compulsion might be washing one’s hands exactly 5 times before continuing with the day. This ritual will likely be repeated whenever a dirty surface is touched or an obsessive thought occurs, which makes it easy to imagine how this might negatively affect an individual’s daily experience.
 
In contrast, Obsessive-Compulsive Personality Disorder (OCPD) is characterized by a “pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency” (APA, 2022, p. 771). People with OCPD do not experience obsessions or compulsions and are instead merely preoccupied with being orderly, perfect, and mentally and socially in control (APA, 2022). People with OCPD are often labeled as “control freaks,” “high-strung,” or “bossy.” While individuals with OCPD also face challenges due to their preoccupations, it is not to the extreme levels seen in OCD, and it is generally not as distressing (APA, 2022). An example of an OCPD preoccupation might be doing too much research into a simple or inexpensive purchase, leading to the purchase never being made (APA, 2022). Some might call this “decision paralysis.” One last factor to note is that research shows that the majority of individuals with OCD do not meet criteria for OCPD (APA, 2022). So, while they share traits and have similar names, they are quite different.
 
Unlike my other blogs in this series, I am not going to offer any try-at-home tips for OCD or OCPD due to the unique challenges that come with these disorders. The most evidence-based treatment method for OCD is a desensitization program (whether systematic or flooding), which should be done with the assistance of a qualified mental health provider. Attempting to do desensitization on one’s own can lead to the opposite effect, known as sensitization, which can make obsessions and compulsions more extreme. I advise that if you are concerned about OCD, you seek out a mental health provider. OCPD and personality disorders in general are very difficult to treat on one’s own and see the best results when treated by mental health providers. So again, if you are concerned about OCPD, you should seek out a mental health provider.
 
By Gabriel Macfee, LCP, LMLP

Gabriel believes firmly that therapy should promote growth in both the client and practitioner, so he is always focused on learning and working.
​
Works Cited
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association.

In recent years, the online discourse around mental health concerns, like anxiety, has had some positive influences, such as reduced stigma. Several social media influencers and celebrities have revealed their own struggles with anxiety and other mental health conditions, which could be considered a net benefit. However, a distinction that often gets lost in this discussion is that there are several key differences between feeling anxious and having Generalized Anxiety Disorder (GAD).

Most everyone feels anxious or has worries on occasion; however, some people experience this at a level that is atypical and is often described as excessive. The DSM-5 TR by the American Psychiatric Association notes a few key features of GAD. First, “the essential feature of Generalized Anxiety Disorder is excessive anxiety and worry about a number of events or activities” (APA, 2022, p. 251). Second, “the individual finds it difficult to control the worry and to keep worrisome thoughts from interfering with the task at hand” (APA, 2022, p. 251). This difficulty with controlling worry is one of the primary differences between “being anxious” and meeting diagnostic criteria for GAD (APA, 2022). Meaning, the anxiety is so severe that it can, at times, significantly impair the individual’s ability to function on a day-to-day basis.

Another key difference between worrying and GAD is that a person with GAD experiences worries that are in excess of or disproportionate to the event or situations causing the worry and interfere with everyday life (APA, 2022). An example of this might be someone worrying they will never succeed at baking a cake after failing to measure the flour correctly a few times. Or, they might have trouble leaving the house because they are convinced some disaster is imminent.
Additionally, a distinguishing feature of GAD is that the anxiety is often accompanied by physical symptoms such as restlessness, difficulty concentrating, muscle tension, heart palpitations, and irritability (APA, 2022).

A potentially useful cognitive-behavioral exercise to help with regulating anxiety or GAD is evaluating your worries. Sokol & Fox (2019) recommend pausing and considering the following 3-5 questions:

1. What am I concerned about, and is it likely to happen or unlikely to happen?
2. If a particular problem occurred, what would be the worst, best, and most likely outcome?
3. If your concern is “likely” to happen, proceed to the next question; however, if it is not, remind yourself not to spend excessive energy on unlikely or minor issues
4. If this problem is likely to occur, what, if anything, can I do to solve it?
5. When addressing the problem, what are my options, and what are the upsides and downsides of these options? If there is nothing you can do, then accept that you have done all you can and move on with your day.

 
As always, I recommend reaching out for professional help if anxiety or other mental health conditions are seriously impacting your life.
 
Works Cited
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association.
Sokol, L. & Fox, M. (2019). The comprehensive clinician’s guide to cognitive behavioral therapy. PESI Publishing.

By Gabriel Macfee, LCP, LMLP

Gabriel believes firmly that therapy should promote growth in both the client and practitioner, so he is always focused on learning and working.

