NEW ORLEANS – HeartMate 3, the latest left ventricular assist device in the HeartMate line, appears to have solved the problem of pump thrombosis, a complication that has dogged ventricular pumps since the issue leapt into medical awareness about 3 years ago (New Engl J Med. 2014 Jan 2;370:33-40).

During 6 months of follow-up, none of 152 heart failure patients assigned to receive a HeartMate 3 left ventricular assist device (LVAD) developed suspected or confirmed pump thrombosis, compared with 14 patients (10%) having pump thrombosis out of 138 recipients of the prior-generation HeartMate II LVAD who served as the control group for the study.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

NEW ORLEANS – HeartMate 3, the latest left ventricular assist device in the HeartMate line, appears to have solved the problem of pump thrombosis, a complication that has dogged ventricular pumps since the issue leapt into medical awareness about 3 years ago (New Engl J Med. 2014 Jan 2;370:33-40).

During 6 months of follow-up, none of 152 heart failure patients assigned to receive a HeartMate 3 left ventricular assist device (LVAD) developed suspected or confirmed pump thrombosis, compared with 14 patients (10%) having pump thrombosis out of 138 recipients of the prior-generation HeartMate II LVAD who served as the control group for the study.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

NEW ORLEANS – HeartMate 3, the latest left ventricular assist device in the HeartMate line, appears to have solved the problem of pump thrombosis, a complication that has dogged ventricular pumps since the issue leapt into medical awareness about 3 years ago (New Engl J Med. 2014 Jan 2;370:33-40).

During 6 months of follow-up, none of 152 heart failure patients assigned to receive a HeartMate 3 left ventricular assist device (LVAD) developed suspected or confirmed pump thrombosis, compared with 14 patients (10%) having pump thrombosis out of 138 recipients of the prior-generation HeartMate II LVAD who served as the control group for the study.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

Click here to download the PDF. 

Click here to download the PDF. 

Click here to download the PDF. 

BOSTON – As part of the push to create value-based care across the specialties, hepatologists should consider medical homes for their patients, such as those with cirrhosis, according to experts.

“Cirrhosis is a chronic condition, highly symptomatic, and occurs in highly comorbid individuals. Treating them in a medical home scenario means we can offer services that we don’t otherwise do, but which are associated with better outcomes for our patients,” Fasiha Kanwal, MD, of the department of medicine at Baylor College of Medicine, Houston, said in a panel presentation at the annual meeting of the American Association for the Study of Liver Diseases.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

BOSTON – As part of the push to create value-based care across the specialties, hepatologists should consider medical homes for their patients, such as those with cirrhosis, according to experts.

“Cirrhosis is a chronic condition, highly symptomatic, and occurs in highly comorbid individuals. Treating them in a medical home scenario means we can offer services that we don’t otherwise do, but which are associated with better outcomes for our patients,” Fasiha Kanwal, MD, of the department of medicine at Baylor College of Medicine, Houston, said in a panel presentation at the annual meeting of the American Association for the Study of Liver Diseases.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

BOSTON – As part of the push to create value-based care across the specialties, hepatologists should consider medical homes for their patients, such as those with cirrhosis, according to experts.

“Cirrhosis is a chronic condition, highly symptomatic, and occurs in highly comorbid individuals. Treating them in a medical home scenario means we can offer services that we don’t otherwise do, but which are associated with better outcomes for our patients,” Fasiha Kanwal, MD, of the department of medicine at Baylor College of Medicine, Houston, said in a panel presentation at the annual meeting of the American Association for the Study of Liver Diseases.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.

Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.

Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.

Understanding giftedness

A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.

A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”

The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:

• Rapid learners.
• Strong memory.
• Large vocabulary.
• Advanced comprehension of nuances.
• Largely self-taught.
• Unusual emotional depth.
• Abstract/complex/logical/insightful thinking.
• Idealism and a sense of justice.
• Intense feelings and reactions.
• Highly sensitive.
• Long attention span and persistence.
• Preoccupied with own thoughts.
• Impatient with self and others’ inabilities and slowness.
• Asks probing questions (able to go beyond what is taught).
• Wide range of interests.
• Highly developed curiosity.
• Interest in experimenting and doing things differently.
• Divergent thinking.
• Keen and unusual sense of humor.

Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”

“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.

How giftedness can be misdiagnosed

It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.

“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.

Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
 

Twice exceptionalism (2e)

Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.

“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”

Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.

Maximizing gifted children’s developmental potential

Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.

In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.

Dr. Peters reported no disclosures.

SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.

Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.

Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.

Understanding giftedness

A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.

A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”

The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:

• Rapid learners.
• Strong memory.
• Large vocabulary.
• Advanced comprehension of nuances.
• Largely self-taught.
• Unusual emotional depth.
• Abstract/complex/logical/insightful thinking.
• Idealism and a sense of justice.
• Intense feelings and reactions.
• Highly sensitive.
• Long attention span and persistence.
• Preoccupied with own thoughts.
• Impatient with self and others’ inabilities and slowness.
• Asks probing questions (able to go beyond what is taught).
• Wide range of interests.
• Highly developed curiosity.
• Interest in experimenting and doing things differently.
• Divergent thinking.
• Keen and unusual sense of humor.

Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”

“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.

How giftedness can be misdiagnosed

It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.

“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.

Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
 

Twice exceptionalism (2e)

Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.

“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”

Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.

Maximizing gifted children’s developmental potential

Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.

In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.

Dr. Peters reported no disclosures.

SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.

Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.

Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.

Understanding giftedness

A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.

A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”

The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:

• Rapid learners.
• Strong memory.
• Large vocabulary.
• Advanced comprehension of nuances.
• Largely self-taught.
• Unusual emotional depth.
• Abstract/complex/logical/insightful thinking.
• Idealism and a sense of justice.
• Intense feelings and reactions.
• Highly sensitive.
• Long attention span and persistence.
• Preoccupied with own thoughts.
• Impatient with self and others’ inabilities and slowness.
• Asks probing questions (able to go beyond what is taught).
• Wide range of interests.
• Highly developed curiosity.
• Interest in experimenting and doing things differently.
• Divergent thinking.
• Keen and unusual sense of humor.

Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”

“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.

