Ah, love. That longed-for, sung-about, praised, desired, elusive, magical, state. The feeling that drives men to battle and women to drop out of college. The one thing that we all want above all else. We all want it. We crave it. Some people will die for it.

But what is it? And how do we even know if we are feeling it? Why do some people not even know if they are in love?

Come with me on a journey to learn about love. And find out why some people don’t know whether or not they’re “in love.”
First of all, can we define love? I started with some online dictionaries and was less than satisfied with what I found. Merriam-Webster, the old standard, provided the following:

Definition of love

 1 a (1) : strong affection for another arising out of kinship or personal ties

maternal love for a child

(2) : attraction based on sexual desire : affection and tenderness felt by lovers

After all these years, they are still very much in love.

(3) : affection based on admiration, benevolence, or common interests

love for his old schoolmates

b : an assurance of affection

give her my love

2 : warm attachment, enthusiasm, or devotion

love of the sea

3 a: the object of attachment, devotion, or admiration

baseball was his first love

b (1): a beloved person : DARLING —often used as a term of endearment

(2)British —used as an informal term of address

4 a : unselfish loyal and benevolent (see BENEVOLENT sense 1a) concern for the good of another: such as

(1) : the fatherly concern of God for humankind

(2) : brotherly concern for others

b : a person's adoration of God

5 : a god (such as Cupid or Eros) or personification of love

6 : an amorous episode : LOVE AFFAIR

7 : the sexual embrace : COPULATION

8 : a score of zero (as in tennis)

9 : capitalized, Christian Science : GOD

at love : holding one's opponent scoreless in tennis

in love : inspired by affection

Wait, what? In love is LAST? After even the score of zero in tennis? No wonder we are confused by what it means to be in love!!

We have the definition of maternal love, a mother for a child. But we all know of mothers who don’t, or can’t, love their children. I spent much of my career evaluating abusive mothers. Maternal love is far from automatic. Post-partum depression has received quite a bit of press in recent years. Most of us have read stories, or even known mothers, who have been unable to feel positive emotions toward even long-awaited infants.

And then there are sex hormones. All human beings, no matter with which part of the SLGBTQ (straight lesbian gay bi trans queer) spectrum you identify, produce all sorts of lovely hormones, including estrogen, testosterone, and oxytocin, to name but a few. These hormones are present in all genders and control sexual arousal and behavior. 

Is sex love? Well - no. But depending on how you were raised and socialized, you might believe it is. You might have heard “you’re so pretty, everyone will love you” so many times growing up that you have learned to equate sexual attractiveness with being loved. Or the opposite. You might have heard “nobody will ever love you” so many times that you believe it. These pronouncements might have been out loud or they might have been implied. Remember that mother who couldn’t love her baby? That might have been your mother. So if you grew up believing you are unlovable, you might be in a wonderful relationship in which you cannot possibly believe you are “in love.”

Everything exists. 

“Love at first sight” describes a (usually fictional) situation where two people, usually young and perfectly beautiful, lock eyes across a crowded room (or possibly, on TV, across a dying patient or a recently deceased victim) and fall desperately in love. They then overcome some obstacles and then live happily ever after. They also have loads of amazing off-screen sex and when they wake up they still have their underwear and, for the female, their makeup, on. 
I prefer the other Hollywood version, though. One of the first movies I remember seeing was Fiddler on the Roof. In this film adaptation of the 1964 Broadway play, itself an adaptation of the Tevye the Milkman stories by Sholom Aleychem, Tevya’s eldest daughter wants to marry for love. Tevye asks his wife Golde, his wife from their arranged marriage: “Do you love me?”

She thinks about it and, of course bursting into song, since it’s a musical, replies:

(Golde)

Do I love you?

For twenty-five years I've washed your clothes

Cooked your meals, cleaned your house

Given you children, milked the cow

After twenty-five years, why talk about love right now?

(Tevye)

Golde, The first time I met you

Was on our wedding day

I was scared

(Golde)

I was shy

(Tevye)

I was nervous

(Golde)

So was I

(Tevye)

But my father and my mother

Said we'd learn to love each other

And now I'm asking, Golde

Do you love me?

(Golde)

I'm your wife

(Tevye)

"I know..."

But do you love me?

(Golde)

Do I love him?

For twenty-five years I've lived with him

Fought with him, starved with him

Twenty-five years my bed is his

If that's not love, what is?

(Tevye)

Then you love me?

(Golde)

I suppose I do

(Tevye)

And I suppose I love you too

(Here’s a link to the actual song in case you want to hear it!)

These days, people want far more than an arranged marriage. Women expect to be far more than child-bearers, clothes-washers, and cow-milkers. In fact, many women rarely wash clothes, are unsure if they plan to have children, and are positive they will never, ever, milk a cow. So is there anything relevant in this song, or even in this story, for the modern couple?

I would argue that our modern expectations are exactly what is preventing so many people from knowing whether or not they are in love. Interestingly, the semi-arranged marriage, still practiced today, has a very good success rate (about 94% according to Wikipedia). In this type of marriage, young people are introduced by their families or by a professional matchmaker (today helped by all sorts of technology and specific matchmaking or “matrimonial” websites). Nobody locks eyes across a crowded room or across a dead body anymore. Interestingly, the dating app is, whether we want to accept it or not, a form of arranged marriage. People specify their romantic resumes and then search for . . . wait for it . . . a match! 

