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ADHD assessments

As a licensed psychologist, I specialized in working with adults with Attention Deficit Hyperactivity Disorder (ADHD). For some of my clients, it may be the first time in their adult life that they think about a possible ADHD diagnosis, and they want to get answers.

However, this idea of a “psychological assessment” or “psychological testing” might seem intimidating. Therefore, in today’s blog, I want to answer some of the most common questions about ADHD assessments, to demystify its typical procedures and to emphasize the potential benefits of obtaining a thorough assessment report by a qualified provider.

In general, to ensure an accurate ADHD diagnosis in adults, it is important to involve licensed mental health professionals (e.g., clinical psychologists, psychiatrists) that are trained in the treatment and assessment of adult ADHD.

ADHD assessments can help clients gain a holistic understanding of their “individual ADHD”, how it’s affecting their everyday life, and it’s necessary to receive individual recommendations for coping strategies based on these assessment outcomes. Another benefit is having a thorough ADHD assessment report that can serve as an objective “baseline” of certain cognitive/mental functions. Clients can revisit or re-do certain assessment parts again in a few years to see if anything changed over time. 

Prevalence of ADHD

Research indicates that the estimated prevalence of ADHD among children is 11%, with approximately one-third of diagnosed children retaining the diagnosis into adulthood (Visser et al., 2014). This persistence is reflected in the overall prevalence of current ADHD among adults aged 18 to 44 years, which stands at 4.4% (Kessler et al., 2006). 

If we take that percentage and apply it to today’s U.S. population ages 18 to 44 (118.3 million people), it translates to an estimated 5.1 million adults between 18 to 44 years with ADHD. For Florida alone, it would translate to 286,000 adults with ADHD.

Even though ADHD awareness has increased over the past years, there may be some barriers in recognizing ADHD symptoms by providers that are not trained in ADHD. Sometimes, ADHD symptoms overlap with depression and anxiety, so people receive treatment for (secondary) depression or anxiety, even though ADHD is the primary reason for said anxiety or depression. 

While some individuals may have received an ADHD diagnosis from their primary care physician or psychiatrist, often based on symptom discussions and brief surveys, it does not automatically mean that they understand their “individual ADHD”. They may lack detailed information about their specific ADHD type, they may not know what executive function may be affected, and/or what to do to tackle very specific ADHD-related symptoms. Even though ADHD shares common diagnostic markers, it manifests uniquely in each person.

This is where I come in. As a provider trained in the treatment and assessment of adult ADHD, I usually inquire about clients’ awareness and knowledge of executive functions, exploring the intricate relationship between executive functions and ADHD. 

ADHD assessments: Important steps

Here is a short summary of the usual ADHD assessment process in my private practice. Please note that other providers may handle the assessment process differently, but some of the key areas (such as executive functions, working memory) should be “gold standard” when it comes to evidence-based assessments for ADHD. 

Officially recognized are three presentations of ADHD: 1.) Predominantly Inattentive, 2.) Hyperactive-Impulsive, and 3.) Combined type. It’s important to note that no single test can definitively diagnose ADHD. Additionally, ADHD is often associated with other mental health conditions like depression and anxiety as symptoms can overlap, so ideally an assessment also factors in those conditions.

Therefore, my assessment process goes beyond confirming ADHD. A comprehensive assessment can take a few hours on multiple days. Depending on how much can be done in one setting, it usually requires people to come in at least three times. 

First step: Usually, the first meeting is dedicated to a thorough examination of your history. I ask very specific questions about your childhood, your education, any struggles in school or at work. If possible, I also ask clients to ask their parents or their partner for their opinions on certain symptoms. This first meeting takes about two hours, and also includes brief screenings of anxiety and depression and other mental health conditions related to ADHD. 

Second Step: After a thorough examination of your history, you will come in for two or three more times for specific psychological tests. These tests are usually administered digitally on an iPad, to assess cognitive and executive functions, such as attention, working memory, cognitive flexibility, etc. It provides valuable insights into specific cognitive strengths and weaknesses. Some of these tests may include:

  • Continuous Performance Tests: These tests measure sustained attention and response inhibition.
  • Executive Functioning Tests: These tests assess various aspects of executive functioning, such as working memory and cognitive flexibility.
  • IQ/Cognitive Functioning Tests: These tests provide a measure of overall cognitive functioning and how working memory impacts certain cognitive functions.
  • Memory Tests to assess verbal and non-verbal memory.
  • Tests for Comorbid Conditions: Specific brief surveys designed to assess symptoms of depression or anxiety that may co-occur with ADHD.

The third step includes compiling all of the data into one easily understandable and comprehensive evaluation report (appr. 15-25 pages). In a feedback meeting, I will go over all of these results with clients, and I will also discuss individualized recommendations for ADHD coping strategies based on these outcomes.

Summary:

After a comprehensive ADHD assessment, clients have a better understanding of individualized recommendations for ADHD strategies. The assessment provides clients with a thorough understanding of their individual ADHD, its impact on daily life, and serves as a baseline for tracking cognitive function changes over time.

When selecting a provider, I can encourage you to ask about their specific training and experience in working with adults with ADHD. Qualified professionals are typically willing to share details about their training and experience working with adult ADHD. Any reluctance to provide such information in response to reasonable inquiries should raise concerns, and it may signal the potential need to seek assistance from a different professional.

