Ian R. Tofler, MBBS

Murray et al have written a timely, thoughtful, and useful article (“Smoking cessation: Varenicline and the risk of neuropsychiatric adverse events,” Current Psychiatry, July 2022, p. 41-45) about the role of the nicotinic acetylcholine receptor partial agonist varenicline for helping patients stop smoking, which is still the main preventable cause of morbidity and premature death. Smoking remains a major problem among patients who are chronically mentally ill and those with substance use disorders, as well as “recovering” populations such as Alcoholic Anonymous participants.¹ Reviews of the EAGLES trial and other research analyses have gone a long way to allaying anxiety about interventions for smoking cessation.²

Just a few caveats regarding Murray et al’s excellent summary:

• The article did not address that nicotine is consumed in multiple ways, such as vaping, snuff, chewing tobacco, and hookah

• The safety of varenicline appears fair when psychiatric illness is well controlled but can be problematic (and even severely detrimental) when mental illness is not well controlled. This should not be glossed over, especially since it was the reason for the original black-box warning (for risks including behavioral impulsivity, suicidality, severe insomnia, and nightmares) that was removed in 2016

• Patients with severe mental illness may not fully understand the risks, benefits, and priorities of the treatment intervention. The importance of psychiatric and internal medicine in addition to pharmacy follow-up is critical and needs to be documented.

Varenicline has been contextualized in its current role as a first-line treatment for smoking cessation. By bypassing a sizeable population of patients who have unstable psychiatric illness (especially bipolar I disorder), the path has been opened for risky “off-label” varenicline prescribing to this population by internists, who should be very cautious and prudent about prescribing for such patients. This alone is probably a good reason to reinstate the black-box warning.

Interestingly, one review found that only 1 of 11 patients receiving varenicline stopped smoking.¹ Not dramatically beneficial for a first-line treatment! Decreasing smoking occurs as well and is more robust with combinational use with bupropion, nicotine replacement therapy, and cognitive-behavioral therapy.

If we are focusing on patients with unstable mental illness—who are seen primarily by psychiatrists—adherence, urgency of intervention, and context regarding acute safety for this population must be seen as top priorities.

So-called “second-line” treatment options must also be considered. Sandiego et al³ make excellent points regarding the role of alpha-adrenergic agonists such as guanfacine, which have been shown to be helpful in smoking cessation. They work by decreasing cortical dopamine release and their calming effects on the noradrenergic system, which may decrease smoking precipitated by stress. For the particularly challenging subpopulation of unstable smokers, the combination of varenicline plus guanfacine ER may turn out to be a game-changer.

Varenicline has not proven itself to be useful in patients who are severely mentally ill, and due to its low success rate, expectations should remain tempered, pragmatically realistic, and safety-based.^4,5 The bottom line is that in an unstable psychiatrically ill patient, interventions other than varenicline should be first-line.

Murray et al have written a timely, thoughtful, and useful article (“Smoking cessation: Varenicline and the risk of neuropsychiatric adverse events,” Current Psychiatry, July 2022, p. 41-45) about the role of the nicotinic acetylcholine receptor partial agonist varenicline for helping patients stop smoking, which is still the main preventable cause of morbidity and premature death. Smoking remains a major problem among patients who are chronically mentally ill and those with substance use disorders, as well as “recovering” populations such as Alcoholic Anonymous participants.¹ Reviews of the EAGLES trial and other research analyses have gone a long way to allaying anxiety about interventions for smoking cessation.²

Just a few caveats regarding Murray et al’s excellent summary:

• The article did not address that nicotine is consumed in multiple ways, such as vaping, snuff, chewing tobacco, and hookah

• The safety of varenicline appears fair when psychiatric illness is well controlled but can be problematic (and even severely detrimental) when mental illness is not well controlled. This should not be glossed over, especially since it was the reason for the original black-box warning (for risks including behavioral impulsivity, suicidality, severe insomnia, and nightmares) that was removed in 2016

• Patients with severe mental illness may not fully understand the risks, benefits, and priorities of the treatment intervention. The importance of psychiatric and internal medicine in addition to pharmacy follow-up is critical and needs to be documented.

Varenicline has been contextualized in its current role as a first-line treatment for smoking cessation. By bypassing a sizeable population of patients who have unstable psychiatric illness (especially bipolar I disorder), the path has been opened for risky “off-label” varenicline prescribing to this population by internists, who should be very cautious and prudent about prescribing for such patients. This alone is probably a good reason to reinstate the black-box warning.

Interestingly, one review found that only 1 of 11 patients receiving varenicline stopped smoking.¹ Not dramatically beneficial for a first-line treatment! Decreasing smoking occurs as well and is more robust with combinational use with bupropion, nicotine replacement therapy, and cognitive-behavioral therapy.

If we are focusing on patients with unstable mental illness—who are seen primarily by psychiatrists—adherence, urgency of intervention, and context regarding acute safety for this population must be seen as top priorities.