How giftedness can be misdiagnosed

It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.

“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.

Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
 

Twice exceptionalism (2e)

Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.

“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”

Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.

Maximizing gifted children’s developmental potential

Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.

In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.

Dr. Peters reported no disclosures.

NEW ORLEANS – Oral iron supplementation was declared ineffective for the treatment of iron deficiency in patients with heart failure with reduced ejection fraction in one major randomized trial while intravenous ferric carboxymaltose improved exercise capacity and quality of life in another study presented at the American Heart Association scientific sessions.

Iron deficiency is present in roughly half of patients with heart failure with reduced ejection fraction (HFrEF). In affected patients it’s associated with diminished functional capacity and poor quality of life, and is an independent predictor of mortality. Thus, it has emerged as a potential therapeutic target in HFrEF.

bjancin@frontlinemedcom.com


 

NEW ORLEANS – Oral iron supplementation was declared ineffective for the treatment of iron deficiency in patients with heart failure with reduced ejection fraction in one major randomized trial while intravenous ferric carboxymaltose improved exercise capacity and quality of life in another study presented at the American Heart Association scientific sessions.

Iron deficiency is present in roughly half of patients with heart failure with reduced ejection fraction (HFrEF). In affected patients it’s associated with diminished functional capacity and poor quality of life, and is an independent predictor of mortality. Thus, it has emerged as a potential therapeutic target in HFrEF.

bjancin@frontlinemedcom.com


 

NEW ORLEANS – Oral iron supplementation was declared ineffective for the treatment of iron deficiency in patients with heart failure with reduced ejection fraction in one major randomized trial while intravenous ferric carboxymaltose improved exercise capacity and quality of life in another study presented at the American Heart Association scientific sessions.

Iron deficiency is present in roughly half of patients with heart failure with reduced ejection fraction (HFrEF). In affected patients it’s associated with diminished functional capacity and poor quality of life, and is an independent predictor of mortality. Thus, it has emerged as a potential therapeutic target in HFrEF.

bjancin@frontlinemedcom.com


 

BOSTON – Though criteria for insurance approval for direct-acting antivirals (DAAs) for hepatitis C virus (HCV) are loosening, many patients are still denied by both public and private carriers. Providers and patients should know that it’s worthwhile to appeal these denials; 78.1% (115 of 145) of initial DAA denials were approved on appeal, according to a recent study.

Jane Giang, PharmD, a clinical pharmacist at the University of North Carolina Health System, Chapel Hill, worked with colleagues to conduct a retrospective study of patients at her facility who were prescribed a DAA for HCV between October 2014 and April 2016.

Dr. Giang, in a video interview at the annual meeting of the American Association for the Study of Liver Diseases, said that she works alongside physicians in her clinic to craft appeals, tailoring appeal letters to individual patients’ circumstances.

koakes@frontlinemedcom.com

On Twitter@karioakes

BOSTON – Though criteria for insurance approval for direct-acting antivirals (DAAs) for hepatitis C virus (HCV) are loosening, many patients are still denied by both public and private carriers. Providers and patients should know that it’s worthwhile to appeal these denials; 78.1% (115 of 145) of initial DAA denials were approved on appeal, according to a recent study.

Jane Giang, PharmD, a clinical pharmacist at the University of North Carolina Health System, Chapel Hill, worked with colleagues to conduct a retrospective study of patients at her facility who were prescribed a DAA for HCV between October 2014 and April 2016.

Dr. Giang, in a video interview at the annual meeting of the American Association for the Study of Liver Diseases, said that she works alongside physicians in her clinic to craft appeals, tailoring appeal letters to individual patients’ circumstances.

koakes@frontlinemedcom.com

On Twitter@karioakes

BOSTON – Though criteria for insurance approval for direct-acting antivirals (DAAs) for hepatitis C virus (HCV) are loosening, many patients are still denied by both public and private carriers. Providers and patients should know that it’s worthwhile to appeal these denials; 78.1% (115 of 145) of initial DAA denials were approved on appeal, according to a recent study.

Jane Giang, PharmD, a clinical pharmacist at the University of North Carolina Health System, Chapel Hill, worked with colleagues to conduct a retrospective study of patients at her facility who were prescribed a DAA for HCV between October 2014 and April 2016.

Dr. Giang, in a video interview at the annual meeting of the American Association for the Study of Liver Diseases, said that she works alongside physicians in her clinic to craft appeals, tailoring appeal letters to individual patients’ circumstances.

koakes@frontlinemedcom.com

On Twitter@karioakes

CORONADO, CALIF. – Among advanced cancer patients with bowel obstruction, surgery was not an independent predictor of the ability to eat at discharge or survival within 90 days of consultation, results from a long-term retrospective study showed.

“I think this represents the complexity in treating these patients,” lead study author Brian D. Badgwell, MD, said at the annual meeting of the Western Surgical Association. “We need future studies to identify the optimal outcome measures.”

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Among advanced cancer patients with bowel obstruction, surgery was not an independent predictor of the ability to eat at discharge or survival within 90 days of consultation, results from a long-term retrospective study showed.

“I think this represents the complexity in treating these patients,” lead study author Brian D. Badgwell, MD, said at the annual meeting of the Western Surgical Association. “We need future studies to identify the optimal outcome measures.”

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Among advanced cancer patients with bowel obstruction, surgery was not an independent predictor of the ability to eat at discharge or survival within 90 days of consultation, results from a long-term retrospective study showed.

“I think this represents the complexity in treating these patients,” lead study author Brian D. Badgwell, MD, said at the annual meeting of the Western Surgical Association. “We need future studies to identify the optimal outcome measures.”

dbrunk@frontlinemedcom.com

One of us practices in the “new south” community of Charlotte, N.C., “a red state”; the other is in the “blue bubble” of Washington. In our respective polarized zones, the divergent reactions we heard about the presidential candidates were akin to projective responses to Rorschach tests.

As mental health clinicians, we knew that the country was wounded and in need of healing long before the outcome of the unconventional and acrimonious 2016 American presidential race. So, we were concerned about how patients, clinicians, and divergent communities would go about healing after an 18-month pre-election slugfest that revealed bigotry that persists more than 150 years after the Civil War.

