The Impact of a One-Day Workshop on Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder.

OBJECTIVE: Despite evidence validating the diagnosis of borderline personality disorder (BPD) in youth, specifically showing persistence of BPD symptoms and morbidity similar to adults, there is reluctance to diagnose this in teens. Further, there is a belief among many trainees and academic child and adolescent psychiatrists (CAPs) that only specialty programs are effective, leading to treatment delays. This study charts the impact of a full-day workshop offered to an entire academic CAP department. METHODS: A Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder in-person workshop was offered to department members. Participants were asked to complete a pre-survey, an immediate post-training survey, and a survey at 6 months post-training. Utilizing a Qualtrics questionnaire, both linear mixed-effect models and paired t-tests were used to estimate the immediate and sustained effects of the training. RESULTS: Thirty-two participants completed the workshop, with 31 answering the pre-survey, 27 the post-training survey, and 23 the 6-month follow-up survey. Immediately after the training and 6 months later, participants demonstrated statistically significant (p < .05) improvements in willingness to disclose the diagnosis of BPD, a reduced negative attitude around BPD, and an enhanced sense of confidence in addressing the needs of adolescents with BPD. CONCLUSIONS: GPM-A training can make a positive impact on groups of clinicians who work with youth who meet criteria for BPD, specifically reducing stigma, encouraging trainees and faculty members to make the diagnosis more readily, and helping them feel more competent in addressing the treatment needs of adolescents with BPD.

Emotional Content of Comics Drawn by Medical Students and Residents.

OBJECTIVE: Medical students and residents face high rates of burnout. Drawing comics may help trainees process their experiences and feel both valued and connected to those who read their work. In this study, the authors sought to elucidate the predominant emotions and themes conveyed in medical students' and residents' comics about stressful situations. METHODS: In 10 different sessions, medical trainees drew "something stressful in medicine". Collected comics were analyzed by three coders, who applied emotional adjectives. Differences were resolved through discussion, with one to two final codes per comic. Codes coded based on items objectively seen in the comic and were encouraged not to project what they would feel in that situation. RESULTS: Two hundred ninety comics were analyzed by our research group. "Overwhelmed" was the most common final code (101 comics, 34.8%). Other common adjectives used by our coders to describe the comics were "inadequate" (24, 8.2%), "frustrated" (21, 7.2%), and "helpless" (16, 5.5%). Twelve of the comics (4%) were considered non-codable because of difficulty deciphering the theme or print. CONCLUSIONS: Brief comic exercises allowed medical trainees to convey what it is like to be "stressed out" in medical training-with trainees most often showing that they are/feel "overwhelmed," "inadequate," "frustrated," and "helpless." This demonstrates that medical students and residents convey these same emotions when reflecting on individual stressful experiences throughout their training. More research on whether graphic medicine for emotional and cognitive processing of stress makes an impact on burnout and satisfaction is warranted.

Eye Openers.

Do you ever find that someone-perhaps an author, actor, or pop icon-comes along and makes you a better therapist? Perhaps the day after reading their work or seeing them on TV, you find yourself just a little more conversationally brave, open, structured, or spontaneous? As our family eye-dabblingly makes our way through the most recent season of Netflix's Queer Eye, lately for me that person has been Karamo Brown. Brown is a therapist and life coach who gracefully repeats phrases of individuals whom the "Fab Five" are trying to help. He affirms ("You deserve the best") and challenges ("I'm going to push back on that"), holding people accountable to their strengths and to the ways that their defenses have become a barrier to fulfilling their desires. Similarly, this month, the Book Forum features 2 books that a pair of academic child and adolescent psychiatrists wrote to me about, feeling that these books make them better therapists.

Getting Real-er.

Dilemmas of diagnostic heterogeneity in psychiatric disorders occur at many levels. Symptoms themselves and the experience of distress with symptoms may differ in nature. Put plainly, one child's sadness is not the same as another's, and the degree to which that young person finds their sadness distressing or impairing may differ from that of their peers.

Writing Notes, Thinking About People.

In 2021, a research group led by Jenny Park published a qualitative study of 600 medical encounter notes written by 138 physicians.2 The researchers found some language that conveyed positive regard, was clearly informative, and effective, while also discovering at least 5 ways in which doctors expressed negative feelings toward their patients. Their paper highlights phrases that convey incredulity ("he claims that nicotine patches don't work for him"), disapproval, stereotyping, and the extent to which providers find patients difficult. They also note diction that emphasizes physician authority and unilateral opposed to shared decision making ("She was told to discontinue…" or "I have instructed him to…"). In their paper, Park's group cautions that, although in and of itself, positive or negative language may not be harmful in the care of individuals, at least 1 study has shown that where dismissive language is used, physicians are less likely to adhere to appropriate guidelines.3.

Family Matters.