So-called “second-line” treatment options must also be considered. Sandiego et al³ make excellent points regarding the role of alpha-adrenergic agonists such as guanfacine, which have been shown to be helpful in smoking cessation. They work by decreasing cortical dopamine release and their calming effects on the noradrenergic system, which may decrease smoking precipitated by stress. For the particularly challenging subpopulation of unstable smokers, the combination of varenicline plus guanfacine ER may turn out to be a game-changer.

Varenicline has not proven itself to be useful in patients who are severely mentally ill, and due to its low success rate, expectations should remain tempered, pragmatically realistic, and safety-based.^4,5 The bottom line is that in an unstable psychiatrically ill patient, interventions other than varenicline should be first-line.

Murray et al have written a timely, thoughtful, and useful article (“Smoking cessation: Varenicline and the risk of neuropsychiatric adverse events,” Current Psychiatry, July 2022, p. 41-45) about the role of the nicotinic acetylcholine receptor partial agonist varenicline for helping patients stop smoking, which is still the main preventable cause of morbidity and premature death. Smoking remains a major problem among patients who are chronically mentally ill and those with substance use disorders, as well as “recovering” populations such as Alcoholic Anonymous participants.¹ Reviews of the EAGLES trial and other research analyses have gone a long way to allaying anxiety about interventions for smoking cessation.²

Just a few caveats regarding Murray et al’s excellent summary:

• The article did not address that nicotine is consumed in multiple ways, such as vaping, snuff, chewing tobacco, and hookah

• The safety of varenicline appears fair when psychiatric illness is well controlled but can be problematic (and even severely detrimental) when mental illness is not well controlled. This should not be glossed over, especially since it was the reason for the original black-box warning (for risks including behavioral impulsivity, suicidality, severe insomnia, and nightmares) that was removed in 2016

• Patients with severe mental illness may not fully understand the risks, benefits, and priorities of the treatment intervention. The importance of psychiatric and internal medicine in addition to pharmacy follow-up is critical and needs to be documented.

Varenicline has been contextualized in its current role as a first-line treatment for smoking cessation. By bypassing a sizeable population of patients who have unstable psychiatric illness (especially bipolar I disorder), the path has been opened for risky “off-label” varenicline prescribing to this population by internists, who should be very cautious and prudent about prescribing for such patients. This alone is probably a good reason to reinstate the black-box warning.

Interestingly, one review found that only 1 of 11 patients receiving varenicline stopped smoking.¹ Not dramatically beneficial for a first-line treatment! Decreasing smoking occurs as well and is more robust with combinational use with bupropion, nicotine replacement therapy, and cognitive-behavioral therapy.

If we are focusing on patients with unstable mental illness—who are seen primarily by psychiatrists—adherence, urgency of intervention, and context regarding acute safety for this population must be seen as top priorities.

So-called “second-line” treatment options must also be considered. Sandiego et al³ make excellent points regarding the role of alpha-adrenergic agonists such as guanfacine, which have been shown to be helpful in smoking cessation. They work by decreasing cortical dopamine release and their calming effects on the noradrenergic system, which may decrease smoking precipitated by stress. For the particularly challenging subpopulation of unstable smokers, the combination of varenicline plus guanfacine ER may turn out to be a game-changer.

Varenicline has not proven itself to be useful in patients who are severely mentally ill, and due to its low success rate, expectations should remain tempered, pragmatically realistic, and safety-based.^4,5 The bottom line is that in an unstable psychiatrically ill patient, interventions other than varenicline should be first-line.

The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.

The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.

Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.^1-5

By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.

His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.

When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.

His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.

The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.

What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.

Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.

While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”

According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.

While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.

Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.

As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.

While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
 

Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

References

1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.

2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.

3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).

4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.

5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.

*Updated 1/25/2021

The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.

The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.

Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.^1-5

By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.

His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.

When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.

His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.

The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.

What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.

Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.

While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”

According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.

While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.

Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.

As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.

While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
 

Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

References

1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.

2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.

3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).

4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.

5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.

*Updated 1/25/2021

The Tiger Woods saga, which has been broadcast on HBO, is a “child” of the ESPN Michael Jordan series – which riveted early pandemic America. It is likely to exert a similar vicelike hold on the imagination of Biden transition/Trump impeachment II United States, despite not having the express participation of Woods himself.

The differences in parenting styles of these young African American men, at least superficially, appears in amazingly stark contrast.

Whereas Michael Jordan’s parents appear to have shown good old, red-blooded North Carolina ambitious and hard-driven tough parenting, Earl and Kultida Woods seem to have exerted a textbook example of what we call “achievement by proxy distortion” (ABPD) parenting style.^1-5

By deciding, even prior to birth, what their son’s future career would be, Earl, aided by Kultida Woods, created a master plan that came to fruition when Eldrick Tont “Tiger” Woods won his first Masters Tournament at the ripe old age of 21.

His parents’ fine-tuning of the ABPD template for professional sports parenting is often emulated. It had been earlier developed, in an industrial model – especially in women’s gymnastics – where Bela Karolyi and others in the Romanian Eastern Bloc system had developed Nadia Comaneci and others to be prepubescent superstars of the 1970s. When it was transferred to the more financially supportive, fertile base of the U.S., physical and sexual abuse were the acceptable price paid for Olympic gold medals.