Background of ‘two sides’

None of the nasty rhetoric delivered by our now president-elect or the clearly defensive responses we heard from our former secretary of state were going to be easily forgotten after Nov. 8, 2016. As the process unfolded, however, the voice of psychiatry, with some notable exceptions (the blog of Justin Frank, MD, for example), was absent from the public dialogue.

There is a virus infecting our politics and right now it’s flourishing with a scarlet fever. It feeds on fear, paranoia and bigotry. All that was required for it to spread was a timely opportunity – and an opportunist with no scruples. ... There have been stretches of history when this virus lay dormant. ... Today its carrier is Donald Trump, but others came before him: narcissistic demagogues who lie and distort in pursuit of power and self-promotion. Bullies all, swaggering across the landscape with fistfuls of false promises, smears, innuendo and hatred for others, spite and spittle for anyone of a different race, faith, gender, or nationality.¹

Alternatively, some had a smoldering fear of the progressive agenda to bring “others” – more women, African Americans, Latinos, the LGBTQ community, Muslims, and the disabled – securely under the tent of American democracy. Others, especially the underemployed cohort in neglected and struggling communities in Middle America, were simply opposed to a continuation of “politics as usual,” a.k.a. Hillary Clinton, and were desperate for change.

Causes of concern

In the months leading up to the election, violent events strained the societal divisions. The police use of force² resulted in the near-daily deaths of African American men and women and other people of color at the hands of police officers. The events built on a long and growing list of violent acts – the racially motivated shootings of nine men and women in a Charleston, S.C., church, the bombing injuries and deaths at the Boston Marathon, the shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School, the homophobia-motivated shootings in a Florida nightclub – that have heightened levels of fear, anxiety, and concern for personal and family safety. For many, life has felt fragile and out of control, the perfect setup to motivate the electorate to cast their votes for the person they imagined had the most power and most interest in restoring their sense of control over their lives and, ultimately, their sense of safety.

Why the fear? A psychodynamic analysis

As psychiatrists trained in psychodynamic theory, we are quite familiar with the concept of identifying with the aggressor as a means of coping. The classic example is when a child watches his or her parents in an abusive relationship and identifies with the abusive parent in an attempt to avoid identifying with the victimized parent.

This dynamic is one that seems to have played out during this presidential election. By October 2016, Donald J. Trump already reportedly had insulted more than 280 people, places, and things on Twitter.³ Despite the evidence that Mr. Trump verbally bullied not only his opponents, but also the media, Latinos, women, the LGBTQ community, the Republican Party (his claimed party), and Muslims, people came out in numbers high enough to make him America’s president-elect. In the classic process of bullying his perceived enemies, those considered “the other,” he assigned names such as “crooked Hillary,” “little Marco,” and “lyin’ Ted” – just as a bully at school assigns names to the kid he’s decided does not have enough worth to be called by his given name.

He depicted women who accused him of sexual assault as either not being pretty enough to be worthy of assault or self-serving in their public accusations. Mexicans entering this country were referred to as “rapists and thugs.” African Americans were told that their lives are so bad that they “have nothing to lose” if they voted for a candidate who talked about erecting a wall to block out other people of color, and changing immigration laws that would banish an entire religion from entering our country.
 

The ‘blue bubble’ – Those who voted for Mrs. Clinton

So … this happened. And, in our consulting rooms, we are seeing a stark increase in the numbers of individuals, couples, and families reporting overwhelming anxiety, sadness, and a sense of de-realization (“it’s surreal”). At the core of their anxiety is concern for self, family, and friends as well as concern for the country as a whole.

The post-election notions that families would be immediately broken up, parents deported, the Affordable Care Act immediately dismantled, and countries bombed immediately after Election Day did not become realities. However, there is valid reason to be concerned. The Southern Poverty Law Center has noted a significant increase in post-election hate crimes throughout the nation.⁴

The new South ‘red states’ – those who voted for Mr. Trump

Trump supporters are feeling victorious because their “underdog” candidate ran an unconventional presidential campaign and won. However, some who voted for Mr. Trump will at some point experience anxiety when the excitement of “winning” wears off. Psychoanalyst Justin Frank speaks to this and more in his Nov. 9, 2016, blog in which he concludes: “While we mourn and blame others and ourselves for our American tragedy, Trump voters must eventually look at themselves in the mirror and exclaim, ‘what have we done?’ ”⁵

In his Oct. 25, 2016, New York Times article, Michael Barbaro summarized the behaviors that will become increasingly of concern to all as Mr. Trump accepts the oath of office:

The intense ambitions and undisciplined behaviors of Mr. Trump have confounded even those close to him.... In interviews, Mr. Trump makes clear just how difficult it is for him to imagine – let alone accept – defeat....

“I never had a failure,” Mr. Trump said in one of the interviews, despite his repeated corporate bankruptcies and business setbacks, “because I always turned a failure into a success.”⁶

This fundamental inability to accept responsibility and the attempt to distort reality is something that must concern each of us, regardless of our ideological differences.

Distress tolerance as a model for healing

Even before the outcome of the election, we were hearing from patients who did not feel safe and who reported being “terrified” about what our country might become. This is where a focus on processing the pain and decreasing anxiety is necessary. This is not an anxiety we can medicate with anxiolytics or rationalize by telling ourselves and our patients that the best man won “fair and square.” We have each – by this time – experienced patients who are quite shaken by this turn of events.

Although it has not received much press, many consider Mr. Trump’s victory to be, in part, a “white backlash.” Many supporters of Mr. Trump have felt too ashamed to publicly admit their support for a candidate who at least by innuendo incited fear, anger, and violence. This failure has created an anxiety reminiscent of the daytime anxiety experienced by people who survived nighttime lynchings in small Southern towns. The day after the lynching, it was not unusual for African American men, women, and children to wonder if their grocer, banker, postal carrier, or sheriff had donned a white hood the night before and lynched someone in their community.