Sources:

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Faraone, S. V., Greenhill, L. L., Howes, M. J., Secnik, K., Spencer, T., Ustun, T. B., Walters, E. E., & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. The American journal of psychiatry, 163(4), 716–723. https://doi.org/10.1176/ajp.2006.163.4.716

Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., Perou, R., & Blumberg, S. J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. Journal of the American Academy of Child and Adolescent Psychiatry, 53(1), 34–46.e2. https://doi.org/10.1016/j.jaac.2013.09.001

Disclaimer: My information is strictly for educational and informational purposes, and not intended to replace any professional therapy or medical advice. I strive to be accurate, but I cannot guarantee that the information is suitable for every individual or situation. The content provided on this blog is for informational purposes only and is not intended as a substitute for professional therapy, diagnosis, or treatment. Please seek the advice of a licensed professional for any questions or concerns you may have regarding your mental health. Never disregard professional advice or delay in seeking it because of something you have read on this blog. Furthermore, I am not responsible for any actions you take or do not take as a result of the information provided in this blog. Please consult with your healthcare provider or mental health professional before making any changes to any treatment plan. By reading my blog, or watching my videos, you acknowledge that you have read and understood this disclaimer. Important: If you experience a crisis or mental health emergency (and you are located in the US), please call 911 or visit the nearest emergency room (do not send me a message or call me, I am not able to respond to messages online).

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Conflict avoidance

Addressing conflicts is crucial for building healthy relationships and effective communication. However, most people shy away from conflicts. It’s normal to feel uncomfortable when you have to address certain things.

And as it happens with most things that feel uncomfortable, our mind tries to avoid doing thinking about it. This avoidance has a clear benefit – it provides relief now because we don’t have to address it right here and right now. However, this avoidance comes with caveats – long-term consequences. Today’s article tries to shed some light on these consequences, and why we tend to avoid conficts.

Where does conflict avoidance come from?

Conflict avoidance can have various roots, and it often stems from a combination of psychological, emotional, and interpersonal factors. Understanding the root causes of your individual conflict avoidance is essential for personal growth and developing healthier communication patterns. Addressing these underlying factors often involves self-reflection, building communication skills, and, in some cases, seeking support from therapists or counselors to explore and overcome barriers to addressing conflict. Here are some of the most common reasons why people avoid conflicts:

  • Fear of rejection: People may avoid conflict because they fear that expressing their opinions or confronting an issue might lead to rejection or disapproval from others. This fear of being disliked or rejected can be a powerful motivator for avoiding conflict. Sometimes, people turn to the other extreme of “pleasing people”, just to avoid any potential for being disliked.
  • Low Self-Esteem: A lower self-esteem may go hand in hand with fears of rejection where people hesitate to engage in conflict because they doubt their ability to handle the situation effectively. They may fear that expressing their needs or concerns will result in negative judgments.
  • Past Trauma: When people grow up without emotional validation and without an opportunity to express their emotions without repercussions from parents or caregivers, it may contribute to a reluctance to engage in conflict. Especially traumatic experiences can contribute to a fear of reliving or exacerbating past hurts.
  • Lack of Communication Skills: Some people may avoid conflict simply because they lack the communication skills that are necessary to express their thoughts and feelings effectively. They may feel overwhelmed by the prospect of navigating a difficult conversation.
  • Cultural or Family Upbringing: Cultural or family backgrounds that discourage open expression of emotions can also contribute to conflict avoidance. Individuals raised in environments where conflict is viewed negatively may find it challenging to engage in healthy discussion and confrontation.
  • Desire for Harmony: Some individuals simply value harmony and peaceful interactions, and they may avoid conflict to maintain a sense of peace and stability in their relationships. The discomfort associated with conflict may override their willingness to address issues.
  • Avoidance as Coping Mechanism: For some, avoiding conflict serves as a coping mechanism to manage anxiety or stress. If there’s a lot of stress going on in their lives, it makes sense to avoid any additional stress, and they may believe that avoiding conflict is the best way to maintain an emotional equilibrium.

How to address conflict avoidance:

Conflicts are a natural part of relationships, especially when it comes to communicating and establishing boundaries. Even though it is uncomfortable in the beginning, addressing conflicts and boundaries in a healthy way can lead to growth and increased understanding long-term. However, it is essential to approach conflicts with the intention of finding solutions and maintaining the overall well-being of the relationship. Here are some general recommendations how to address conflict avoidance:

  • Self-Reflection: Take time to understand your own feelings and reactions to conflict. A diary may help you with Identifying any patterns or underlying fears that contribute to avoidance.
  • Communication Skills: There are many books and videos online that explain communication skills. Effective communication skills, including active listening, expressing yourself clearly, and using “I” statements to convey your feelings without blaming the other person, are very helpful to get to a solution that works for both parties.
  • Understanding Conflict: Conflict is not automatically negative. It may be helpful to change your perspective on conflict. If you see it as an opportunity for growth and understanding rather than a negative experience, you may recognize that not all conflict is harmful and that addressing issues can lead to stronger relationships.
  • Embrace Uncomfortable Conversations: The more you engage in having difficult conversations, the less uncomfortable you will feel about it, and the more skilled you will become. Start with smaller issues before tackling more significant concerns.
  • Choose the Right Time and Place: Right in the morning before leaving for work is not the best time to address conflict. Try to pick an appropriate time and setting for the conversation with both partners in mind. Make sure both parties are in a calm and receptive state of mind.
  • Focus on Solutions: Shift the focus from blame to finding solutions. Collaborate with the other person to work towards resolutions that benefit both parties. If needed, don’t hesitate to involve a neutral third party, such as a psychologist or counselor, to facilitate the conversation. They can provide guidance and help create a safe space for open communication.
  • Set Boundaries: Establish and communicate your boundaries. Be clear about what behavior is acceptable and what is not, and encourage the other person to do the same. However, also discuss consequences if boundaries are not respected. Those consequences are often the hardest part about setting boundaries, but they are necessary otherwise your boundaries won’t be respected. 

Summary:

Avoiding conflicts might provide immediate relief, but it often leads to long-term negative consequences in relationships and personal growth. Understanding the roots of conflict avoidance—such as fear of rejection, low self-esteem, past trauma, lack of communication skills, cultural upbringing, desire for harmony, and using avoidance as a coping mechanism—is crucial for addressing it effectively. By engaging in self-reflection, improving communication skills, reframing the perception of conflict, embracing uncomfortable conversations, choosing appropriate times and places, focusing on solutions, and setting clear boundaries, individuals can overcome conflict avoidance and foster healthier relationships. If needed, seeking support from psychologists or counselors can provide valuable guidance and help create a safe space for addressing conflicts constructively.

