1. Emotional Dimension
December 2013

2. Goals Review wellness Review the 6 dimensions of wellness
Define the emotional dimension
Review what is meant by different emotional words
Review depression in physicians
Explore ways to thrive
Emotional IQ
Express yourself

3. Wellness

4. Wellness- Thriving in all areas of life

5. 6 Dimensions of Wellness
Professional
Perceived stress and goal setting
Social
Gratitude and communication
Emotional
Depression and emotional intelligence
Physical
Exercise and sleep
Financial
Debt and saving
Spiritual
Purpose and service

6. Emotions

8. Life Events History has an impact.
Current life situation has an impact.
Can’t separated your life from your feelings.

9. Bodily Arousal Biological activation. Autonomic and hormonal systems.
Prepare and activate adaptive coping behavior during emotion.
Body prepared for action.
Alert posture, clenched fists.

10. Sense of Purpose Give emotion its goal-directed force.
Motivation to take action.
Cope with emotion-causing circumstances.
Why people benefit from emotions.
Social and evolutionary advantage.

11. Social Expression Emotion’s communicative aspect.
Postures, gestures, vocalizations, facial expressions make our emotions public.
Verbal and nonverbal communication.
Helps us interpret the situation.
How person reacts to event.

12. Why we cry
Science of tears

13. Feelings- Quiz

14. Distress
Acute anxiety
Without stress
Furry
Happy

15. Nauseating
Concern
Satisfied
Loathing
Love

16. Nervousness
Sadness
Unease
Peaceful
Repugnant

17. Apprehensive
Dejected
Hateful
Foreboding
Peace

18. Aversion
Anxiety
Bliss
Extreme dislike
Attraction

19. Pensive
Irritated
Wariness
Amused
Brooding

20. Delight
Distaste
Wonder
Blue
Great pleasure

21. Amused
Pleasing
Unhappy
Disbelief
Annoy

22. Bewilderment
Puzzle
Ecstatic
Frustrated
Terror

23. Amazement
Serene
Frustrate
Astonishment
Expected

24. Indignant
Down
Outraged
Disbelief
Joy

25. Annoyance
Dejected
Shock
Satisfied
Bother

26. How do you feel after taking this quiz?
Sadness
Fear
Disgust
Happiness
Surprise
Anger

28. Struggling in Silence: Physician Depression and Suicide
Physicians and medical students often do not attend to their own health, failing to recognize depression in themselves or in their colleagues. Even if they do recognize depression, which affects between one quarter and one third of medical students, they fail to seek mental health services. One of the most tragic, yet largely unheralded results of this failure is suicide.
Suicide remains a disproportionately high cause of death among physicians, especially among women physicians. Suicide rates are several-fold higher among physicians than in the general population. Mood disorders like major depression or bipolar depression are the major risk factor. Although depression is eminently treatable, it continues to kill medical students and physicians, leaving a wake of devastation among family members and patients. Research has shown that barriers for medical students seeking help include time, money, stigma (both internal and external) and fears of sanction by the profession.
As part of a multi-year campaign to address the unmet needs of depressed physicians and medical students, the American Foundation for Suicide Prevention has created two documentary films and accompanying materials for use as an educational tool by medical schools, hospitals, medical societies and state medical licensing boards. The first is an hour-long public television special titled Struggling in Silence: Physician Depression and Suicide (a 15-minute version of this film is included on this DVD). It features interviews with families and friends that have been touched by a physician’s suicide, and practicing physicians with depression. The second film, Out of the Silence: Medical Student Depression and Suicide, is a 15-minute program that shares a student’s journey through the symptoms, diagnosis and treatment of a mood disorder, and a school’s effort to combat the problem of suicide among the nation’s next generation of physicians.
The goal of the campaign, as articulated in the AFSP consensus statement published in the Journal of the American Medical Association (289(23): 3161–3166, 2003), is to change the institutional culture of medicine, and to promote and encourage recognition and treatment of depression in the nation's medical students and physicians.
Another goal of this campaign is to help physicians to better recognize depression in themselves, so they will be more likely to recognize it in their patients.
To this end, this companion presentation addresses the incidence, causes, risk factors, role of stressful life events and barriers to care. It concludes with real life case vignettes of physicians in the films and questions you might pose to start a discussion.
A Companion Presentation Paula J. Clayton, M.D. Charles F. Reynolds III, M.D.