The question of survival, how to survive the unimaginable, is what most distresses people. They’ve wondered out loud whether they, their family, and friends would be attacked and/or killed by those who now feel emboldened and authorized to act on their latent aggressive impulses. And, our patients’ fears are legitimate because, unfortunately, studies show that verbal aggression is correlated with increased risk of physical violence and even murder.⁷

In the dialectical behavioral therapy (DBT) construct developed by Marsha M. Linehan, PhD, the goals of distress tolerance are crisis survival, reality acceptance, and then freedom.⁸

As we apply our skills, we are uniquely positioned to help our patients and their families survive this crisis, accept that this is our president-elect, and ultimately be free from the anxiety created by the behavior that we all witnessed. We can aid in the navigation through this storm.

Acceptance

We’re already on to reality acceptance. The reality that so many African Americans and people of color have been living is now known and experienced by many who had felt immune to being marginalized. They now understand the loss of security that accompanies overwhelming fear of being the object of verbal, emotional, and physical aggression and violence.

Some are coping by entertaining fantasies that this election outcome will be undone, that the Electoral College will not approve our president-elect when it meets on Dec. 19 or that Mr. Trump will be impeached early in this upcoming term. The results of the presidential election are unlikely to be undone, so having more than 2 months between Election Day and the inauguration to work on acceptance will be helpful. The goal here is to accept the past, be hopeful about the future, and be vigilant in the present.
 

Freedom

Now, on to freedom. Our goal is to have all of our patients, families, colleagues, and communities able to live without fear that our leaders are not able to apply humanitarian principles to keep all of us safe. The next few months are crucial. Americans must speak out and debride the wound that bullying intentionally causes. Just as with a school bully, Mr. Trump’s behavior has to be called what it is, not sugarcoated or normalized.

History is full of critical moments in time in which, even in our fear, we said nothing. Even the most empathic of us watched the bully at school and felt relief that his behavior was not directed toward us. But we must not avert our gaze.

Bill Moyers and Michael Winship compared Mr. Trump to Sen. Joseph McCarthy, whose reign of terror was ended when journalist Edward R. Murrow courageously spoke out in defiance of the senator. At the end of one of his segments on “See It Now,” Mr. Murrow concluded as he signed off:

We will not walk in fear, one of another. We will not be driven by fear into an age of unreason, if we dig deep in our history and our doctrine, and remember that we are not descended from fearful men — not from men who feared to write, to speak, to associate and to defend causes that were, for the moment, unpopular.⁹

And, so, how do we cope?

Fortunately, we understand bullying. The bully doesn’t take over the entire school and won’t have the power to take over one’s entire life if the behavior is brought out in the open and openly discussed. But bullies need to accept responsibility, which is what Sen. Harry Reid of Nevada and other legislators urged President-elect Trump to do in days immediately following the election.¹⁰ They have called on him to discourage the fear, anger, and violence leading up to and following the election. This action on Mr. Trump’s part would promote a vitally needed national healing process.

Ultimately, this is “the land of the free, the home of the brave …” and we will do what we have always done as psychiatrists and mental health professionals who help to heal wounds. Not all of us will participate in social justice initiatives. However, each of us can listen with intense compassion and interest to those with whom we identify politically and to those whose views diverge from our own. This is our most potent tool in a conflict where we don’t understand the motives of unpredictable leaders or their followers. It is only with this skilled listening that a space is created in which each “other” hears the “other.” This is where real healing begins.

The views expressed in this article are solely those of the authors, and are not meant to represent the views of the American Psychiatric Association, Novant Health, Clinical Psychiatry News, or any other organization.

References

1. http://billposters/story/trump-virus-dark-age-unreason

2. http://blackdoctor.org/495036/national-medical-association-statement-on-police-use-of-force

3. http://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html?_r=0

4. https://www.splcenter.org/hatewatch/2016/11/11/over-200-incidents-hateful-harassment-and-intimidation-election-day

5. http://www.obamaonthecouch.com

6. http://www.nytimes.com/2016/10/26/us/politics/donald-trump-interviews.html

7. “The Nature of Prejudice,” (New York: Perseus Books Publishing, 1979).

8. DBT® Skills Training Handouts and Worksheets, Second Edition (New York: The Guilford Press, 2014).

9. http://billmoyers.com/story/trump-virus-dark-age-unreason

10. http://www.reid.senate.gov/press_releases/2016-11-11-reid-statement-on-the-election-of-donald-trump#.WC0iA6IrKgR

Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is the immediate past president of the Washington Psychiatric Society, and associate clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics. Dr. Ifill-Taylor, a child, adolescent, and adult psychiatrist, is in practice as a medical director in Charlotte, N.C. Previously, she was in private practice in the Washington area and worked as a staff psychiatrist for the Department of Veterans Affairs. She is particularly interested in the effect of our social, political, and occupational environment on mental and physical health.

One of us practices in the “new south” community of Charlotte, N.C., “a red state”; the other is in the “blue bubble” of Washington. In our respective polarized zones, the divergent reactions we heard about the presidential candidates were akin to projective responses to Rorschach tests.

As mental health clinicians, we knew that the country was wounded and in need of healing long before the outcome of the unconventional and acrimonious 2016 American presidential race. So, we were concerned about how patients, clinicians, and divergent communities would go about healing after an 18-month pre-election slugfest that revealed bigotry that persists more than 150 years after the Civil War.

Background of ‘two sides’

None of the nasty rhetoric delivered by our now president-elect or the clearly defensive responses we heard from our former secretary of state were going to be easily forgotten after Nov. 8, 2016. As the process unfolded, however, the voice of psychiatry, with some notable exceptions (the blog of Justin Frank, MD, for example), was absent from the public dialogue.

There is a virus infecting our politics and right now it’s flourishing with a scarlet fever. It feeds on fear, paranoia and bigotry. All that was required for it to spread was a timely opportunity – and an opportunist with no scruples. ... There have been stretches of history when this virus lay dormant. ... Today its carrier is Donald Trump, but others came before him: narcissistic demagogues who lie and distort in pursuit of power and self-promotion. Bullies all, swaggering across the landscape with fistfuls of false promises, smears, innuendo and hatred for others, spite and spittle for anyone of a different race, faith, gender, or nationality.¹

Alternatively, some had a smoldering fear of the progressive agenda to bring “others” – more women, African Americans, Latinos, the LGBTQ community, Muslims, and the disabled – securely under the tent of American democracy. Others, especially the underemployed cohort in neglected and struggling communities in Middle America, were simply opposed to a continuation of “politics as usual,” a.k.a. Hillary Clinton, and were desperate for change.