Is it any wonder, then, that people don’t really know if they are “in love?” When dating and marriage has been reduced back to an algorithm, with expectations that resemble the college application process?

One famous-ish study purports to guarantee that two people can fall in love in a day if they just ask and answer only thirty-six questions. I went back to look at the original study myself and found, unsurprisingly, that the media co-opted the study’s findings and that no, we cannot fall in love based on those questions. As usual, media and social media corrupts science every day. 

However, I’m trained as a scientist, so I’d send you right back to one of my most favorite books, written by Jared Diamond of Guns, Germs, and Steel fame. Before he became a household name, Dr. Diamond was a regular professor of geography and anthropology and wrote a wonderful little book titled Why is Sex Fun? in which he explains the book’s subtitle: The Evolution of Human Sexuality. In this book, we can learn all about weird little things like how the distance between our eyes and the thickness of our earlobes are genetic programs that cause us to instantly become sexually attracted to someone. Those are things that - up until now - no phone or even computer dating app has been able to incorporate. 

So how do we know if we are in love? Mathew Boggs and Jason Miller, two single guys in their twenties at the time (around 2007) set off to find out when they started Project Everlasting. Devastated by his own parents’ divorce, Mat was surprised to find that his grandparents’ marriage of sixty-three years was still full of love. 

He and his best friend traveled around the United States and interviewed two hundred couples to find out what made love last. The result was this book. I’ve heard Mat speak about this project many times and I have no doubt that the experience changed his life. Mat’s most important message is this: Love is not a feeling. It is a decision that we make on a daily basis. Here’s a video where he talks about what he learned. Many marriage experts, such as Mort Fertel, Alison Armstrong, and Laura Doyle, all teach versions of the same thing. If we want to be loved and cherished, we start by loving ourselves and behaving in a loving way toward our partners.

Social media, movies, books, and our friends all insist that we can behave badly, selfishly, and meanly, and that Prince Charming will show up and love will conquer all. The fairy tale meme is that when the right prince shows up, he will kiss us and we will wake up from sleep, or the glass slipper will fit, or we will prefer to become an ogre like him (because obviously the only two ogres in the world will love each other) and everything will be perfect. 

Yet how often do people fall in love with the person in the next room? Actually the answer is very frequently! We don’t have to travel the world to find the right person. We just have to become the person we want to be in order to attract love. And then make a decision, every day, to keep loving that person, as well as to keep loving ourselves.

If we keep waiting for perfection, for someone else to make us happy, to read our minds, to be like those mysterious men in the movies who know exactly what we want before we even want it, we might be waiting a long time. 

For example, the media is full of the meme of getting flowers at the office. I actually watched the show The Office the other day (I was getting my nails done and they were playing it nonstop) and it was about getting flowers and gifts because it was Valentine’s Day. Here’s the thing - do we LIVE at the office? I have received gifts at the office - from patients, vendors, etc. Why would someone who loves me send me a gift at work? I don’t live there. Those gifts would go to my home, where my personal life is. The real world is not the office and it is not The Office.

If we feel good with someone, if we feel understood, if we feel happy, if we have common values, if we feel we can build a life together - that is enough. Perfection does not exist. We should never force ourselves to love someone. But I believe that we know when we love someone. We do not have to wait for the approval of our friends and family. We do not have to wait for the biggest diamond, the fanciest house, the most expensive honeymoon. That is not love. Love is the little things that happen over the course of a lifetime.

As Golde sings, “For twenty-five years I've lived with him, Fought with him, starved with him, Twenty-five years my bed is his, If that's not love, what is?” The journey of twenty-five years begins with a single step. You can’t get to that lifetime if you don’t allow yourself the dream. Think about how it would feel to love that person forever. If it feels good, then you’re in love. If it feels wrong, then it is. It’s that simple.

You never thought it would happen - and somehow it did.

How to maintain your self respect while separated from the person you love the most.

Nobody gets married thinking that one day they will end up in tears yelling “it’s over.” Yet at least half the marriages in the United States break up at some point. Some forever, some for a while. The good news is that divorce is on the decline. The bad news is that marriage is on the decline, too, so the new stats might only be a false artifact of these new trends.

Either way, unfortunately, you have about a fifty-fifty chance of one day living apart from your beloved spouse or significant other.

If you love your person, and you want them to love you back, how can you get to that happy place again? It’s all about self-love and self-respect.

What is self-respect anyway, and how can we maintain our self-respect while separated? When a marriage breaks down, it’s a symptom of a breakdown of respect. We start losing respect for ourselves and for each other, and then the relationship begins to crumble.

Can you identify the erosion of respect in your relationship? What better place to begin to build respect than toward yourself? And what better place to learn to love unconditionally than to learn to love yourself?

There’s a famous meme going around that says: “If he can’t handle me at my worst, he doesn’t deserve me at my best.” Now take a good look in the mirror. No joke. Walk over to the mirror and take a good look. Do you love that person, deeply, fully, and without reservations? Do you love and respect yourself at your worst? Or do you repeatedly beat yourself up?