29. Suicide and Other Illness Rates Among Physicians
Smoking
Heightened attention to problem
Mortality rates from smoking-related cancer, heart disease and stroke are lower than for the general population
Smoking-related deaths have declined 40%–60% since 1960
Suicide
Little attention to problem
Suicide rate is higher than among the general population, especially among women physicians
Suicide rates in physicians are not changing
Depression is a major risk factor
Slides 2–7 commentary:
Physicians practice what they preach when it comes to (not) smoking; however, physicians as a group neglect their mental health. This contributes to their high suicide rate. Untreated depression is the major risk factor for suicide in physicians, especially among women.

30. Suicide Rates Among Physicians
Standardized Mortality Rate
Actual/Expected
Male physicians/age matched males in the general population
Female physicians/age matched females in the general population 2.27
Schernhammer E, Colditz G, Am J Psych, 2004
Schernhammer E, NEJM, 2005

31. Suicide and Occupation Study in Denmark
Methods
Subjects who died by suicide from 1991–1997 while aged 25–60 and for each, 25 controls of same gender who were born in the same year: 3,195 suicides (898 females), 63,900 controls
Results RR
Highest risk of suicide is among medical doctors 2.73
Higher risk of suicide by poisoning in physicians
Higher risk in females working in male-dominated occupations
Particularly high-risk in doctors who have been admitted to the hospital with a psychiatric disorder
Agerbo et al., Psych Med, 2007

32. Suicide and Occupation Study in Denmark
Suicide, five highest occupational rate ratios:
Occupation DISCO-88* RR (95% CI)
Highest
Medical doctors (1.77–4.22)
A residual group without occupation (1.87–3.28)
Nursing associate professionals (1.34–3.11)
Elementary occupations
(largely unskilled manual workers) (1.47–2.68)
Plant and machine operators and assemblers (1.22–2.76)
*DISCO: Danish version of the International Classification of Occupations
Agerbo et al., Psych Med, 2007

33. Additional Facts
In the general population, the male suicide rate is four times that of females; in physicians the rates are equal
Physicians have higher rates of completion to attempts which may result from greater knowledge of lethality of drugs and easy access to means
Nordentoft M, Laegeforeningens Forlag Kobenhavn 2007, pp. 22
Slide 8 commentary:
In the general population, men die by suicide at a rate four-fold greater than that of women. This I gender gap does not hold for women, however, reflecting the increased rate of death by suicide among women physicians.

34. Risk Factors For Suicide
Major risk factors include mental disorders:
Major depressive disorder
Bipolar disorder, depression
Alcohol abuse
Drug abuse
Other disorders
Slide 9 commentary:
The major risk factors for suicide (mood and substance abuse disorders) often coexist, placing the physician at particular risk in the absence of recognition and treatment.

35. Epidemiology of Depression in Physicians
Lifetime rates of depression in women physicians were 39 percent compared to 30 percent in age matched women with PhD’s, both being higher than the general population figures
Lifetime rates of depression in male physicians (13%) may be similar to rates of depression in men in the general population, or they may be elevated. Data from Denmark using population-based case controls and hospital or outpatient care for a first-time ever diagnosis of depression (broadly define) show that male physicians have elevated rates of care
Rates of depression are higher in medical students (15%–30%), interns (30%), and residents than in the general population
Welner et al., Arch Gen Psych, 1979
Clayton et al., J Ad Dis, 1980
Frank & Dingle, Am J Psych, 1999
Wieclaw et al., Occup Environ Med, 2006
Center et al., JAMA, 2003
Valko & Clayton, Am J Psych, 1975
Kirsling & Kochar, Psychol Rep, 1989
Slide 10–12 commentary:
The higher lifetime prevalence of depression among women physicians, as compared with the general population, is an important factor in their higher suicide rate.