Causes of concern

In the months leading up to the election, violent events strained the societal divisions. The police use of force² resulted in the near-daily deaths of African American men and women and other people of color at the hands of police officers. The events built on a long and growing list of violent acts – the racially motivated shootings of nine men and women in a Charleston, S.C., church, the bombing injuries and deaths at the Boston Marathon, the shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School, the homophobia-motivated shootings in a Florida nightclub – that have heightened levels of fear, anxiety, and concern for personal and family safety. For many, life has felt fragile and out of control, the perfect setup to motivate the electorate to cast their votes for the person they imagined had the most power and most interest in restoring their sense of control over their lives and, ultimately, their sense of safety.

Why the fear? A psychodynamic analysis

As psychiatrists trained in psychodynamic theory, we are quite familiar with the concept of identifying with the aggressor as a means of coping. The classic example is when a child watches his or her parents in an abusive relationship and identifies with the abusive parent in an attempt to avoid identifying with the victimized parent.

This dynamic is one that seems to have played out during this presidential election. By October 2016, Donald J. Trump already reportedly had insulted more than 280 people, places, and things on Twitter.³ Despite the evidence that Mr. Trump verbally bullied not only his opponents, but also the media, Latinos, women, the LGBTQ community, the Republican Party (his claimed party), and Muslims, people came out in numbers high enough to make him America’s president-elect. In the classic process of bullying his perceived enemies, those considered “the other,” he assigned names such as “crooked Hillary,” “little Marco,” and “lyin’ Ted” – just as a bully at school assigns names to the kid he’s decided does not have enough worth to be called by his given name.

He depicted women who accused him of sexual assault as either not being pretty enough to be worthy of assault or self-serving in their public accusations. Mexicans entering this country were referred to as “rapists and thugs.” African Americans were told that their lives are so bad that they “have nothing to lose” if they voted for a candidate who talked about erecting a wall to block out other people of color, and changing immigration laws that would banish an entire religion from entering our country.
 

The ‘blue bubble’ – Those who voted for Mrs. Clinton

So … this happened. And, in our consulting rooms, we are seeing a stark increase in the numbers of individuals, couples, and families reporting overwhelming anxiety, sadness, and a sense of de-realization (“it’s surreal”). At the core of their anxiety is concern for self, family, and friends as well as concern for the country as a whole.

The post-election notions that families would be immediately broken up, parents deported, the Affordable Care Act immediately dismantled, and countries bombed immediately after Election Day did not become realities. However, there is valid reason to be concerned. The Southern Poverty Law Center has noted a significant increase in post-election hate crimes throughout the nation.⁴

The new South ‘red states’ – those who voted for Mr. Trump

Trump supporters are feeling victorious because their “underdog” candidate ran an unconventional presidential campaign and won. However, some who voted for Mr. Trump will at some point experience anxiety when the excitement of “winning” wears off. Psychoanalyst Justin Frank speaks to this and more in his Nov. 9, 2016, blog in which he concludes: “While we mourn and blame others and ourselves for our American tragedy, Trump voters must eventually look at themselves in the mirror and exclaim, ‘what have we done?’ ”⁵

In his Oct. 25, 2016, New York Times article, Michael Barbaro summarized the behaviors that will become increasingly of concern to all as Mr. Trump accepts the oath of office:

The intense ambitions and undisciplined behaviors of Mr. Trump have confounded even those close to him.... In interviews, Mr. Trump makes clear just how difficult it is for him to imagine – let alone accept – defeat....

“I never had a failure,” Mr. Trump said in one of the interviews, despite his repeated corporate bankruptcies and business setbacks, “because I always turned a failure into a success.”⁶

This fundamental inability to accept responsibility and the attempt to distort reality is something that must concern each of us, regardless of our ideological differences.

Distress tolerance as a model for healing

Even before the outcome of the election, we were hearing from patients who did not feel safe and who reported being “terrified” about what our country might become. This is where a focus on processing the pain and decreasing anxiety is necessary. This is not an anxiety we can medicate with anxiolytics or rationalize by telling ourselves and our patients that the best man won “fair and square.” We have each – by this time – experienced patients who are quite shaken by this turn of events.

Although it has not received much press, many consider Mr. Trump’s victory to be, in part, a “white backlash.” Many supporters of Mr. Trump have felt too ashamed to publicly admit their support for a candidate who at least by innuendo incited fear, anger, and violence. This failure has created an anxiety reminiscent of the daytime anxiety experienced by people who survived nighttime lynchings in small Southern towns. The day after the lynching, it was not unusual for African American men, women, and children to wonder if their grocer, banker, postal carrier, or sheriff had donned a white hood the night before and lynched someone in their community.

The question of survival, how to survive the unimaginable, is what most distresses people. They’ve wondered out loud whether they, their family, and friends would be attacked and/or killed by those who now feel emboldened and authorized to act on their latent aggressive impulses. And, our patients’ fears are legitimate because, unfortunately, studies show that verbal aggression is correlated with increased risk of physical violence and even murder.⁷

In the dialectical behavioral therapy (DBT) construct developed by Marsha M. Linehan, PhD, the goals of distress tolerance are crisis survival, reality acceptance, and then freedom.⁸

As we apply our skills, we are uniquely positioned to help our patients and their families survive this crisis, accept that this is our president-elect, and ultimately be free from the anxiety created by the behavior that we all witnessed. We can aid in the navigation through this storm.

Acceptance

We’re already on to reality acceptance. The reality that so many African Americans and people of color have been living is now known and experienced by many who had felt immune to being marginalized. They now understand the loss of security that accompanies overwhelming fear of being the object of verbal, emotional, and physical aggression and violence.

Some are coping by entertaining fantasies that this election outcome will be undone, that the Electoral College will not approve our president-elect when it meets on Dec. 19 or that Mr. Trump will be impeached early in this upcoming term. The results of the presidential election are unlikely to be undone, so having more than 2 months between Election Day and the inauguration to work on acceptance will be helpful. The goal here is to accept the past, be hopeful about the future, and be vigilant in the present.
 