Given the focus of the Journal this month, the Book Forum features Jessica Lahey's The Addiction Inoculation: Raising Healthy Kids in a Culture of Dependence. Lahey is a former teacher and writer whose work has appeared in the New York Times, The Atlantic, and Washington Post, focusing mostly on parenting and development. Her guide to decreasing children's risk of substance use disorders (SUDs) and building a sense of self-efficacy is reviewed this month by psychiatry resident Nat Mulkey and their faculty mentor, Amy Yule. While the Monitoring the Future survey shows that the COVID-19 era has featured an unprecedented drop in teen reports of illicit substance use,2 Lahey's book seems particularly important as parents/families are poised for a resurgence in teen SUDs for many reasons. As caregivers return to work, youth are apt to have more and more unsupervised time. Furthermore, with youth increasingly contending with mental health challenges,3 they are at increased risk for coping through unhealthy means including substance use.

Eco-Anxiety.

People of all ages are increasingly worried about our planet. The burden, though, rests on the young, and they are feeling it. Caroline Hickman and colleagues at the University of Bath polled 10,000 youths aged 16 to 25 years from 10 countries. In their project (the report of which is available but not yet peer reviewed), they discovered that 75% of youths polled feel the "future is frightening," 56% sense that "humanity is doomed," and 39% are "hesitant to have children" because of global warming.2.

Dark Skies, Rays of Hope.

In this month's Book Forum, Deepika Shaligram and Raman Baweja confront loss in their review of the Hindi-language film, The Sky Is Pink. Together these academic child and adolescent psychiatrists contemplate what happens to parents and siblings when the threat of losing a child to medical illness looms over family life. They note that-with breaks in the existential clouds and levity here and there-The Sky Is Pink is a thought-provoking meditation on the vulnerability of being a parent and being a pediatric physician. We imagine the best outcomes possible, but must learn to live when the worst becomes a reality.

Helping Adolescents Through Affective Storms, Suicidality, and Interpersonal Strife.

Over the last few years, on our consultation-liaison and emergency services we have met an increasing number of youths struggling with suicidality and self-harm.1 Many of these young people have had solid, evidence-based treatment of depression or anxiety, yet still find "something" missing. They are in deep pain, and feel that almost nothing is right or safe or good enough. Recognizing that young people who have attempted suicide are at high risk for suicide in the future,2 we have tried to slow down, reflect, and think about the "something" that is missing.

Of Triggers, Tigers, and Tactics: Managing Emotional Dysregulation.

The frustration of defining, understanding, and addressing irritability in child psychiatry and the difficulties that children with emotion dysregulation face on a daily basis can be seen as parallel processes. We know that irritability is one of the most common reasons for which children are referred for evaluation.1 We also know that the stakes are extremely high, with persistent irritability associated with suicidality.2 Despite this, we do not have a readily available nosological paradigm. Our current clinical approach remains muddled by outbursts' transdiagnostic nature. We find ourselves listing things such as posttraumatic stress disorder, disruptive mood dysregulation disorder, attention-deficit/hyperactivity disorder, anxiety, and depressive disorders in the chart, but feeling that we have not fully captured the unique neurobiological and subjective essence of a child's irritability syndrome.3 Furthermore, despite extensive research, we lack accessible diagnostic tools or effective treatment protocols to implement on a community-wide basis. So, we (JC, CU) think we have every right to be irritable as we experience frustrative non-reward (thinking and focusing on this issue with blocked goal attainment) and face existential threat (desperately wanting children and families to enjoy better developmental trajectories, and wanting it now!).4.

Qualitative analysis of the Meals, Mindfulness, & Moving Forward (M3 ) lifestyle programme: Cultivating a 'safe space' to start on a 'new path' for youth with early episode psychosis.

AIM: The Meals, Mindfulness, & Moving Forward (M3 ) programme included nutrition education, hands-on cooking classes, mindfulness meditation practice, physical activities and facilitated group sharing. M3 was designed as a supplement to standard care for youths (age 15-25 years) with first-episode psychosis (FEP) who were clients of coordinated specialty care teams. M3 's primary aim was feasibility by demonstrating high programme attendance; secondary aims included cardiometabolic measures. Data collection included quantitative and qualitative outcomes. The aim of the qualitative study was to understand participants' and study partners' experiences during the programme and to understand programme elements that were helpful for young people to sustain healthy lifestyle choices 6 weeks post-programme. METHODS: During the last programme session, we conducted two focus groups, one with participants (n = 13) and one with their study partners (n = 11); 6 weeks post-intervention, individual semi-structured interviews were conducted with 11 participants. All interviews were audio recorded and transcribed; grounded theory methods guided thematic analysis. RESULTS: Main themes from the focus groups included appreciation for a 'non-stigmatizing' environment providing participants and study partners with a sense of 'dignity' that enabled a 'new path'. Six weeks post-intervention, participants reported continued use of mindfulness practice to stay grounded and assist with making healthful lifestyle changes. However, many were unsure of how to sustain these changes long-term. CONCLUSION: The results suggest that young people with FEP value a non-stigmatizing space that allows for social engagement and facilitates healthy behaviours. Short-term, M3 participants reported behaviour change but wanted on-going support to sustain healthy behaviours.

A Little Magic.