36. Depression in Medical Faculty
A survey of physician well-being and health behaviors at an academic health center found that nearly 30 percent of respondents (attendings and house staff) reported past or present depressive symptoms. This correlated with female gender, younger age, living alone, and not having a primary care physician
Reinhardt et al., Med Educ Online, 2005

37. Women Physicians and Addiction
969 impaired physicians from 4 state physician health programs
Female: 125 Male: 844
Alcohol was primary abused substance for all
Women Men
Age, average p <
OR*
Med for psych problem
Past suicidal ideation
Current suicidal ideation
Made attempt under influence
Made attempt not under influence
Abused sedatives
*OR (odds ratio) >1.5 = statistically significant results
Wunsch et al., J Add Dis, 2007

38. Another Risk Factor: Family History of Mood Disorders
Several of the studies with interns and physicians indicate that depressed physicians, compared to appropriate controls, had positive family histories of depression and more previous depressions
Waterman, Jt Comm J Qual Patient Saf, 2007
Clayton et al., JAD, 1980
Valco & Clayton, Am J Psych, 1975
The Pharos, Winter 2008
Slide 13 commentary:
Former history of a mental disorder is a very important risk factor.

39. Another Important Issue
There is no evidence that stressors in general are linked to elevated rates of suicide in physicians
Gross et al., Arch Intern Med, 2000
Slide 14 commentary:
Although it is commonly believed that stressors are linked to higher suicide rates in physicians, there is no systematic evidence to support this belief. Rather, it may be the case that physicians with pre-existing depression are more likely to find themselves in stressful situations and/or less able to cope with them.

40. Access of Care and Barriers to Care cont.
Among practicing physicians, barriers to mental health care include:
discrimination in medical licensing
hospital privileges
health insurance
malpractice insurance
Miles SH, JAMA, 1998
APA, Am J Psych, 1984

41. Additional Barriers to Adequate Mental Health Care for Physicians
Professional attitudes that broadly discourage admission of health vulnerabilities
Professional attitudes and lack of knowledge about psychiatric illnesses
Physician-patients’ concerns about breaches of confidentiality by the treating clinician
Compromised treatment due to collegial relationships; deference from the treating clinician may give more freedom to the physician-patient to control the focus of therapy and to self-medicate

42. Licensing and Physician Mental Health
Invited analysis of all State Medical Boards on policies regarding mental illness
35/50 responded
37 percent indicated that a diagnosis of mental illness was sufficient for sanctioning (although only 69% of these asked about it)
40 percent indicated that the diagnosis of substance abuse was sufficient for sanctioning and the majority had questions about it
Survey urged that sanctioning be on basis of impairment for physical or psychiatric illness
Arkansas and 18 other states focus on impairment
Hendin et al., Fed Bull, 2007
Slide 18 commentary:
AFSP believes that state medical licensing boards should not ask about mental illness or treatment but rather focus its questions on impairment from either physical or psychiatric illness.

43. Suicide Inquiry in Primary Care
Using standardized depressed patients with 154 participating physicians.
In 36 percent of 298 encounters, suicide was explored. It was significantly more likely to happen when:
the “patient” portrayed major depression
if the “patient” made a request for an antidepressant
in an academic setting
among physicians with personal experience with depression
Feldman et al., Annuals of Family Med, 2007

44. Patient Vignette: A Depressed Medical Student
Patient: Blanca
Blanca is a first-year medical student at a large West Coast
university. Having always been an outstanding student, Blanca was
overwhelmed with anxiety when struggling with her academics for the
first time. She recalls feeling both distracted by her sadness and
hampered by her anxiety while attempting to study for exams. Yet, like
many others, Blanca did not recognize her feelings as being symptoms
of depression and anxiety. Initially, Blanca’s fear that therapy would be
just another stressor in her already-packed schedule prevented her from
seeking treatment. Eventually she became so desperate to “fix” her
mental state that she visited a physician. Upon being assessed, Blanca
was referred to a psychiatrist and began taking medication for both
depression and anxiety. She also participated in talk therapy with the
Slide 20–25 commentary:
These are three of the physicians with mood disorders portrayed in the 15-minute version of Struggling in Silence: Physician Depression and Suicide.
The hour-long PBS version features them, as well as two families whose physician husbands died by suicide.