Freedom

Now, on to freedom. Our goal is to have all of our patients, families, colleagues, and communities able to live without fear that our leaders are not able to apply humanitarian principles to keep all of us safe. The next few months are crucial. Americans must speak out and debride the wound that bullying intentionally causes. Just as with a school bully, Mr. Trump’s behavior has to be called what it is, not sugarcoated or normalized.

History is full of critical moments in time in which, even in our fear, we said nothing. Even the most empathic of us watched the bully at school and felt relief that his behavior was not directed toward us. But we must not avert our gaze.

Bill Moyers and Michael Winship compared Mr. Trump to Sen. Joseph McCarthy, whose reign of terror was ended when journalist Edward R. Murrow courageously spoke out in defiance of the senator. At the end of one of his segments on “See It Now,” Mr. Murrow concluded as he signed off:

We will not walk in fear, one of another. We will not be driven by fear into an age of unreason, if we dig deep in our history and our doctrine, and remember that we are not descended from fearful men — not from men who feared to write, to speak, to associate and to defend causes that were, for the moment, unpopular.⁹

And, so, how do we cope?

Fortunately, we understand bullying. The bully doesn’t take over the entire school and won’t have the power to take over one’s entire life if the behavior is brought out in the open and openly discussed. But bullies need to accept responsibility, which is what Sen. Harry Reid of Nevada and other legislators urged President-elect Trump to do in days immediately following the election.¹⁰ They have called on him to discourage the fear, anger, and violence leading up to and following the election. This action on Mr. Trump’s part would promote a vitally needed national healing process.

Ultimately, this is “the land of the free, the home of the brave …” and we will do what we have always done as psychiatrists and mental health professionals who help to heal wounds. Not all of us will participate in social justice initiatives. However, each of us can listen with intense compassion and interest to those with whom we identify politically and to those whose views diverge from our own. This is our most potent tool in a conflict where we don’t understand the motives of unpredictable leaders or their followers. It is only with this skilled listening that a space is created in which each “other” hears the “other.” This is where real healing begins.

The views expressed in this article are solely those of the authors, and are not meant to represent the views of the American Psychiatric Association, Novant Health, Clinical Psychiatry News, or any other organization.

References

1. http://billposters/story/trump-virus-dark-age-unreason

2. http://blackdoctor.org/495036/national-medical-association-statement-on-police-use-of-force

3. http://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html?_r=0

4. https://www.splcenter.org/hatewatch/2016/11/11/over-200-incidents-hateful-harassment-and-intimidation-election-day

5. http://www.obamaonthecouch.com

6. http://www.nytimes.com/2016/10/26/us/politics/donald-trump-interviews.html

7. “The Nature of Prejudice,” (New York: Perseus Books Publishing, 1979).

8. DBT® Skills Training Handouts and Worksheets, Second Edition (New York: The Guilford Press, 2014).

9. http://billmoyers.com/story/trump-virus-dark-age-unreason

10. http://www.reid.senate.gov/press_releases/2016-11-11-reid-statement-on-the-election-of-donald-trump#.WC0iA6IrKgR

Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is the immediate past president of the Washington Psychiatric Society, and associate clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics. Dr. Ifill-Taylor, a child, adolescent, and adult psychiatrist, is in practice as a medical director in Charlotte, N.C. Previously, she was in private practice in the Washington area and worked as a staff psychiatrist for the Department of Veterans Affairs. She is particularly interested in the effect of our social, political, and occupational environment on mental and physical health.

One of us practices in the “new south” community of Charlotte, N.C., “a red state”; the other is in the “blue bubble” of Washington. In our respective polarized zones, the divergent reactions we heard about the presidential candidates were akin to projective responses to Rorschach tests.

As mental health clinicians, we knew that the country was wounded and in need of healing long before the outcome of the unconventional and acrimonious 2016 American presidential race. So, we were concerned about how patients, clinicians, and divergent communities would go about healing after an 18-month pre-election slugfest that revealed bigotry that persists more than 150 years after the Civil War.

Background of ‘two sides’

None of the nasty rhetoric delivered by our now president-elect or the clearly defensive responses we heard from our former secretary of state were going to be easily forgotten after Nov. 8, 2016. As the process unfolded, however, the voice of psychiatry, with some notable exceptions (the blog of Justin Frank, MD, for example), was absent from the public dialogue.

There is a virus infecting our politics and right now it’s flourishing with a scarlet fever. It feeds on fear, paranoia and bigotry. All that was required for it to spread was a timely opportunity – and an opportunist with no scruples. ... There have been stretches of history when this virus lay dormant. ... Today its carrier is Donald Trump, but others came before him: narcissistic demagogues who lie and distort in pursuit of power and self-promotion. Bullies all, swaggering across the landscape with fistfuls of false promises, smears, innuendo and hatred for others, spite and spittle for anyone of a different race, faith, gender, or nationality.¹

Alternatively, some had a smoldering fear of the progressive agenda to bring “others” – more women, African Americans, Latinos, the LGBTQ community, Muslims, and the disabled – securely under the tent of American democracy. Others, especially the underemployed cohort in neglected and struggling communities in Middle America, were simply opposed to a continuation of “politics as usual,” a.k.a. Hillary Clinton, and were desperate for change.

Causes of concern

In the months leading up to the election, violent events strained the societal divisions. The police use of force² resulted in the near-daily deaths of African American men and women and other people of color at the hands of police officers. The events built on a long and growing list of violent acts – the racially motivated shootings of nine men and women in a Charleston, S.C., church, the bombing injuries and deaths at the Boston Marathon, the shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School, the homophobia-motivated shootings in a Florida nightclub – that have heightened levels of fear, anxiety, and concern for personal and family safety. For many, life has felt fragile and out of control, the perfect setup to motivate the electorate to cast their votes for the person they imagined had the most power and most interest in restoring their sense of control over their lives and, ultimately, their sense of safety.

Why the fear? A psychodynamic analysis

As psychiatrists trained in psychodynamic theory, we are quite familiar with the concept of identifying with the aggressor as a means of coping. The classic example is when a child watches his or her parents in an abusive relationship and identifies with the abusive parent in an attempt to avoid identifying with the victimized parent.