Depression is one of the most common mental health disorders in the United States — this is not a controversial statement. The DSM 5-TR by the American Psychiatric Association notes that the “twelve-month prevalence of Major depressive disorder in the United States is approximately 7%” (APA, 2022, p. 187).* This means that over one year, approximately 7% of the entire U.S. population will experience at least one episode of major depressive disorder. This number does not include individuals experiencing other forms of depression, such as persistent depressive disorder or premenstrual dysphoric disorder. Cognitive theorists (a school of psychological thinking) believe that depression is primarily fueled by two main issues: first, depressed individuals are overly negative in their beliefs about themselves, the future, and the world (Sokol & Fox, 2019). Put simply, individuals who are depressed speak or think poorly of themselves, believe that the future will not be bright, and believe that the world either is ruined or will be ruined. The second issue is that depressed people behaviorally withdraw from life, which often leads them to reinforce their unhealthy negative beliefs (Sokol & Fox, 2019). For example, it is difficult to determine if you are skilled at running if you never go out to run. Another example, it is difficult to notice that the weather outside is great if you don’t smell the roses.

While depression is a complex interaction of social, psychological, and biological factors, here are some suggestions to potentially assist you in managing depressive symptoms. To address negative thinking, the simplest step is to notice and/or document when, how often, and what you are thinking about when you are feeling down. Many people are surprised when they discover just how much of the day is spent brooding when feeling depressed. Once you are aware of your unhealthy negative thinking patterns, consider alternative perspectives. Next, compare and contrast your mood when you adopt the alternative thought process versus your typical ruminative thought process. For example, rather than ruminating on “today is bound to be awful,” the alternative could be, “today could be hard, but maybe something enjoyable could happen as well.”

To address the behavioral withdrawal, the most accessible step to take is to become behaviorally activated. Go for a walk, start a new hobby, call a friend on the phone, bake a cake. Get up and move your body, or spend time with someone with whom you can take in new data to compare with your negative beliefs. Avoid doomscrolling and staying in bed all day. Depression often contributes to a sense of inertia that makes you believe you must be “in the mood” to do something when, in reality, this is false. The research shows that “action in the face of depression is what leads to energy, motivation, and a positive mood” (Sokol & Fox, 2019, p. 75). If depression persists, it is, of course, always a good idea to seek out additional support and treatment.

*American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association.
Sokol, L. & Fox, M. (2019). The comprehensive clinician’s guide to cognitive behavioral therapy. PESI Publishing.

By Gabriel Macfee, LCP, LMLP

Gabriel believes firmly that therapy should promote growth in both the client and practitioner, so he is always focused on learning and working.

 As someone who has worked with many children with Attention Deficit Hyperactivity Disorder (ADHD) and who has ADHD myself, I often encounter a few behaviors that can be frustrating for parents and teachers. One of the most common issues mentioned is that children with ADHD frequently lie about relatively minor issues. This can be incredibly frustrating to parents, as repeated lying sometimes leads them to feel that their child or teen is ignoring their family values of honesty or that there is something “wrong” with their child's character. This is an understandable line of thought for adults who, on average, have high levels of self-discipline or a logical mindset. Some of the main diagnostic features of ADHD can be enlightening on this issue.

The DSM-5 TR by the American Psychiatric Association notes that impulsivity manifests from the hyperactivity portion of attention-deficit hyperactivity disorder and that this impulsivity may manifest as “making important decisions without consideration of long-term consequences” (APA, 2022, p. 70). To put this more plainly, individuals with ADHD often do not consider potential consequences when making decisions, particularly when they are experiencing heightened emotions, as is often the case with children or adolescents. For example, when caught breaking a rule or not following through on a previous request, that child/teen may quickly decide that lying or doubling down with a lie is the best or safest choice to avoid experiencing negative consequences with their caregivers. The adolescent or child often does not foresee that in that moment, they may get in more trouble if they are caught lying, or that their parents could be proud of them for taking accountability and admitting the mistake.
             
So, you may be asking how do I help my child be more successful and avoid lying when emotionally pressed? One simple step that parents can take is to model considerate and patient responses in those situations. Children/adolescents learn from observing individuals they look up to and will likely attempt to emulate the more deliberative and non-plussed approach if it is shown to them. Anecdotally, I can attest to this. I was envious of my parents, who were able to slow down and give more consideration to issues when I was a child and struggled with impulsivity.

Another simple step is to reduce the amount of emotion and urgency in the situation when a child is in trouble. Giving reassurance that the child does not need to offer immediate explanations, reminding them that they can be in less trouble if they are honest. This may provide the incentive for children and teens to tell the truth.

A last basic step is to use targeted praise when children are being honest. An example might be: “I really appreciate you telling the truth that you have not finished your homework yet, thank you.” When giving targeted praise, do not include backhanded comments such as “I wish you would always do that” or “thank you for doing that for once.” Make the praise unambiguously positive and genuine with warmth.

Please stay tuned. Each entry in this series examines a common mental health concern. If you're interested in setting up an appointment to meet with Gabe Macfee, please call us at 785-537-6051 or use our contact page here: ​https://www.manhattanmentalhealthservices.com/contactform.html
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​*American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association.