Disclaimer: My information is strictly for educational and informational purposes, and not intended to replace any professional therapy or medical advice. I strive to be accurate, but I cannot guarantee that the information is suitable for every individual or situation. The content provided on this blog is for informational purposes only and is not intended as a substitute for professional therapy, diagnosis, or treatment. Please seek the advice of a licensed professional for any questions or concerns you may have regarding your mental health. Never disregard professional advice or delay in seeking it because of something you have read on this blog. Furthermore, I am not responsible for any actions you take or do not take as a result of the information provided in this blog. Please consult with your healthcare provider or mental health professional before making any changes to any treatment plan. By reading my blog, or watching my videos, you acknowledge that you have read and understood this disclaimer. Important: If you experience a crisis or mental health emergency (and you are located in the US), please call 911 or visit the nearest emergency room (do not send me a message or call me, I am not able to respond to messages online).

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Cognitive distortions & cognitive biases: Understanding the way we think

As human beings, we are all subject to biases and distortions in the way we perceive, interpret, and remember information. In today’s blog, I want to explore and explain two related concepts: cognitive distortions and cognitive biases. These biases and distortions can affect our thoughts, emotions, and behaviors, leading us to make inaccurate or unhelpful judgments and decisions.

Cognitive distortions

Cognitive distortions are patterns of thinking that are biased, inaccurate, or unhelpful. They can affect the way we perceive ourselves, others, and the world around us. Cognitive distortions are often automatic and unconscious, meaning that we may not even be aware that we are engaging in them. Most people have cognitive distortions to some extent, it is important to be aware of it; they can be thought of as “thinking traps” that can lead to negative emotions, behaviors, and outcomes. 

There are many different types of cognitive distortions, but they all share a few common characteristics. First, they involve a departure from reality, in which our thoughts and perceptions are not in line with the actual facts or evidence. Second, they often involve a negative or unrealistic view of ourselves, others, or the world around us. Finally, cognitive distortions tend to be self-perpetuating, meaning that once we start engaging in them, they can be difficult to break free from. Here are some cognitive distortion categories:

  • Black/White, or All-or-Nothing Thinking: Seeing things in black-and-white terms, without any shades of gray. For example, thinking that a minor mistake means that you are a complete failure.
  • Catastrophizing: Assuming that the worst-case scenario is going to happen, even if there is little evidence to support this belief, e.g. thinking that one small setback will completely ruin your life (“making a mountain out of a molehill”).
  • Overgeneralization: Drawing broad conclusions based on one or a few isolated incidents. E.g., assuming that all people of a certain race, gender, or profession are the same based on one negative experience with a single individual.
  • Personalization: Assuming that events or situations are related to us personally, even if there is little evidence to support this belief, e.g., thinking that a stranger’s angry expression is directed at you, even though they are actually upset about something else entirely.
  • Emotional Reasoning: Believing that our emotions are an accurate reflection of reality, e.g., thinking that if we feel anxious about a situation, it must be dangerous or threatening.
  • Discounting the Positive: Ignoring or dismissing positive experiences, achievements, or feedback, while focusing only on the negative, e.g., thinking that a positive review of your work is only due to luck or chance, while negative feedback reflects your true abilities.
  • Jumping to Conclusions: Making assumptions or judgments without sufficient evidence, e.g., assuming that someone dislikes you without ever speaking to them or hearing their perspective.
  • Magnification and minimization (magnifying the negative, minimizing the positive):
    • Magnification involves exaggerating the importance, significance, or potential negative consequences of a situation or event, e.g., someone may magnify a small mistake they made at work, thinking that it will result in them losing their job or ruining their career. Minimization, on the other hand, involves downplaying or dismissing the importance or potential positive consequences of a situation or event, e.g., someone may minimize the importance of a promotion at work, thinking that it was just luck or that they didn’t really deserve it.

Cognitive bias

Cognitive biases are similar to cognitive distortions in that they involve a departure from reality and can lead us to make inaccurate or unhelpful judgments and decisions. However, cognitive biases are often more systematic and predictable than cognitive distortions. They are also more likely to be influenced by external factors such as context, culture, and social norms.

Cognitive biases are often based on mental shortcuts or heuristics that our brains use to make quick judgments and decisions. While these heuristics can be useful in many situations, they can also lead us to make errors in judgment when they are applied inappropriately.

Some examples of cognitive biases include:

  • Confirmation bias: The tendency to seek out and interpret information in a way that confirms our pre-existing beliefs or hypotheses.
  • Availability heuristic: The tendency to rely on the most readily available information when making decisions, even if it is not necessarily the most accurate or relevant.
  • Anchoring bias: The tendency to rely too heavily on the first piece of information we receive when making decisions, even if it is not necessarily relevant or accurate.
  • Hindsight bias: The tendency to believe that we would have predicted an event or outcome after it has occurred, even if we had no basis for predicting it at the time.
  • Framing effect: The tendency to be influenced by how information is presented, rather than the actual information itself.
  • Negativity bias: The tendency to give more weight to negative experiences, information, or feedback than positive ones.
  • Dunning-Kruger effect: The tendency to give more weight to negative experiences, information, or feedback than positive ones.

What can you do about it?

Cognitive distortions and biases are closely related, as they both involve a departure from reality and can lead us to make inaccurate or unhelpful judgments and decisions. However, cognitive biases are often more situation-specific and can be influenced by external factors, while cognitive distortions tend to be more persistent and internally driven.

It is important to recognize both cognitive distortions and biases in order to understand the way we think and make decisions. By becoming more aware of our own biases and distortions, we can work to overcome them and make more accurate and helpful judgments and decisions in our daily lives. I usually recommend to keep track of negative thoughts, and to try to classify it with the cognitive distortion categories mentioned above – that is usually a good way of identifying unrealistic thoughts. A psychologist/psychotherapist can also be helpful to give you a more neutral/realistic perspective of your thoughts.