This dynamic is one that seems to have played out during this presidential election. By October 2016, Donald J. Trump already reportedly had insulted more than 280 people, places, and things on Twitter.³ Despite the evidence that Mr. Trump verbally bullied not only his opponents, but also the media, Latinos, women, the LGBTQ community, the Republican Party (his claimed party), and Muslims, people came out in numbers high enough to make him America’s president-elect. In the classic process of bullying his perceived enemies, those considered “the other,” he assigned names such as “crooked Hillary,” “little Marco,” and “lyin’ Ted” – just as a bully at school assigns names to the kid he’s decided does not have enough worth to be called by his given name.

He depicted women who accused him of sexual assault as either not being pretty enough to be worthy of assault or self-serving in their public accusations. Mexicans entering this country were referred to as “rapists and thugs.” African Americans were told that their lives are so bad that they “have nothing to lose” if they voted for a candidate who talked about erecting a wall to block out other people of color, and changing immigration laws that would banish an entire religion from entering our country.
 

The ‘blue bubble’ – Those who voted for Mrs. Clinton

So … this happened. And, in our consulting rooms, we are seeing a stark increase in the numbers of individuals, couples, and families reporting overwhelming anxiety, sadness, and a sense of de-realization (“it’s surreal”). At the core of their anxiety is concern for self, family, and friends as well as concern for the country as a whole.

The post-election notions that families would be immediately broken up, parents deported, the Affordable Care Act immediately dismantled, and countries bombed immediately after Election Day did not become realities. However, there is valid reason to be concerned. The Southern Poverty Law Center has noted a significant increase in post-election hate crimes throughout the nation.⁴

The new South ‘red states’ – those who voted for Mr. Trump

Trump supporters are feeling victorious because their “underdog” candidate ran an unconventional presidential campaign and won. However, some who voted for Mr. Trump will at some point experience anxiety when the excitement of “winning” wears off. Psychoanalyst Justin Frank speaks to this and more in his Nov. 9, 2016, blog in which he concludes: “While we mourn and blame others and ourselves for our American tragedy, Trump voters must eventually look at themselves in the mirror and exclaim, ‘what have we done?’ ”⁵

In his Oct. 25, 2016, New York Times article, Michael Barbaro summarized the behaviors that will become increasingly of concern to all as Mr. Trump accepts the oath of office:

The intense ambitions and undisciplined behaviors of Mr. Trump have confounded even those close to him.... In interviews, Mr. Trump makes clear just how difficult it is for him to imagine – let alone accept – defeat....

“I never had a failure,” Mr. Trump said in one of the interviews, despite his repeated corporate bankruptcies and business setbacks, “because I always turned a failure into a success.”⁶

This fundamental inability to accept responsibility and the attempt to distort reality is something that must concern each of us, regardless of our ideological differences.

Distress tolerance as a model for healing

Even before the outcome of the election, we were hearing from patients who did not feel safe and who reported being “terrified” about what our country might become. This is where a focus on processing the pain and decreasing anxiety is necessary. This is not an anxiety we can medicate with anxiolytics or rationalize by telling ourselves and our patients that the best man won “fair and square.” We have each – by this time – experienced patients who are quite shaken by this turn of events.

Although it has not received much press, many consider Mr. Trump’s victory to be, in part, a “white backlash.” Many supporters of Mr. Trump have felt too ashamed to publicly admit their support for a candidate who at least by innuendo incited fear, anger, and violence. This failure has created an anxiety reminiscent of the daytime anxiety experienced by people who survived nighttime lynchings in small Southern towns. The day after the lynching, it was not unusual for African American men, women, and children to wonder if their grocer, banker, postal carrier, or sheriff had donned a white hood the night before and lynched someone in their community.

The question of survival, how to survive the unimaginable, is what most distresses people. They’ve wondered out loud whether they, their family, and friends would be attacked and/or killed by those who now feel emboldened and authorized to act on their latent aggressive impulses. And, our patients’ fears are legitimate because, unfortunately, studies show that verbal aggression is correlated with increased risk of physical violence and even murder.⁷

In the dialectical behavioral therapy (DBT) construct developed by Marsha M. Linehan, PhD, the goals of distress tolerance are crisis survival, reality acceptance, and then freedom.⁸

As we apply our skills, we are uniquely positioned to help our patients and their families survive this crisis, accept that this is our president-elect, and ultimately be free from the anxiety created by the behavior that we all witnessed. We can aid in the navigation through this storm.

Acceptance

We’re already on to reality acceptance. The reality that so many African Americans and people of color have been living is now known and experienced by many who had felt immune to being marginalized. They now understand the loss of security that accompanies overwhelming fear of being the object of verbal, emotional, and physical aggression and violence.

Some are coping by entertaining fantasies that this election outcome will be undone, that the Electoral College will not approve our president-elect when it meets on Dec. 19 or that Mr. Trump will be impeached early in this upcoming term. The results of the presidential election are unlikely to be undone, so having more than 2 months between Election Day and the inauguration to work on acceptance will be helpful. The goal here is to accept the past, be hopeful about the future, and be vigilant in the present.
 

Freedom

Now, on to freedom. Our goal is to have all of our patients, families, colleagues, and communities able to live without fear that our leaders are not able to apply humanitarian principles to keep all of us safe. The next few months are crucial. Americans must speak out and debride the wound that bullying intentionally causes. Just as with a school bully, Mr. Trump’s behavior has to be called what it is, not sugarcoated or normalized.

History is full of critical moments in time in which, even in our fear, we said nothing. Even the most empathic of us watched the bully at school and felt relief that his behavior was not directed toward us. But we must not avert our gaze.

Bill Moyers and Michael Winship compared Mr. Trump to Sen. Joseph McCarthy, whose reign of terror was ended when journalist Edward R. Murrow courageously spoke out in defiance of the senator. At the end of one of his segments on “See It Now,” Mr. Murrow concluded as he signed off:

We will not walk in fear, one of another. We will not be driven by fear into an age of unreason, if we dig deep in our history and our doctrine, and remember that we are not descended from fearful men — not from men who feared to write, to speak, to associate and to defend causes that were, for the moment, unpopular.⁹

And, so, how do we cope?