When Tiger first appeared on the U.S. radar at the age of 2 on the Mike Douglas show in 1977, he was already definitively on the way to “prodigy” territory. Earl, a retired Vietnam veteran and product of the U.S. Marines, was able to model his own extraordinarily rigorous training where breaking down soldiers psychologically helps them survive special ops behind enemy lines. He trained his son essentially from birth, imprinting through somatic and postural echo these golf skills and habits for playing under pressure, handling annoying distraction, and self-hypnosis. These all clearly accelerated his son’s ability to enter the “zone,” a level of high attunement required, even demanded, at the highest levels of professional golf.

His parents’ ruthless approach, clearly accompanied by undoubted love and enthusiasm, to ending what appears to have been an age-appropriate high school relationship with his then “sweetheart,” appears on the surface a little cruel. But their approach achieved its purpose of sacrificing a distraction on the glorious golden path toward inevitable success and superstardom. This likely also produced a degree of self-objectification and further compartmentalization.

The typical outcome of ABPD is a fairly unidimensional identity defined by the activity, or in this case, the sport. In this case, where Earl was building or imagining a Messianic role for Tiger, multidimensionality was important as the self-described “Cablinasian” moniker suggests, whereby all of Tiger’s background of Caucasian, Black, Indian, and Asian ancestry was acknowledged as they all became lifelong fans.

What most likely saved Tiger Woods from the most debilitating aspects of his father’s master plan was that golfers cannot compete and achieve mega endorsements at the professional level until they have established credentials and grow into their adult bodies, when their stroke making becomes fully competitive and their product image ideal.

Therefore, a 6-year-old JonBenet Ramsey competing in beauty contests, or a 7-year-old Jessica Dubroff flying across country could have been Tiger, but they were not.

While awaiting his preordained career and endorsement deals, Tiger still needed to at least spend some time at college, in his case on a Stanford (Calif.) University golfing scholarship, while he accumulated U.S. amateur titles and fully established his credentials during this crucial time of normal development and “adolescent moratorium.”

According to the documentary,* being exposed to the “secret” extracurricular fringe benefits and sexual proclivities of golf pros with his father is likely to have been part of a traumatic “adultification” and compartmentalizing process. Whereby, one of Tiger’s roles became keeping his parents’ marriage together. That alleged exposure may also have planted the seeds for the “groupie” and sexual acting out challenges he so publicly experienced later in his career.

While Michael Jordan’s career has almost receded into the ancient and “hoary” past, Tiger Woods’s career at age 45, after overcoming significant back injuries and multiple failed surgeries, continues to astonish the golf and sporting world in general.

Most of his now deceased father Earl’s ambitions have indeed been realized despite some hiccups, setbacks, and loss of endorsements.

As parents in these challenging times, we all make sacrifices for our children, and in turn, expect them to step up to the plate and within reason, sacrifice and defer short-term excitement and fun for long-term educational, social, and life goals. How we as parents, and that includes Tiger Woods now, rise to this challenge is often a daily and humbling struggle.

While you watch this series, please keep your psychiatrist and family dynamics eyes wide open.
 

Dr. Tofler is a child and adolescent, sport psychiatrist, and is affiliated with Kaiser Permanente Psychiatry in West Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

References

1. Tofler IR et al. N Engl J Med. 1996 Jul 25;335(4):281-3.

2. Jellinek MS et al. J Am Acad Child Adolesc Psychiatry. 1999 Feb;38(2):213-6.

3. Tofler IR and DiGeronimo TF. “Keeping Your Kids Out Front Without Kicking Them From Behind: How to Nurture High-Achieving Athletes, Scholars, and Performing Artists.” (Hoboken, N.J,: Jossey-Bass, 2000).

4. Tofler IR et al. Clin Sports Med. 2005 Oct;24(4):805-28.

5. Clark TP et al. Clin Sports Med. 2005 Oct;24(4):959-71.

*Updated 1/25/2021

The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.

Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.

And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.

CANCER CIFTCI/Getty Images

We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.

The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.

Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.

Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.

But another reason might be the lowered expectations. As one stable patient with schizophrenia said, “No one is hassling me now; no one is aggravating me to go to this group or that, to leave the house to volunteer, to get a job. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.

As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.

Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.

It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.

How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.

Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.

This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
 

Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.

Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.

And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.

CANCER CIFTCI/Getty Images

We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.

The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.

Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.

Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.

But another reason might be the lowered expectations. As one stable patient with schizophrenia said, “No one is hassling me now; no one is aggravating me to go to this group or that, to leave the house to volunteer, to get a job. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.

As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.

Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.

It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.

How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.

Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.

This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
 

Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.

Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.

And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.

CANCER CIFTCI/Getty Images

We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.

The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.

Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.

Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.

But another reason might be the lowered expectations. As one stable patient with schizophrenia said, “No one is hassling me now; no one is aggravating me to go to this group or that, to leave the house to volunteer, to get a job. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.

As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.

Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.

It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.

How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.

Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.

This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
 

Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.