Dr. Mario Lehenbauer-Baum

Disclaimer: My information is strictly for educational and informational purposes, and not intended to replace any professional therapy or medical advice. I strive to be accurate, but I cannot guarantee that the information is suitable for every individual or situation. The content provided on this blog is for informational purposes only and is not intended as a substitute for professional therapy, diagnosis, or treatment. Please seek the advice of a licensed professional for any questions or concerns you may have regarding your mental health. Never disregard professional advice or delay in seeking it because of something you have read on this blog. Furthermore, I am not responsible for any actions you take or do not take as a result of the information provided in this blog. Please consult with your healthcare provider or mental health professional before making any changes to any treatment plan. By reading my blog, or watching my videos, you acknowledge that you have read and understood this disclaimer. Important: If you experience a crisis or mental health emergency (and you are located in the US), please call 911 or visit the nearest emergency room (do not send me a message or call me, I am not able to respond to messages online).

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ADHD and perfectionism

Perfectionism and ADHD? How does that go together? In my private practice, I work a lot with adult clients with ADHD. It does not matter if ADHD was diagnosed late in life, or early on in their childhood: A tendency for perfectionism is something I frequently notice and work on with my clients.

I usually like to explain that there is a complex relationship between ADHD and perfectionism. On one hand, some individuals with ADHD may struggle with perfectionism and wanting everything they do to be flawless, while on the other hand, others may struggle with procrastination and difficulty with completing tasks. These struggles seem to be on the opposite end of perfectionism, but are ironically connected to ADHD and perfectionism as a coping mechanism.

What is perfectionism?

Usually, perfectionism can be characterized as a personality trait that leads to setting impossibly high standards for oneself; people strive for flawless performance in all areas of life. While striving for excellence and having high standards can be positive traits, perfectionism can become problematic when it interferes with daily life and causes excessive stress or anxiety. It can sometimes also be problematic when people try to work on “perfectionism”, but are also afraid of failure if they’re not “perfect” anymore. There is a tendency to attribute their success to perfectionism instead of attributing it to their skills (that are there regardless if there’s perfectionism or not). 

People who struggle with perfectionism may believe that they need to be perfect in order to be accepted or valued, and may be highly critical of themselves when they fall short of their expectations. There can often be a rigid mindset and people can be highly critical of others as well. They may have difficulty delegating tasks or asking for help, and may feel anxious or overwhelmed when things don’t go according to plan.

Perfectionists may engage in behaviors such as overworking, overthinking, and overanalyzing, which can interfere with their ability to complete tasks and achieve their goals. They may also experience feelings of guilt, shame, and self-doubt when they fail to meet their own high standards.

Perfectionism as a coping strategy

I see it in my work a lot that for individuals with ADHD, perfectionism can sometimes be a coping mechanism, a way to compensate for difficulties with attention and focus. By striving for perfection, individuals with ADHD may feel a greater sense of control over their environment and their abilities, and try to make up for procrastination and difficulty with completing tasks with delivering “perfect” results.

However, this can also lead to feelings of frustration, disappointment, and self-criticism when they inevitably fall short of their unrealistic and high expectations.

The pursuit of perfectionism can lead to negative consequences, such as increased anxiety, self-doubt, and burnout. Individuals with ADHD who struggle with perfectionism may find themselves engaging in behaviors such as overworking, overthinking, and overanalyzing, which can interfere with their ability to complete tasks and achieve their goals.

Perfectionism can also create a vicious cycle of self-criticism and negative self-talk. When individuals with ADHD set unrealistic standards for themselves and fail to meet them, they may experience feelings of shame, guilt, and self-doubt. This can lead to a negative cycle of perfectionism, in which the individual sets even higher standards to avoid the negative feelings associated with failure.

Strategies to combat perfectionism

It’s important for individuals with ADHD to recognize the role that perfectionism may be playing in their lives, and to seek support and strategies for managing it. Some strategies that may be helpful include setting realistic goals, practicing self-compassion, and focusing on progress rather than perfection. 

Additionally, seeking support from a mental health professional who is experienced with ADHD can be beneficial in developing individual coping strategies and improving overall well-being. Perfectionism can usually be treated with cognitive-behavioral therapy, which involves identifying and challenging negative thought patterns and learning new coping strategies for managing anxiety and stress.

It is important to realize that sometimes good enough is just that – GOOD ENOUGH!

You can also view a short video of me explaining perfectionism here: https://www.instagram.com/reel/CqL0mitjl9R/?igshid=YmMyMTA2M2Y=

Disclaimer:

My information is strictly for educational and informational purposes, and not intended to replace any professional therapy or medical advice. I strive to be accurate, but I cannot guarantee that the information is suitable for every individual or situation. The content provided on this blog is for informational purposes only and is not intended as a substitute for professional therapy, diagnosis, or treatment. Please seek the advice of a licensed professional for any questions or concerns you may have regarding your mental health. Never disregard professional advice or delay in seeking it because of something you have read on this blog. Furthermore, I am not responsible for any actions you take or do not take as a result of the information provided in this blog. Please consult with your healthcare provider or mental health professional before making any changes to any treatment plan. By reading my blog, or watching my videos, you acknowledge that you have read and understood this disclaimer. 

Important: If you experience a crisis or mental health emergency (and you are located in the US), please call 911 or visit the nearest emergency room (do not send me a message or call me, I am not able to respond to messages online).

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How to deal with uncertainty

Uncertainty is a recurring theme these days. Most people are worried about the pandemic, about the economy, about politics, about relationships, about their jobs, and so on. A lot of these these things are uncertain; nobody knows what’s going to happen with the current pandemic, where the economy will be in a few years from now, or even what is going to happen in our relationships. Constant worrying creates anxiety. As human beings, we have a natural tendency for “control”, wanting to be in control of things – and uncertainty is not compatible with control. While definitely uncomfortable, anxiety is also kind of a natural reaction to uncertainty.