Until you love her, warts and all, as the saying goes, you won’t respect her. When you get to that place, then you will know that anything you want in the world is yours. 

So how do you maintain your self respect while separated?

Here are five ways.

1. STAY FAB

   You are awesome. Take this time to remember what makes you YOU! Somehow along the way, you lost your mojo.

   Imagine your life is a big pie. Choose your favorite, or, if you’re like me, each slice can be different - one is apple, one is cherry, one is peach - you get the idea. Your pie has an infinite number of slices, but for today we will count up just a few.

   There’s the beautiful home slice, the work slice, the relationship slice, the friends slice, the hobbies slice, the travel slice, the altruism slice, the physical exercise slice, the kids slice, the extended family slice, the animal lover slice, the shopping slice, the learning to quilt slice . . . you get the idea.

   Right now your relationship slice is missing or unappetizing. But that’s okay, because all your other slices can be awesome. You have the ability to make them the most delicious pie you’ve ever had. This pie is magic and can be re-baked any time and in any form and flavor you want. 

   You get to decide about that relationship slice. While you’re working on figuring it out, make sure that you are enjoying every single crumb of the rest of that pie. Remember, every slice comes back exactly as you want it the next day!

2. DON’T BLAB

   That’s right. Your life - including your struggle - is nobody’s business but your own. As much as you might want to talk to your friends and family about your situation, the minute you start complaining is the minute your self-respect goes out the window. Worse, the people who are supposed to love and care for you are going to start losing respect for you, too. In this day and age of instant information and instant opinions, think hard before you announce your situation on social media. 

   Everyone is going to have an opinion. You might want to be part of the 13% of couples who reconcile after separation. You might even want to be part of the 6% who reconcile after divorce. 

   But once you start telling people your story, the party line is going to be that your EX (he is now officially going to be your EX or STBX - “soon to be ex”) is a “narcissist,” “psychopath” or another trend of the day. 

   Remember, this is the man you loved with all your heart, the man who could finish your thoughts without you ever saying them aloud. The guy you did sexual things with that  you that you could only imagine before you met him. The father of your children, who watched you give birth. Think hard before you let the opinions of others toss him to the curb for good. Zip it.

   Oh and one more thing. If the person telling you “for your own good” that this man is a “psychopath or narcissist who has to go” is a therapist whom you pay for these words - then the person who has to go is that therapist. Only YOU get to make that decision.

3. DON’T JAB

   At your partner. We know that whatever happened hurt. Often it’s tempting to lash out and hurt back. If you ignore tip #2 and start blabbing to all your friends about what happened, you will find yourself “supported” by your well-meaning friends and relatives who will say things like “I never liked him.” 

   “I never thought he was good enough for you.” 

   “We never liked the way he treated you.” 

   Sadly, that is a lot of people’s version of being supportive.

   Ask yourself this: Do you routinely pick assholes to hang out with? What’s the probability, then, that you married one? And are your friends really being respectful of you when they tell you that you picked a total jerk to marry and to be the father of your children? 

   No? So maybe you might want to follow tip #1 and also tip # 2. Your current situation is yours alone. You might end up choosing to leave this person forever. For right now, you’re still married, and whatever the future holds, you don’t pick jerks with whom to populate your social circle - let alone to marry! 

   You are an amazing person with great judgment. Continue to respect the person you are not living with at the moment, and you will find great reserves of respect for yourself. Not only will you continue to respect yourself, but so will everyone around you. I’m not sure if there’s an expression for the opposite of a vicious cycle, but this is an example of one. 

   The more you respect yourself, the more other people will respect you, and the more other people respect you, the more respect you will have for yourself.

4. DON’T FLAB

   OK, I put this one in so it would rhyme. But my point is that you want to really look after yourself. Exercise, eat well, get out, feel good. Do all the things you love to do, as much and as often as you can. Make every day the day of YOU. 

   Obviously you still have to go to work and clean the kitchen. But you can commute with an audiobook, clean up while dancing to your favorite music, cook all the meals you never made because your husband didn’t like them or was allergic or whatever. 

   You and the kids (or on your nights alone, just you) can go to the frozen yogurt place for dinner. It is totally allowed. Pick up those hobbies you stopped doing a long time ago. Join a theater group or a chorus. Pick up those knitting needles or dust off that sewing machine. Create something. 

   Dig deep into the corners of your mind and remember what it was like when you used to focus on what you loved.

5. DON’T GRAB

   At any old guy or relationship that might come your way. You might be tempted to immediately replace your missing husband with a brand-spanking new model.

   I’d like to explain to you why this maneuver rarely works.

   There are plenty of so-called experts online who will tell you that making your partner jealous will bring him right back to you. In some cases, that might work. In other cases, having the attention and superficial love that you felt was lacking in your previous relationship might make you feel better for a while.

   But here is the cold, hard, truth: All love relationships work or don’t work based upon how much we love ourselves. Our capacity for love is infinite, but it starts and ends with our capacity for self-love.

   Inside all of us is a still, small, voice that tells us either: “I’m not good enough,” or “I’m fine.” We don’t hear the voice that says, “I’m fine just the way I am,” because those of us who know that - the very few - are the ones who are busy doing other things with our lives. 