Despite advances in the neuroscience of addiction, progress in medication-assisted treatment (MAT), and legislative momentum, in 2017 more than 70,000 Americans died due to drug overdose.2,3 Clearly there are no perfect answers to the opioid crisis. Albeit messy, we must begin somewhere, and one upstream approach includes providing public education and reducing stigma such that people will reach out for help and find support readily accessible.4 Kate Messner's middle-reader novel, The Seventh Wish and Jarret Krosoczka's young adult-focused graphic memoir, Hey, Kiddo provide excellent starting points. This pair of books introduce what it is like to love someone who is addicted to drugs, and they do so without frightening readers away. As reviewer Anandam Hilde offers, these books seem "filled with truths, and a little magic."

Minds, Maps, Meanderings.

In her book Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, historian Anne Harrington challenges psychiatrists to embrace complexity. Her central message is that society has often projected a lot onto psychiatry, with our field far too eager to accept these and to fill an expertise void: at one point, with psychoanalytic grandiosity, later with overpromised, underperforming biological boasts and reified diagnostic labels. Echoing Foucault, Harrington invites us to avoid mistaking the name of the thing for the thing itself and to keep struggling for answers, embracing a slow science, marketing expertise humbly.2 Although some may feel defensive in their reading of Mind Fixers, I found it an invitation to recognize that the successes and failures of psychiatry's past are our inheritance. It is up to us to learn from this past, to be humbled and encouraged by it, and to examine how we are promoting our field in the present. We need to advertise that although many aspects of neural functioning elude us and although we rely on many of the same therapeutic practices from the past, we are not without direction for the future. For example, an elegant roadmap was laid out a year ago by Karolina Kauppi and colleagues wherein they combined a data set for schizophrenia risk genes and another set of genes associated with antipsychotic drug targets.3 Using this "network biology" approach, they identified four schizophrenia risk genes that were also antipsychotic drug targets (GRM3, DRD2, CHRM4, and CYP2D6); they also found several molecular targets that are not currently connected to antipsychotic drug treatment, providing researchers with some potential targets for novel therapeutics.4.

CAPs and College.

Time flies. Young people grow up and are off to college. It's exciting. Yet even for the most well-adjusted student, it is fraught with uncertainty. It is a time of tension. Young people take on greater academic responsibility, are more independent in tasks of daily living, must navigate mature relationships, and must take charge of their own health care. In years past, transitional age youth with mental illness may have had inadequately controlled symptoms, functional impairment, or faced stigma preventing them from going to a college or university. Their academic paths and career options were limited. Changing attitudes and improvements in identifying mental health conditions have allowed an increasing number of young people to access appropriate treatment, and this has led to improvements in educational achievement. However, although students with mental illness may enjoy improved access to college, they struggle more than others when making the transition. Stress can exacerbate symptoms and make attending class regularly or completing projects difficult.2.

Meals, Mindfulness, & Moving Forward: A feasibility study to a multi-modal lifestyle approach in early psychosis.

AIM: The primary aim was to demonstrate adherence to a novel 6-week lifestyle intervention program ("Meals, Mindfulness, & Moving Forward" [M3 ]) designed to help improve lifestyle practices of youth with a history of at least 1 psychotic episode. METHODS: M3 used a non-equivalent control group design involving clients from a community early intervention program. Seventeen individuals in the active M3 program and 16 controls were assessed for secondary outcomes at baseline, 6-weeks, and 12-weeks (6 weeks post-intervention) on cardiometabolic and symptomatic outcomes. RESULTS: The program met its primary aim with 88% (15/17) of participants meeting adherence criteria. Compared with the controls, M3 participants showed significant improvement in positive psychotic symptoms (P = .002). CONCLUSION: This pilot study showed that young people involved in a community early intervention program adhered to an activity-based lifestyle program which included mindfulness meditation, yoga and nutrition education, warranting further evaluation with a larger sample size.

The Body and the Traumatic Real.

The symbol (word) first manifests itself as the killing of the thing…-Jacques Lacan1 This month our books and reviewers challenge us to examine the mental worlds and lived experience of women whose bodies are brutalized, pushed to extremes of overeating and undereating, of wishing to shout yet being unable to say a word. Nathalie Szilagyi reviews writer and feminist Roxane Gay's Hunger, a memoir detailing the author's struggles with self-acceptance and her body in the aftermath of severe trauma. In her review, Szilgayi asks us to imagine how we can help people facing situations like that of Gay, in ways more affirming and effective. Meanwhile, Michael Goldenberg, Kimberly Myers, and Jennifer Aengst examine three graphic memoirs and novels (Ink in Water, Lighter Than My Shadow, Speak: The Graphic Novel). They encourage us to look beyond our patients' speech balloons, affects, and exteriors, imagining the thought bubbles that loom overhead.

Metamorphosis.

It is little wonder that the ancient Greeks used the same word for butterfly and for soul (ψυχή = psyche), or that our specialty adopted this name. In child and adolescent psychiatry we know well the powerful feeling of seeing a young person truly get their wings. Bursting from that which may have nurtured and encumbered, the chrysalis of unfortunate circumstance or psychiatric disorder, we feel a thrill when our patients fly free. In our field we also know what it is to get "psyched" by something that we read. Reading a great book opens up possibility. Turning that last page holds promise that in clinical encounters to come, we may adopt a new way of listening, be more fluid and facile, with fresh therapeutic tools.