As a psychologist, I am confronted with uncertainty and resulting anxiety on many sides: it affects my clients and how I work with them, but it also affects my personal life. Today’s article is intended to provide some information about uncertainty, anxiety and how to deal with uncertainty in these unprecedented times. Disclaimer: Please note that my blogs do not replace professional advice from health providers.

Anxiety, stress and fears as natural and normal reactions: Autonomic nervous system

One of the first things I do with new clients, and I also bring it up constantly later on, is to explain how our body works. It’s important to get an idea about how emotions works, how stress works, and what your body is doing. Working with my clients, it is very important for me to explain how stress and anxiety work on a physiological level.

Talking about stress and anxiety, I usually explain how our autonomic nervous system works. The autonomic nervous system (ANS) regulates most of our body processes without our conscious effort (which is why it is called “autonomic”), and it includes processes like heart rate, blood pressure, breathing, digestion, sexual functions, etc. (imagine if we would have to consciously *think* about breathing all the time!).

The ANS has two main divisions (actually, there are three, but I usually leave out the third branch – the enteric system – because the enteric system is capable of functioning independently from the nervous system, and is mainly responsible for digestive processes); those two divisions mostly compete with each other (which means, they usually cannot be activated at the same time):

  1. The sympathetic nervous system “activates” our body and is responsible to prepare us for stressful or emergency situations. It is connected to our “fight-flight” response, and increases our heart rate, we breathe faster, we feel more alert, etc. It activates us, and it prepares our body to do something, to “fight” something, or to run away really fast (flight). 
  2. The parasympathetic nervous system mainly inhibits body reactions, it “slows” us down. We feel relaxed, calm, the body is ready for “rest and digest”; the heart rate is slowing down, the breathing pattern changes (slower and more deeper breathing into our belly), etc.

Think about how you feel, what you feel in your body, when you think about stress and anxiety – you probably already know how it makes you feel: your heart rate increases, your hands may feel shaky, you may feel on edge, etc. These are all reactions governed by the autonomic nervous system. I am using stress and anxiety synonymously here, because they overlap a lot in the way our body reacts to them.

We need both systems to function and perform well in our everyday life. For example, driving a car requires our attention; we need to be activated and to be ready to react quickly to danger (e.g., when a car brakes in front of us). However, we cannot be alert AND at the same time feel “relaxed” or “tired” because the sympathetic and the parasympathetic nervous system are mostly incompatible with each other (either A or B is activated at the same time).

Anxiety, stress and fears “activate” us; our reactions to anxiety and stress are very similar on a physiological level. Our brain recognizes “danger” and puts our body into an activated, more alert mode. This is extremely important for our survival; for example, if a venomous snake appears in front of us and attacks us all of a sudden, we need to be prepared to run away really fast. However, sometimes the “threat” is less real, more diffuse and not tangible at all.

Being in control: anxiety and uncertainty

In general, human beings love to be in control. We love being able to plan (for) things, to anticipate outcomes. However, we are also hardwired to notice things that may be threatening to us. During unprecedented times, where we all are confronted with a global pandemic, many of us feel like we are in danger and like there’s not much we can do about it. We don’t know outcomes, we feel like we can’t control the spread of the virus, we feel like we can’t control how long we have to stay at home – it seems like there are too many things that are uncertain, that we cannot control.

Whenever life feels uncertain and we cannot control certain situations, we feel stressed and/or anxious. The sympathetic nervous system take over; it tries to “active” and “prepare” us. It wants us to take actions to be in control again; most of us are hardwired to take actions whenever we feel like we are not in control. This natural reaction is there to protect us from danger. If you wouldn’t feel anxious, you probably wouldn’t care about consequences, and you wouldn’t wash your hands multiple times per day, or wouldn’t care about wearing masks, etc.

A certain level of anxiety can therefore be useful for our survival, so we can control certain outcomes. However, if we are too worried about too many things, all of our sudden our brain tries to prepare us for too many things at once, and we get too anxious or overwhelmed.

The current pandemic may make us feel helpless about the future; we hear many conflicting information on the news, and things change(d) very quickly. Our natural tendency to be in control is not compatible with the current level of uncertainty about the pandemic; we simply don’t (always) know what is going to happen. Whenever things or situations are uncertain, our body tries to be “activated” and “prepared” for whatever is going to happen. Once we feel like we are in control again, we feel like we can relax (and “breathe”) again.

While these reactions are normal and necessary, it can also be detrimental for our mental health, especially if we are too “activated” for a longer period of time. Some people feel angrier, some feel more “on edge”, some feel helpless, sad or more depressed than usual; dealing with uncertainty interferes with our innate desire to be in control. 

How to take back some level of control: Create a routine

When you think about your life before the pandemic, you probably remember that you had a routine with certain rituals. You got up every morning to shower, you had your coffee at home, you read the news, you went to gym to work out, etc. These “little” things are very important because they give us a feeling of certainty and normalcy. Now, having to stay at home, or having to work from home, it messed up our routines. All of a sudden, we have to stay inside, we cannot go to gym, we cannot go to the mall whenever we want to – our daily routine is messed up, and that level of certainty is seemingly gone.

There are many things that we cannot control with the current pandemic, like, how long it will take, and how it’s going to play out. However, there are still many things that we still have control over, and one of them is our daily life and our daily routine.

There are still the seemingly “little” things that you can do, and it is really important to focus on those. I usually recommend it to any of my clients these days that they create a new routine; it is important to have your own little things that you can do every day. It should be a routine that you can stick to and that makes you feel better. Try to create a plan for the next 2-4 weeks, with all the “little” things you can do every day.

It’s also very important to plan “self-care” as well, now more than ever. Do anything that makes you feel more calm and relaxed (and to give your body the chance to be more calm): it can by anything, a warm bath, play time with a pet, cuddle time with a partner, reading a good book, or – if you are located in South Florida – a walk on the beach.

At the end of the day, try to be kind with yourself; we all live during very unprecedented times, almost none of us had to live through a pandemic like this before. It is okay to not feel okay sometimes, but it is very important to give yourself permission to do something that makes you happy. Make the best out of your days and weeks, and try to create and stick to a routine; it is one of the first steps you can do to gain back some level of control.