Fortunately, we understand bullying. The bully doesn’t take over the entire school and won’t have the power to take over one’s entire life if the behavior is brought out in the open and openly discussed. But bullies need to accept responsibility, which is what Sen. Harry Reid of Nevada and other legislators urged President-elect Trump to do in days immediately following the election.¹⁰ They have called on him to discourage the fear, anger, and violence leading up to and following the election. This action on Mr. Trump’s part would promote a vitally needed national healing process.

Ultimately, this is “the land of the free, the home of the brave …” and we will do what we have always done as psychiatrists and mental health professionals who help to heal wounds. Not all of us will participate in social justice initiatives. However, each of us can listen with intense compassion and interest to those with whom we identify politically and to those whose views diverge from our own. This is our most potent tool in a conflict where we don’t understand the motives of unpredictable leaders or their followers. It is only with this skilled listening that a space is created in which each “other” hears the “other.” This is where real healing begins.

The views expressed in this article are solely those of the authors, and are not meant to represent the views of the American Psychiatric Association, Novant Health, Clinical Psychiatry News, or any other organization.

References

1. http://billposters/story/trump-virus-dark-age-unreason

2. http://blackdoctor.org/495036/national-medical-association-statement-on-police-use-of-force

3. http://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html?_r=0

4. https://www.splcenter.org/hatewatch/2016/11/11/over-200-incidents-hateful-harassment-and-intimidation-election-day

5. http://www.obamaonthecouch.com

6. http://www.nytimes.com/2016/10/26/us/politics/donald-trump-interviews.html

7. “The Nature of Prejudice,” (New York: Perseus Books Publishing, 1979).

8. DBT® Skills Training Handouts and Worksheets, Second Edition (New York: The Guilford Press, 2014).

9. http://billmoyers.com/story/trump-virus-dark-age-unreason

10. http://www.reid.senate.gov/press_releases/2016-11-11-reid-statement-on-the-election-of-donald-trump#.WC0iA6IrKgR

Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is the immediate past president of the Washington Psychiatric Society, and associate clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics. Dr. Ifill-Taylor, a child, adolescent, and adult psychiatrist, is in practice as a medical director in Charlotte, N.C. Previously, she was in private practice in the Washington area and worked as a staff psychiatrist for the Department of Veterans Affairs. She is particularly interested in the effect of our social, political, and occupational environment on mental and physical health.

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Patients who develop a venous thromboembolism (VTE) following severe hemorrhage are more susceptible to complications, compared with their counterparts who do not; they also exhibit hypercoagulability and enhanced platelet function at admission, and have delayed recovery of coagulation and platelet function following injury.

Those are the key findings from a secondary analysis of data from the Pragmatic Randomized Optimal Platelet and Plasma Ratio (PROPPR) trial, which randomized 680 severely injured trauma patients from 12 level I trauma centers to receive 1:1:1 or 1:1:2 ratios of plasma to platelets to red blood cells (JAMA 2015;313[5]:471-82). “The prevention of VTE following traumatic injury is an ongoing challenge,” Belinda H. McCully, PhD, said at the annual meeting of the Western Surgical Association. “Despite prophylaxis, about 25% of patients present with VTE, which is associated with higher complications and an increased risk for mortality. Common risk factors for mortality include age, body mass index, extremity injury, and immobility, but the precise mechanisms that contribute to VTE development are not well understood. We do know that the three main factors contributing to thrombosis include static flow, endothelial injury, and hypercoagulability. Clinically, coagulation is the most feasible factor to assess, mainly through the use of conventional coagulation tests, thromboelastography, platelet levels, and platelet function assays.”

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Patients who develop a venous thromboembolism (VTE) following severe hemorrhage are more susceptible to complications, compared with their counterparts who do not; they also exhibit hypercoagulability and enhanced platelet function at admission, and have delayed recovery of coagulation and platelet function following injury.

Those are the key findings from a secondary analysis of data from the Pragmatic Randomized Optimal Platelet and Plasma Ratio (PROPPR) trial, which randomized 680 severely injured trauma patients from 12 level I trauma centers to receive 1:1:1 or 1:1:2 ratios of plasma to platelets to red blood cells (JAMA 2015;313[5]:471-82). “The prevention of VTE following traumatic injury is an ongoing challenge,” Belinda H. McCully, PhD, said at the annual meeting of the Western Surgical Association. “Despite prophylaxis, about 25% of patients present with VTE, which is associated with higher complications and an increased risk for mortality. Common risk factors for mortality include age, body mass index, extremity injury, and immobility, but the precise mechanisms that contribute to VTE development are not well understood. We do know that the three main factors contributing to thrombosis include static flow, endothelial injury, and hypercoagulability. Clinically, coagulation is the most feasible factor to assess, mainly through the use of conventional coagulation tests, thromboelastography, platelet levels, and platelet function assays.”

dbrunk@frontlinemedcom.com

CORONADO, CALIF. – Patients who develop a venous thromboembolism (VTE) following severe hemorrhage are more susceptible to complications, compared with their counterparts who do not; they also exhibit hypercoagulability and enhanced platelet function at admission, and have delayed recovery of coagulation and platelet function following injury.

Those are the key findings from a secondary analysis of data from the Pragmatic Randomized Optimal Platelet and Plasma Ratio (PROPPR) trial, which randomized 680 severely injured trauma patients from 12 level I trauma centers to receive 1:1:1 or 1:1:2 ratios of plasma to platelets to red blood cells (JAMA 2015;313[5]:471-82). “The prevention of VTE following traumatic injury is an ongoing challenge,” Belinda H. McCully, PhD, said at the annual meeting of the Western Surgical Association. “Despite prophylaxis, about 25% of patients present with VTE, which is associated with higher complications and an increased risk for mortality. Common risk factors for mortality include age, body mass index, extremity injury, and immobility, but the precise mechanisms that contribute to VTE development are not well understood. We do know that the three main factors contributing to thrombosis include static flow, endothelial injury, and hypercoagulability. Clinically, coagulation is the most feasible factor to assess, mainly through the use of conventional coagulation tests, thromboelastography, platelet levels, and platelet function assays.”

dbrunk@frontlinemedcom.com