   Many of us are capable of doing amazing things even while we believe we are not good enough, because we have so much to prove, both to ourselves and the world. But all the outside love in the world will not make us love ourselves.

   Take this time to learn how to love yourself. You will be amazed how learning how to love yourself will lead you to a place where self-respect is automatic, the respect of others comes naturally, and your previous partner, if that’s who you want, or a new one, if that’s your choice, appears in your life.

How do we get to the place of fully loving and respecting ourselves so we can fully live our lives while separated? We start by practicing all the things I mentioned above. We practice self-love and self-respect until we start to feel it. 

The famous New Thought writer and leader, Neville Goddard, created the idea of Living In the  End.  If we apply this concept to our everyday lives, it means that if we want something, we start to live as if we already have it. Many of us are already familiar with this idea from the popular: “Dress for the job you want, not the job you have.” What Neville created was the idea to live the life you want as if you already have it.

That is how you maintain your self-respect while you are separated. You live the life you want as if you already have it. So if there is no partner there right now? Live as if he (or she) is there. And behave in every other way like the partner you want to be. Treat yourself like the kind, loving, authentic, creative, amazing person that anyone in the world would want to be with. 

You are allowed to be happy. Our happiness does not come only from having one person living with us and saying “What’s for dinner?” every night. It helps to think about all the things you’re grateful for and all the things you have been grateful for throughout your life. 

I encourage all my patients to keep gratitude journals (I admit I am not as diligent at keeping mine as I could be, but I have learned how to be very grateful in the moment). Write down ten things you’re grateful for every night (or another time of day that is convenient for you). Some days you will be able to be grateful for the air you breathe and the water you drink. Other days you will have more complex gratitudes. 

As you continue to practice self-love and self-respect, you will gain greater clarity about what you want in your life and who you want to share it with.

I’d love to help you navigate your separation and heal yourself and your relationship. Visit my website at https://www.Shnaidman.com/life-coaching and, if you’re in the New Jersey area, sign up for a free vision workshop. If you’re further away, sign up for a free strategy session, or take the plunge and contact me about individual or group coaching It would be my honor and privilege to help you navigate these challenging waters and help you find a safe harbor!

Published on Yourtango

Back when we rode our dinosaurs to the hospital, psychiatrists had one patient care philosophy for treating our patients: To help them live their best possible lives. 

If our patients were schizophrenic, we wanted them to be as psychosis-free as possible. If they were depressed, we wanted them to be happy. If they suffered from obsessions and compulsions, we wanted them to be free of the forces that drove them to needlessly repeat thoughts and actions instead of living their lives.

Today, most psychiatrists are corralled into a fake patient care philosophy that tries to convince us that the only treatment required is to keep our patients out of the hospital. Anything else we can do for them is optional and - most importantly - not reimbursable.

The standard of care has changed since I became a psychiatrist. As long as the insurance companies are protected from having to shell out big bucks for inpatient treatment, the well-being of the actual human beings we are treating is not really important.

We have been indoctrinating young psychiatrists into this patient care philosophy for so many years now that most psychiatrists actually believe it. And this philosophy must change.

There is no magic medication that can give a person a happy life. There is no magic medication that can solve a person’s financial problems, relationship problems, academic problems. There is no magic medication that can address anyone’s existential issues. 

Medications can treat the symptoms of different psychiatric disorders, but they do not treat the person. 

When psychiatry was first developed as a separate field of medicine, the whole premise was that each individual had a unique history, with unique experiences, perceptions, and reactions, that rendered him or her - well - unique. 

The goal of psychiatry as introduced by the father of psychiatry, Sigmund Freud (himself a neurologist) and later refined by generations of other psychiatrists, psychologists, and neurologists, was to tailor treatment to each individual patient.

The original philosophy of patient care was that each person who suffered from some psychic pain could be helped to recover and live his or her best life and go on to achieve all of his goals and dreams, free from the burden of mental anguish.

So what have we accomplished today, in the twenty-first century? We have developed a bunch of medications, many with a plethora of side effects. We have created a pretend treatment called “medication management.” 

I often have students in my office. They are usually surprised to hear that I never ask my patients “how’s the medication?” That is because I am one of the few psychiatrists left in the world who knows that no patient has any idea how their medication is! 

Would you go to your internist for your blood pressure and expect to hear “how’s the medication?” How about for your gout, or your ulcerative colitis? No? You might be asked, “how’s your pain?” or “have you been checking your blood pressure?” 

Psychiatry has become so marginalized despite its quest for parity that even psychiatrists now believe that “how’s the medication?” is a legitimate question.

Let me tell you something: It’s not. I ask my patients how they are doing. There are specific questions I ask to find out if the medication is working the way it’s meant to. But that’s only a start. 

Medication is like the sanding and spackling a good painter would do to a wall before painting on the color of your choice. It’s the base layer. After that needs to come the real work - the therapy that will help the patient become the true person he or she wants to be.

So why does the patient care philosophy of psychiatrists need to change? Why isn’t it enough to ply the patients with all our new miracle drugs and send them on their way? 