Also, it is important to know that anxiety and worries are usually centered around possible outcomes in the future (“What if…”). Challenge yourself to stay in the present, and if you have to think about anxieties and worries, try to view it in terms of possibility and probability. Anxiety is usually centered around possibility; literally anything is possible! However, how LIKELY (probability) is it that something is going to happen? Anxiety and worries want us to feel activated for any possible situation, so it is important to remind yourself that not everything that’s possible is also likely going to happen.

Don’t hesitate to reach out to friends, family, or trained mental health professionals for support. Especially these days and weeks, most mental health providers (including myself) switched to providing Telehealth services (online only), making it easier and so much more convenient for people to access mental health services from the comfort of their own home. 

About the author: Mario Lehenbauer-Baum is a licensed psychologist, located in Fort Lauderdale, Florida. In his private practice, he focuses primarily on anxieties/phobias, adult ADHD, issues with relationships and sexuality, and general men’s issues. He offers Telehealth services as well. This blog is intended for entertainment and information purposes; however, Dr. Mario Lehenbauer-Baum is not responsible for any actions you may or may not take based on information from this blog. This blog does not replace therapy or counseling, and it does not replace any professional advice from health care providers.

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In the spotlight: How a cognitive bias impacts your perception of reality

Many of my clients are surprised when I explain that our perception of what’s happening around us is usually not necessarily “real”. Among many things, cognitive biases also influence the way how we perceive certain things in life, and it affects our emotions and behaviors as well. Today’s blog post is intended to provide some information about cognitive biases.

Rational thinking is very slow, if you think about it (pun intended). To rationally make a decision, we usually have to slow down our thinking; we have to consciously think and deduce information in front of us, how we can get from “A” to “B” to “C” etc. – it’s slow!

While this slow way of thinking can be more efficient, it’s also incredibly time-consuming. Thousands of years ago, in order to survive in wilderness, we simply didn’t have this time – we had to “connect the dots” fast to compare the information (or whatever is happening in front of us) with and connect to other information that’s already stored in our brain. Our brain is literally hardwired to make certain cognitive errors, to use mental shortcuts to speed up mental processing, without us rationally realizing it.  Sometimes it works out, but sometimes it’s also not useful for us because it’s subject to certain limitations.

We all construct our own “subjective reality” based on our hardwired cognitive connections and the information that’s already stored in our brain. To construct our own reality quickly, we also need to process information quickly, so we rely on cognitive biases as mental shortcuts. However, a cognitive bias can also be a disadvantage – it can be a systematic error in thinking, processing and interpreting information in the world around us.

Therefore, whenever clients work with me, I usually also explain how our brain processes information. It’s helpful to know how certain cognitive biases influence how we interpret and perceive information from other people; at the end of the day, it’s also influencing our emotions and subsequent behaviors. It’s important to be able to “re-think” some of our initial decisions by slowing down and appropriately rationalizing certain decisions. There are quite a few cognitive fallacies out there, but I’d like to introduce you to some of the cognitive biases that I often work with.

Spotlight effect

This cognitive bias makes people believe that they are being noticed much more than they really are. Think about it – you live with yourself 24/7, you always hear your own thoughts, always thinking about yourself. It sometimes makes us believe that other people are similarly thinking about us. It is important to remember that most people are more concerned about themselves than they are about you. The next time you feel like the center of attention, it’s important to remember the spotlight effect. Also, try to remember that most other people are most likely concerned with their own thoughts.  

Anchoring

Human minds connect things to speed up cognitive processes; your judgement can be heavily influenced by the first piece of information. Whenever we make estimates and judge if something is cheaper, better, taller, etc., we usually judge it from the reference point of our first available information, the “anchor”. This knowledge is especially useful for financial negotiations because the first number we see has a significant effect on how we perceive the following prices. For example, if you see pants for $ 1500 and then another pair of pants for $ 100, you perceive the second pair automatically as “cheap”. If you see a pair of pants for $ 20 and then another one for $ 100, you would perceive the second pair as “expensive”. 

Confirmation Bias

A confirmation bias impacts how we gather, store, and disregard information. Human minds are prone to look out for any pieces of information that justifies our existing beliefs. Any other pieces and bits of information that possibly contradict our existing beliefs are more easily disregarded as “fake”, not relevant, or we simply oppose it. Over time, our own assumptions take over and confirm themselves. This is especially relevant for people with social fears; they constantly monitor their environment for any negative social clues. Even neutral behavior may be interpreted as something negative, while positive behavior is disregarded as a “fluke” or just random accidental behavior. It’s also relevant for political beliefs that may be reinforced by only consuming certain news or websites.

Sunk cost fallacy

It may be harder to let go (loss aversion) of something or someone if a lot of time, energy, emotions or money was already invested. However, we also lose more in the process of hanging on. Human minds have a natural aversion to pain, and it creates pain and uncomfortable feelings when we realize that something or someone is a lost cause. Our brain is hardwired to avoid any uncomfortable feelings or pain, so we try to hang on. We may justify it by thinking that it has to get better at some point; sunk cost fallacy makes it difficult for people to let go. It can cause us to make unwise investments, or to hang on to unwise investments or unhealthy relationships (because we tell ourselves that we already invested so much money and/or time).

Dunning-Kruger effect

This cognitive bias describes the behavior of people who wrongly overestimate their knowledge or ability in specific areas. Experts usually know how much they know, but they also know how much they don’t know, and they are prone to underestimate their abilities and skills. However, it is very easy to be over-confident if you only have a simple idea of something; your incompetence keeps you from recognizing your own inability.

Framing effect

The way we perceive our information is strongly influenced by how it is delivered and framed. The advertising industry utilizes the framing effect by displaying information in a certain way. For example, it makes a difference if something is labeled as “5% fat” or “95% fat free” although the information behind it is the same. It also depends on how things are said and how the visual information surrounding it is presented (by using certain keywords, colors, fonts, etc.).