45. Patient Vignette: A Depressed Medical Student cont.
school psychologist. Blanca admits that upon hearing of her diagnoses
— major depression and generalized anxiety disorder — she was taken
by surprise. Indeed, her reaction typifies that of many newly diagnosed
individuals: “It was hard to take. Because there’s always the sense of
that’s never me. ‘That’s never going to be me.’ But it was.” Though
Blanca recognizes that receiving treatment does not lighten the work
load of medical school, she does feel very strongly that the combination
of medication and therapy has helped her to handle her work, and her
life, more efficiently. Blanca now uses her experiences to help other
medical students, as part of a peer mentoring group.

46. Patient Vignette: A Depressed Surgeon
Patient: Robert
Robert is a plastic surgeon who practices in the Midwest. Like so many
others, he did not consider the possibility that he was depressed until
someone else suggested it to him. He recalls having a professor in
medical school tell him that he needed to “get over” being depressed if
he wanted to go on to become a doctor, a reflection of the attitudes
held toward medical students and doctors seeking treatment for mood
disorders. Though many, and indeed perhaps most, depressed people
find it nearly impossible to be productive at work, Robert found that the
more time he devoted to work, the less time he had to feel depressed.
While his intense drive to work benefited Robert with regard to his
career, he felt as though the rest of his life was suffering for it.

47. Patient Vignette: A Depressed Surgeon
Despite his unhappiness, Robert was reluctant to seek treatment, mainly
due to concerns over stigma. The stigma attached to a physician
receiving psychiatric services has the potential to affect many aspects of
his career, including his referral base, his reputation as a competent
physician, both among colleagues and patients, and even his license to
practice medicine. Once he finally did enter treatment, Robert was
happy to learn that his concerns were unfounded, and his career — and
his life — only benefited from his decision to get treatment. His only
regret is that he did not seek treatment sooner, as he feels that the
years he spent denying his depression were wasted. Invigorated by his
new outlook on life, Robert is now leaving his plastic surgery practice
and pursuing a lifelong dream, to work in a hospice.

48. Patient Vignette: A Bipolar Physician
Patient: Alice
Alice is a neurologist specializing in movement disorders at a prestigious
hospital in the Northeast. She began experiencing intense feelings of
sadness after delivering stillborn twins, which she attributed to the
grieving process. She dismissed others’ comments that she seemed
withdrawn and depressed. In fact, Alice did not begin to recognize
anything unusual within herself until she began experiencing what she
calls “extreme agitation” wherein she felt that her mind was
overwhelmed with ideas. Wanting to keep track of this constant flow of
ideas, Alice began to write compulsively (known as “hypergraphia”). She
filled countless notebooks, and when there was no paper around, she
even wrote on her own skin. Although this type of behavior could cause
a disruption of a person’s normal functioning, Alice felt good about her

49. Patient Vignette: A Bipolar Physician cont.
urge to write. Indeed, she says it felt “like I was doing work.” Alice also
recalls that she felt no need to see a psychiatrist, and only relented once
her Chairman suggested she should. Once her treatment began, Alice
received what she calls “significant” medication therapy and participated
in psychotherapy (“talk therapy”). While she feels that the majority of
her psychological improvement came from the medication, she also
acknowledges that the psychotherapy helped her to deal with her
feelings more adequately. As she learned more about the mania that
enveloped her, Alice’s scientific curiosity was piqued. Eventually Alice felt
compelled to write a book, The Midnight Disease, that combined her
personal experiences with those of famous writers, as well as medical
case histories. Alice now uses her experience with bipolar illness to help
her understand her patients better.