One reason it needs to change is that the true, adjusted suicide rate today is about twice what it was only fifty years ago. Despite the availability of all the magic medications, people are killing themselves at unprecedented rates. I believe it is because we are asking pills to do the work of people. 

We are over-medicating people who actually need to learn self-love. Self-love is the sanding and spackle. We live in a society where we are taught that we are only lovable if we look a certain way, dress a certain way, and spend a certain way. We are constantly bombarded with information on a million different platforms all designed to show us how we don’t measure up because we are not as good and worthy as the fake people we see on the screens surrounding us anywhere we look. Instead of bringing us closer together, social media is creating isolation and loneliness. 

The biggest irony I learned about the history of media is this: Right after Sigmund Freud, the father of psychiatry, discovered that we all have a basic need to love and be loved, his own nephew, Edward Bernays, moved to the United States and figured out how to monetize this concept. Edward became the founder of public relations and advertising. 

So what can we do to go back to basics? How can we serve our patients’ need to love and be loved? 

In my own personal quest to learn how to better serve my patients, I discovered the field of life coaching. Life coaching is not yet standardized, so certification can be hit or miss. 

But the philosophy is fairly standard: We focus on the patient’s, or client’s, goals and desires, rather than patching up the problems in order to keep people out of the expensive hospital. This philosophy is suspiciously similar to the original goal of Dr. Freud and all of his followers in the first hundred years of psychiatry, before big insurance took over!

I carefully evaluated a great number of programs and decided to train as a life coach. I’m no stranger to hard work, and I found that my understanding of neuroscience and medication has been a great help and foundation. 

Now my patient care philosophy is this: We conquer our past and we create our best future. Sometimes we might need some medication, and that's okay.

We can all create a life we love living!

Until psychiatrists move their philosophy away from keeping patients out of the hospital and toward creating a life they love living, we will continue to have both unhappy, dissatisfied patients and unhappy, dissatisfied psychiatrists. 

I invite every single one of you to consider working with a life coach to create a life you love living. And a psychiatrist who is also a life coach? Few and far between, but definitely available! Sign up for a free vision workshop or a free strategy session for more information! Spackle up your wall, and paint it any color you want!! The time is now!!

Many people identify as having some sort of mental illness. Rock stars sing about mental illness. Writers write about it. Characters are described as being “ADD” or “OCD” as if these descriptors are adjectives. 

In some cases - even in many cases, I’ve heard people identify as actually being the mental illness: “I’m ADD.” “I’m OCD” “I’m bipolar.” People who actually suffer from these conditions are the first to tell you: Stop it! 
Nobody is served when people make fun of a mental illness or diagnose themselves. What counts as a mental illness? What makes someone really count as mentally ill, in need of treatment? Or able to respond to treatment? 

The simple answer is that we have some books, compiled by a bunch of self-proclaimed experts, which define mental illness. These are the DSM-V and the ICD-10 which describe, in meticulous detail, the requirements for each of the latest incarnations of every defined mental disorder. 

Of course, some of these include things like nicotine addiction, and some of them are speculative, and some of them are disorders that are so severe that anyone who suffers from them would not even be aware that they are ill, because they would be unconscious or relatively unaware of their surroundings. 

So let’s get started. Does your potential mental illness fall into one of these groups?

MOOD DISORDERS
Mood disorders include all disorders of mood. There are big mood disorders, where the sufferer loses contact with reality. My first patient, as a medical student, had depression. But not any old depression. He had psychotic depression and believed that all his clothes had been stolen and he was being held prisoner. 

In learning his history, I discovered that he had a history of bipolar disorder. He’d had previous manic episodes where he’d believed he was the owner of some sort of business and had millions of dollars. In reality, he was a retired low-level civil servant who’d had multiple previous psychiatric hospitalizations. 

There are smaller mood disorders, that include milder forms of depression, or more serious depression that never swings to mania. Mood disorders can hit anyone, at any age, at any time.

The most important thing, though, is to make sure that your mood disorder really counts as a mental illness and is not a psychiatric manifestation of a medical problem. For this reason, it is very important to see a medical doctor, such as an actual psychiatrist, for a good differential diagnosis. You don’t want your thyroid disorder or your brain tumor misdiagnosed as depression.

ANXIETY DISORDERS

All disorders that present with anxiety are filed under this heading. There are many. 

Obsessive-compulsive disorder (OCD) is probably the most famous one which people self-diagnose when they like things to be tidy. Actual OCD is an often-devastating mental illness which can affect people’s lives so severely that they become unable to leave the house. 

I’ve had patients who cannot finish school, are unable to go to work, and who essentially become invalids because of this devastating disorder. Yet so many people who come in for other reasons casually mention: “I’m OCD” as if it is a joke. It’s not a joke. It’s a horrible mental illness. See the diagnostic criteria I mentioned, above. One Quora user wrote very poignantly about her experiences with OCD and I up

Anxiety, too, can mimic medical disorders, and vice versa. Your thyroid, again, a small gland in your neck, could be responsible. So could any one of a dozen other organs in your body, including your heart. 
Posttraumatic Stress Disorder (yes, that’s how it’s spelled in the DSM) is another anxiety disorder that must be diagnosed according to specific diagnostic criteria. You don’t get to say you have PTSD because you were upset when someone yelled at you. 