Availability heuristic

This cognitive bias is another example of a mental shortcut. Whatever information is easiest for us to recall or retrieve from our memory, that provides the best frame of reference for our future decisions. For example, if people see something in news stories, they are more likely to exaggerate the likelihood of things to happen. If you hear more stories about people being laid off, you may reconsider your spending habits; even though it may not affect you directly, you may overestimate the likelihood of you being laid off. 

Optimism bias

The optimism bias lets people believe that they are less likely to experience a negative event; the likelihood of positive outcomes is overestimated. A good example for that is smoking. Most people know and are aware of how negatively smoking affects their health. However, most people also try to rationalize it by saying “I can stop any time” or “It won’t affect me”, thus overestimating positive outcomes. One way to combat your optimism bias is to use your loss aversion (think about the losses and expenses that are likely to occur because of bad habits), and utilize your availability heuristic (make a conscious effort to read up on negative consequences, thus make bad events or consequences more easily retrievable from memory).

About the author: Mario Lehenbauer-Baum is a licensed psychologist, located in Fort Lauderdale, Florida. In his private practice, he focuses primarily on anxieties/phobias, adult ADHD, issues with relationships and sexuality, and general men’s issues. He offers Telehealth services as well. This blog is intended for entertainment and information purposes; however, Dr. Mario Lehenbauer-Baum is not responsible for any actions you may or may not take based on information from this blog. This blog does not replace therapy or counseling, and it does not replace any professional advice from health care providers.

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Some things people regret before they die…

 

“In the end, it’s not the years in your life that count. It’s the life in your years“. (Abraham Lincoln)

When I was a psychology student, I worked part-time in a palliative care home. It shaped my personality and how I approach things as a psychologist and as a man. People talked to me a lot about their regrets in life (similarly, Bronnie Ware, a palliative nurse, recorded the most common regrets of older people before they die, and published a book “The Top Five Regrets of the Dying: A Life Transformed by the Dearly Departing”).

I remember when I talked to my grandmother about the “speed of life” (“How fast did your life go by”). She told me that the first 50 years went by really fast. The following 30 years even faster (she raised kids, took care of the family and her home, and this was her life). She passed away a few years ago, but I like to think about the lesson I learned – you may think that you so much time left, but the harsh truth is, life is unpredictable, and it goes by in the blink of an eye.  

I would like to share the most common regrets of dying people with you; YOU are still alive, and YOU are still capable to change things in YOUR life, no matter how old YOU are.

Here are the top regrets:

To have the courage to live a life true to yourself, and not a life others expected of you.

Caring too much about what other people think? This was one of the most common regrets, according to Bronnie Ware (see above-mentioned book). Many old people realize that they once had dreams, but they were unable to fulfill those dreams. They lived a life planned by other people, shaped by their parents, their spouses, their friends or neighbors – but some of them did not live the life they wanted to have.

To avoid this regret, you may consider starting a diary. Reflect on your dreams – what are they? What do you REALLY want in life? You have got one precious life, what are YOU going to do with it? Also, who or what is holding you back, and how?

I worked too much.

Yes, I am guilty as charged. I found myself working too much as well, and it affected my physical and mental health. Thankfully, I found a way out of it. But, for example, many male seniors missed their children’s youth, important life events, or their partner’s companionship, simply because they worked too hard. It is probably very rare that someone – once they get to old age – says they wished they had worked much more, or spent so much more time in the office.

To avoid having this regret later on, make it a habit to find some time during the week (and especially on the weekends) to spend it with your family and friends. Schedule it! You should also make it a habit to meet important friends at least once a week, and if it is just for a coffee somewhere (see the next regret).

Stay in touch with old friends.

Everyone misses friends when they are dying. Many of the older people in above-mentioned book deeply regret that they didn’t spend time with friends, to let friendships slip by over the years. It is easy to forget friends over work and time you want to spend with the family, but try to meet friends at least once a week. Or try to at least reach out to them by sending a simple text message.

To have the courage to express the feelings, and standing up for yourself more.

Many people suppress their feelings, just to keep peace with others, instead of standing up for themselves. Moreover, some older people regret not telling someone how they truly felt. Even if the “right one” does not exist, telling someone how you really feel will save you from regrets such as “What if…”.

Sure, it feels uncomfortable to provide feedback to other people, and most of us do not like conflicts. Still, is it really worth to suppress your own feelings just to keep peace with everyone? Be nice, but not at the expense of your own happiness.

I wish that I had let myself be happier.

Bronnie Ware states that this is a surprising regret. Many old people realize that happiness can be a choice. More importantly, it is a choice that you make at every point in your life, even right now, reading this. Connected to this, another regret is that people realized they did not live “in the moment” enough. Many are dwelling on past experiences, or concerned about the future, but they are not really “present”.

About the author: Mario Lehenbauer-Baum is a licensed psychologist, located in Fort Lauderdale, Florida. In his private practice, he focuses primarily on anxieties/phobias, adult ADHD, issues with relationships and sexuality, and general men’s issues. He offers Telehealth services as well. This blog is intended for entertainment and information purposes; however, Dr. Mario Lehenbauer-Baum is not responsible for any actions you may or may not take based on information from this blog. This blog does not replace therapy or counseling, and it does not replace any professional advice from health care providers.

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Addicted to Video Games?

Internet Gaming Disorder or “Video Game Addiction”

One of my specialty research area are video games, combining my passion for new technology (like video games) with psychology. In my blog today, I want to discuss “Video Game Addiction” (or Internet Gaming Disorder, the more scientific name for it), to shed some light on this issue from a professional psychological perspective.

If you recognize yourself in some of the symptoms mentioned, or if you think a loved one may suffer from video game addiction, please do not hesitate to connect with me or another psychologist or mental health professional who is familiar with this topic.

As a researcher and psychologist, I am very familiar with “internet addiction”, video game addiction or Internet gaming disorder for over a decade now. Several studies confirmed that a high amount of time spent with playing online games is associated with higher levels of depression, loneliness, anxiety disorders or aggression. On the other hand, gamers seem to have more fun with playing video games, and most of them report a greater number of friends they found online. Therefore, the occasional gaming can definitely increase the quality of life!