50. Discussion Questions
Have any of you known a doctor/medical student/resident who killed himself or herself?
What were the “causes” as you understood them?
One wife whose husband killed himself as a medical student saw the film and said Blanca was very brave. He couldn’t have done that. What does that imply?
What are the serious drawbacks to seeking treatment? As a medical student? As a resident? As a practicing physician?
How would you go about getting help?
Slide 26–27 commentary:
This presentation concludes with recommended discussion questions to pose when presented to health care or mixed (lay and health care) audiences.

51. Emotional IQ

52. Simple Definition
Ability to manage emotions in one’s self and in others in order to reach desired outcomes.
There are many definitions of EI
The simplest definition is the ability to understand emotions as they happen, and the using that emotion effectively. In other words, managing emotions in yourself and in others, so that you can achieve your goals

53. The "New Yardstick" On how we handle ourselves and each other
Goes beyond intellectual ability and technical skills
Focuses on personal qualities such as initiative, empathy, adaptability, persuasiveness

54. Emotional Intelligence
Seen as the fundamental key to success and leadership - and it can be learned!
Working with people
Not just about being nice
Managing one’s own emotions
Ability to handle encounters
Teamwork
Leadership

55. Job Success, not Survival
Today's great growth and prosperity is running parallel to some of the highest rates of job turnovers.
Just because you work hard does not mean you will rise to the top or that the job is secure.

56. Common employer complaints
Lack of social skills, motivation to keep learning, and inability to take criticism
Leads to plateaued or derailed careers because of crucial gaps in EQ (EI)

57. The Two Sides of Emotional Intelligence
Personal Competence – how we manage ourselves Self Awareness – knowing your strengths and weaknesses Self Regulation - trustworthiness, responsibility, adaptability, Motivation - drive, commitment, initiative, optimism, charisma Social Competence - how we handle relationships Empathy - awareness of other’s feelings and concerns Social skills - adeptness a inducing desirable responses, such as communication, conflict management, cooperation, and leadership

58. The more complex the job, the more EQ (EI) matters!!

59. Goleman’s Competencies Model

60. Mayer & Salovey’s Ability Model
4 inter-related abilities
Perceiving Emotions
Using Emotions
Understanding Emotions
Managing Emotions
Mayer and Salovey 60

61. Perceiving Emotions
Can you tell…?

62. Perceiving Emotions Identify how you feel Identify how others feel
Sense emotions in music
Sense emotions in art
Detect real vs fake emotions - accuracy

63. Perceiving Emotions Basic emotions with very clear facial signals
Anger
Sadness
Fear
Surprise
Disgust
Happiness
Ekman, 2003

64. Using Emotions
We all do it…

65. Using Emotions
The capacity to generate and feel an emotion in order to focus attention, reason, and communicate.
The capacity to use emotion to influence cognitive processes such as decision making, deductive reasoning, creativity, and problem solving.

66. Using Emotions: Happiness
Up-side
Generate new ideas
Think in new ways
Be creative
Enhance “big-picture” thinking
Enhance decision-making abilities
Downside
More problem-solving errors
Off task at times
May miss problems

67. Understanding Emotions
Connecting all the parts

68. Understanding Emotions
Recognizes what events are likely to trigger different emotions
Knows that emotions can combine to form complex blends of feelings
Realizes that emotions can progress over time and transition from one to another
Provides a rich emotional vocabulary for greater precision in describing feelings and blends of feelings

69. Managing Emotions

70. Manage Emotions
Stay open to feelings
Blend emotions with thinking
Reflectively monitor emotions

71. Manage Emotions Research findings:
Significant relationship between managing emotions ability and burnout and mental health
Teams with higher scores for managing emotions received higher performance rankings

72. Why do people with high IQs not always succeed?

74. “All I Need to Know I Learned in Kindergarten”
Four of the five skills emphasize for school readiness are socio-emotional:
- mastery of educational building blocks
- motivation to succeed in school
- ability to get along & make friends
- ability to function in a group
- capacity to manage emotions

75. In Essence
Being intelligent about emotions means that we can perceive and use emotions to create optimal relationships and produce desired outcomes.