You must have a qualifying event, which must be outside of the realm of normal, everyday, human experience. If it’s just a normal upset (up to and including sexual harassment and bullying) then it’s a plain old Adjustment Disorder, a disorder that gets its own category, but still counts as a diagnosis.

SUBSTANCE ABUSE DISORDERS

Speak for themselves. They count as mental illness. Interestingly, the better part of the money spent on mental illness in this country goes toward substance abuse treatment. There is a huge overlap, also known as comorbidity, of substance abuse and other types of mental illness. 

In other words, people who suffer from one psychiatric disorder often also suffer from a substance abuse disorder. These individuals are often best treated in dual diagnosis or co-occurring diagnosis programs.

NEUROCOGNITIVE AND DEVELOPMENTAL DISORDERS

This category includes the famous Attention-Deficit Hyperactivity Disorder, as well as Attention Deficit Disorder without Hyperactivity. These are the same disorder. The distinction about whether or not hyperactivity is present is important mainly to the observer. Teachers and parents are more likely to be annoyed and to notice if someone is afflicted when hyperactivity is present. 

Autism and Autism-Spectrum disorders are in this category. So are intellectual impairment that children are both with and, at the other end of the life cycle, the ones that people acquire later in life, like Alzheimer’s Disease. 

Confusingly, the DSM has lumped all of these under the label of Major and Minor Intellectual and Cognitive Impairment, doing away with the older names of mental retardation and dementia, so finding a specific diagnosis, such as Fragile X syndrome, Lewy Body Disease, or something else, might be a longer time coming. And a traumatic brain injury can occur at any time during the lifespan. Still, if your brain is literally not functioning properly, you get a DSM diagnostic code.

PSYCHOTIC DISORDERS

The most famous psychotic disorder is Schizophrenia. There are various sub-forms of schizophrenia, and other disorders which can include psychosis. The one criterion required for a psychotic disorder is a thought disorder. If you have a thought disorder, you won’t know it, and other people might not realize it either. 

News flash: Believing that everyone in a school deserves to die because you were unhappy when you were a high school student is actually a thought disorder. It’s not a motive, as the news media would like for us to believe. A thought disorder is when your thinking is - disordered. Illogical, makes no sense, messed up. 

The concept of a thought disorder is one that many people, including mental health professionals, often have difficulty understanding. We can all understand hallucinations, and we can understand bizarre delusions (“the satellites are controlling me.”) But many, if not most, patients will never share these thoughts.

Many people who hallucinate are never aware that they are hallucinating. They “hear” words that others speak as if others are really speaking those words. They believe things as if they were actually true. Every day I hear (for real) medical students ask patients: “Do you hear or see things that other people don’t hear or see/that aren’t really there?” If you know that those things are not really there, you are in luck, my friends! You might have some other problem, but you are not psychotic. 

Psychotic people, with their thought disorders and hallucinations, have a profound lack of insight. They are not aware that their delusional worlds are not real. This lack of insight is what makes treating them so difficult, yet so rewarding. If you are suffering from living in a secret world where you get special messages from the TV, where you have been chosen by G-d for a special mission, where you control all the money in the world with your mind, where nanobots have been injected into your body while you sleep, or some other special thing like that - well, it might not have really happened. You might be psychotic. And if you are planning a mass shooting, I promise you - no good will come of it. It’s a terrible idea. Please go to your nearest psychiatric emergency room right now. There is help for you.

SO WHAT COUNTS AS A MENTAL ILLNESS?

We’ve only touched on the biggies - there are many more categories, disorders, and syndromes that we psychiatrists treat. Here’s the take home message. If your thoughts, feelings, and emotions are bothering you, a psychiatrist can help you identify if a mental illness is brewing, and if it is treatable, and how to treat it.

There’s also another perspective. There’s a Russian proverb that goes something like this: If one person at the party tells you you’re drinking too much, well, he’s probably not having a good time. But if two people tell you, maybe it’s time to go home and go to sleep.

In other words, when you see that your life is not going well, when you keep getting fired or your relationships keep failing, or your family situation is going badly, or problems keep happening to you, then it might be worth it to check out the common denominator - YOU! Sometimes figuring out what you are doing at your own party might be a huge help in resolving your problems.

We all deserve to take care of ourselves and have the best lives possible. Call a psychiatrist or a psychologist. The right help is available for you, from medication to therapy to life coaching. I’d love for you to visit  my website at http://www.shnaidman.com for more information.

Rohan’s journey with mental illness has taken him from Medical School to prison. He is now managing his condition with both medication and therapy. This is a story of recovery and of perseverance. Rohan: I can’t forget to thank Dr. Vivian Chern Shnaidman for going above and beyond for me during this especially difficult time; you’re the proof that there are doctors who truly care about their patients, and for that I am so grateful.

Adam Bierman, Kurt Tazelaar, Raya Arbil and Dr. Vivian Shnaidman discuss political party conventions, police shootings, black lives matter and other current topics

Vivian is an expert in the application of psychiatry to legal matters, and has provided testimony in over 50 published court cases.