From a professional point of view, I do not believe that everyone who plays video games is “addicted”. I do not even believe that everyone who plays video games “a lot” is automatically addicted. My own research suggests that we have to distinguish between a healthy and an unhealthy use of video games. In my practice, my goal is usually a “controlled use” of video games; it can be part of a healthy lifestyle when used in moderation.

However, where do we draw the line between a “healthy” and “addicted” use of video games?

Internet Gaming Disorder: Criteria

Millions of people play video games online without no serious negative effects at all. They have fun engaging with other players, they collect items online, they go on quests, and they are able to explore virtual worlds. That’s fun!

However, a small minority of gamers seem to have problems with an “overuse” of video games. These problems seem to be comparable to behavioral addiction, which is why the American Psychiatric Association (APA) introduced “Internet Gaming Disorder” (IGD) in their recent edition of the Diagnostic and Statistical Manual of Mental Disorders—5th Edition (DSM-5) as “a condition that needs further research”.

The DSM-5 proposes nine criteria for IGD:

  • preoccupation,
  • withdrawal,
  • tolerance,
  • unsuccessful attempts to control the use of video games
  • loss of interests in other activities,
  • continued excessive use despite psychosocial problems (e.g., problems at work)
  • deceiving (lying about the use of video games)
  • escape, and
  • functional impairment.

An excessive use of the Internet in general (for either video games, social media, pornography, etc.) seems to be linked to a variety of comorbid (co-existing) psychopathological and personality differences. Studies suggest that users with depression tend to spend significantly more time online compared to non-depressed users (mood disorders seem to be connected with a higher use of the Internet). It is interesting to note that massively multiplayer online roleplaying game (MMORPG) users usually also have higher depression scores compared to other game types. It also seems like anxiety is another significant predictor of an excessive or problematic Internet use.

However, it is very important to note that correlation does not equal causation! Just because MMORPG user seem to have higher levels of depression does not mean that MMORPGs lead to depression. It may actually be quite the opposite – playing games like MMORPG can be very similar to “self-medication” – users with depression usually also have a lack of external gratification, something that video games can very easily provide, gratification online (e.g., by exploring worlds, finishing quests, collecting rare items, etc.). While this is not necessarily a bad thing, further studies are needed to look into long-term effects of the use of online-games for purposes like gratification or stress management.

Differences between engagement and addiction

My own research points out that there are two factors explaining an an “over-use” of video games:

A) Engagement is connected to variables like cognitive salience, tolerance, and euphoria. It means that engaged players have fun playing the games, they report feelings of euphoria, and they need to play more to experience the same feeling of euphoria they had in the beginning of playing games.

B) Addiction is connected to symptoms like conflicts, withdrawal symptoms, relapse and reinstatements, and certain behavioral symptoms. However, just because someone spends a lot of time playing video games online, he/she/they cannot be labeled as addicted right away.

Early warning signs of “addiction”

It is very important to note that even in a large sample of high-level players, I was only able to classify 3% of them as “addicted”. 97% of high-level players are NOT addicted; therefore, I caution against labeling any gamers as “addicted” just because they play a lot of games online or because they spend a lot of time per week online playing games.

Compared to engaged players, my research suggests that addicted players seem to spend more time playing games online: 32 hours/week compared to 21 hours/week, on average. While 21 hours per week is still a lot of time spent online, it is not necessarily automatically addiction.

While engagement might be just experiencing fun playing games, addiction is a more serious issue. Some of the warning signs of behavioral addiction to video games include:

  • Playing more and more, investing more and more time and money into video games
  • Escapism: using video games as a vehicle to avoid real life issues
  • Skipping meals, showers or important meetings because of video games
  • Deceive other people, lying to other people about the amount of time spent with video games
  • Problems at work or in school, the performance decreases

Assessment and treatment possibilities

If you think that you or a loved one might suffer from IGD or “video game addiction”, I recommend that you talk to me or any other psychologist with experience on that topic.

I usually use several surveys to get a complete picture of IGD and surrounding factors like mood disorders, anxiety disorders, and negative effects on one’s life. I may also have a look into who else is affected by an over-use of games; for example, in many cases a spouse reaches out to me because a partner’s gaming time leads to marital problems.

For treatment, certain cognitive-behavioral techniques seem to be the gold-standard for the treatment of IGD. I usually recommend to address one or more of the following steps:

  • Explore and examine any thoughts that lead (or are connected) to IGD
  • Explore behavioral triggers that lead to a use of video games
  • Replace irrational thoughts with “healthier” ones
  • Modify behavioral triggers
  • Modify any thoughts, feelings and ultimately the behavior that can lead to IGD

Each individual with problems coming from an “overuse” of games is unique, therefore it is important to adjust any therapy individually as well.

Conclusion

While millions of people play video games online without any serious negative effects at all, a small minority seem to have problems with an overuse of video games. Some of the warning signs include spending more and more time (and sometimes money) for video games, negative consequences on one’s life (such as work, school, or relationship issues), using video games to escape “real life” issues, and skipping meals, showers or important meetings because of video games. Cognitive-behavioral tools are useful to address some of these issues; therapy usually includes exploring and modifying behavioral triggers, thoughts and emotions. One of my therapy goals usually includes a “controlled use” of video games; it can be part of a healthy lifestyle when used in moderation.

Please note: Parts of this blog come from my peer-reviewed publication: Lehenbauer-Baum, M. et al., (2015). Addiction and Engagement: An Explorative Study Toward Classification Criteria for Internet Gaming Disorder. Cyberpsychology, Behavior, and Social Networking, 18(6), 343–349. http://doi.org/10.1089/cyber.2015.0063

Dr. Mario Lehenbauer-Baum is a Licensed Psychologist in private practice in Wilton Manors, Florida. This blog post is strictly for informational purposes and is not intended to be a substitute for professional counseling or therapy.