Vivian Chern Shnaidman, MD wrote Forensic Psychiatry: A Lawyer’s Guide, published by Elsevier, to help lawyers understand their psychiatric expert witnesses.

Recently one of Fox News’ television anchors asserted that her boss created a hostile work environment due to unwanted sexual advances. What exactly is a hostile work environment?

Hostile environment/sexual harassment occurs when the plaintiff employee’s work environment is made intolerable by sexual misconduct, or the work environment is permeated with unwelcome discriminatory intimidation, ridicule, and insult, based upon sex, that is sufficiently severe or pervasive to alter the conditions of the victim’s employment and create an abusive working environment. Unwelcome sexual conduct that interferes with job performance or creates an intimidating, hostile, or offensive working environment creates a hostile work environment.

How is a Hostile Work Environment Proven?

The plaintiff need not show that the harasser knew that the conduct was unwelcome, just that it was in fact unwelcome. In other words, the plaintiff doesn’t not have to tell the harasser to stop or notify him that his comments and actions are upsetting.

In order to allege a hostile work environment, it is not necessary to allege any sexual advances whatsoever. Nor does the conduct have to be stamped with explicit signs of overt discrimination, or be explicitly sexual in nature. It just has to relate to sex or be part of a course of conduct tied to evidence of discriminatory intent. Sexually harassing conduct that sufficiently offends, humiliates, distresses or intrudes upon its victims so as to disrupt their emotional tranquility in the workplace, affect their ability to perform their job as usual, or otherwise interfere with and undermine their personal sense or well being, constitutes a sexually hostile environment.

Hostile Work Environment Evaluation

Determining whether a given situation constitutes a hostile environment is a “fact-based inquiry into the severity and pervasiveness of the conduct…the jury looks at all the circumstances supported by credible evidence.” However, a single incident of sexual assault sufficiently alters the conditions of the victim’s employment to create an abusive work environment.

Evaluations of whether a hostile work environment exists are based on 1) the nature of the unwelcome sexual acts (considering that generally touching is more offensive than verbal remarks); 2) the frequency of the offensive encounters; 3) the total number of days over which all of the offensive conduct occurs; and 4) the context in which the sexually harassing conduct occurred.

I recently had the pleasure of being on the Dr. Joy Show from Princeton Community Television. There I had the opportunity to discuss the field of  forensic psychiatry, and share about some of my experiences. If you are an attorney interested in finding out more about forensic psychiatry check out my comprehensive lawyers guide book on the subject.

Female sex offender evaluations, as with males evaluations, is predominately driven by the need to establish the likelihood of future recurrences of sexual offending behavior and to identify interventions that would reduce their risk of recidivism.

In order to make a determination of risk of sexual recidivism, one must consider the individual characteristics of the offender that increase or decrease the probability of recidivism. These are referred to as static and dynamic factors. Dynamic risk factors are amenable to change and the elements that are addressed in treatment and in the management of sexual offenders in order to reduce the risk of recidivism. Risk factors may indicate a higher risk of recidivism than other female sex offenders.

Static risk factors for female sex offenders include:

1. A prior criminal history;
2. Number of prior convictions;
3. Number of prior sexual offense arrests;
4. Number of prior child abuse offenses (non-sexual);
5. Number of prior drug arrests.

Dynamic risk factors for female sex offenders include:

1. Denial and minimization of the offending behavior;
2. Distorted view about the sexual offending and sexual abuse in general;
3. Problematic relationship (e.g., characterized by abuse) and intimacy deficits;
4. Use of sex to regulate emotional states or fulfill intimacy needs;
5. Desire for intimacy with victim or co-defendant;
6. Wanting revenge or wanting to humiliate;
7. Antisocial attitudes or attitudes tolerant of sexual offending;
8. Antisocial associates;
9. Substance abuse;
10. Lack of an adequately supportive social network.

At times a forensic psychiatrist may be called on by the court or one of the parties to evaluation a defendant’s competency to stand trial. This evaluation involves a comprehensive assessment of the defendant’s mental status, the defendant’s understanding of the nature and objective of the legal proceedings, and the defendant’s capacity to assist in his or her defense. A competency to stand trial evaluation may also involve the administration of specialized psychological tests, depending on the particular clinical issue at hand (e.g., mental retardation, malingering).

When a Competency to Stand Trial Evaluation is Necessary

When a legitimate question arises as to competency, the defendant has a right to a hearing to determine fitness to stand trial. All trial courts have authority to order psychological evaluations of defendants, and in many states, an evaluation is automatic once a party raises the competency issue. Judges are to give great weight to the results of an evaluation, but can consider other factors, too, like the defendant’s demeanor in court. Among the points a court should consider are whether the defendant can:

• adequately communicate with defense counsel
• understand and process information
• make decisions regarding the case, and
• understand the elements of the charges, the gravity of the charges, and the possible penalties.

A defendant’s lack of intelligence, education level, language difficulties, and challenges communicating are generally insufficient to support a finding of incompetency.

The Court & Fitness to Proceed

The determination of whether a defendant is competent is left to the judge. The judge must decide competency before trial, as soon as reasonably possible after it comes into question. The prosecution, defense counsel, and even the court can raise the issue at any time. Competency usually comes into doubt when the defendant’s behavior indicates a lack of understanding.

When parents divorce and families break up, the standard for child custody is always the best interest of the child (or children). In order to determine the child’s best interests, a psychiatric evaluation is often used to assess the parents’ and/or the children’s mental statuses, any psychiatric illness or abnormality, the family dynamics, and any conditions or situations which would lead to a better understanding of what appropriate parenting time or custody arrangements would lead to the most psychologically beneficial living situation for the children. Additionally, any treatable psychiatric conditions can be assessed and appropriate treatment can be recommended to ensure the ongoing safety and a good future outcome for each child.

Dr. Vivian Shnaidman, forensic psychiatric consultant and conference speaker, along with Adam Bierman and  Kurt Tazelaar, interviews Dinesh Sharma, well known Harvard  social scientist on the dynamics of the 2016 upcoming US election.

There comes times when a worker may be required to leave the workplace because of the experience of an extreme stressor on the job, disability, discipline, or concern about threat. That same worker may wish to return to the job, raising questions about whether the worker may effectively resume functioning. At this point there are  several kinds of evaluations conducted by forensic psychiatrists or psychologists to determine if a worker is fit to return to the job. The first, the fitness-for-duty evaluation (FFDE), is a specialized evaluation that occurs in safety-related or “high-risk” jobs such as fire fighting, police work, or security. The second, the return-to-work evaluation (RTE), occurs in more general situations in which the worker has been removed from the job because of disability.

Forensic psychiatry versus the other side: Why the need for a forensic psychiatrist

Anyone who has ever been to court for any reason knows that people’s behavior in front of judges is not always polite, decorous, or appropriate. We often attribute the anxiety, yelling, or tears to the stress of the high-pressure situation, and many times, that’s all it is. But what about those cases that simply scream “crazy” from the very beginning?

Forensic Psychiatric Evaluations

Psychiatry is a branch of medicine which incorporates biological, psychological, and social information and constructs for assessing and treating patients. Forensic Psychiatry is different. Forensic psychiatrists are trained to evaluate individuals for a third party. Unlike general medicine or general psychiatry, people involved with the legal system generally do not wish to consult a psychiatrist for help with their emotional problems. Of course, there are some applications of forensic psychiatry in which an individual will bring psychiatric information about himself to the court, and we will deal with those specific issues later. However, there are  incidents and eventualities which might require the expert testimony of a psychiatrist, and, most importantly, how to understand, interpret, and utilize the information the psychiatrist brings to the case. After all, an expert might look really professorial in his pin-striped suit, but if he does not really know what he is talking about, neither will rot firm.

Over all, Forensic psychiatry is a sub-specialty of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry. A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment like medications and psychotherapy to criminals.

These types of evaluations are among my favorite, although saying so out loud is possibly not quite politically correct. Still, I didn’t kill them, so let us consider what types of evaluations I might be asked to perform, and how these evaluations might be utilized in a court of law.

Testamentary Capacity refers to the ability of an individual to make a will under the law. Sometimes I’m asked to evaluate a still living person, for example someone in a nursing home. But although the criteria are the same, it is fairly easy to evaluate someone who alive. I can ask them questions, we can bring witnesses to the party, and people generally have an idea if the person has an idea of the requirements necessary to write a will, which in virtually every jurisdiction in the United States includes only a few elements: the person must know the nature and extent of his bounty, who his natural heirs are, and to whom he or she wishes to leave his estate. While there are some local additions (in New Jersey, the person is supposed to know in what type of business he or she worked), those additions are minimal and beside the point.

These evaluations become really interesting when a person writes a will, dies of natural causes, and then the heirs and non-heirs start to contest the will. Sometimes only one heir does not like the way the will is written — an heir might not like having to wait until a certain age to get her money, or might not like having to share with siblings. Then the heirs can contest the will, and to contest a will, these heirs must hire attorneys.

Attorneys then look for experts. Often the attorneys hire any random doctor whom they can convince to write something stating that the dead person lacked testamentary capacity on the day he or she wrote their will. Smart attorneys, however, hire me.

In reader to really assess testamentary capacity, we have to recreate the person’s mental status examination as it pertains to the requirements for testamentary capacity on the date of the will writing. A three-sentence letter stating that the individual took medications that might impair consciousness is insufficient. I have seen all manner of ridiculousness submitted in lieu of actual psychiatric expert reports. “Because I said so” is not an expert report. “Because I am a doctor and I said so” is not an expert report. Lawyers need to hire experts who know how to read and understand medical records and apply the appropriate legal standards to them, and then communicate their findings in a way the courts can understand. Otherwise the “expert” reports are useless.

In addition to testamentary capacity, there are other cases in which mental status of deceased people has to be recreated. One example is the psychiatric autopsy, when someone committed suicide or otherwise died and there are legal matters that need to be investigated. Sometimes a wrongful death suit requires information not uncovered in any other investigation. Both civil and criminal matters often require the input of a psychiatrist in uncovering the details of someone’s mental status when that person is unavailable for interview. Those details are important. We do not guess. We reconstruct, based on available information. This work is detailed, painstaking, and challenging. And it is not a letter saying “Because I said so.”