Dr. Camsari:  Dr. McHugh, would you please share with me, how did you come up with the approach of the Perspectives of Psychiatry throughout your professional development as a psychiatrist?

Dr. McHugh: I had wonderful training from the best people in neurology and psychiatry in the world, I think,  I had neurology training at MGH from Professor Dr. Raymond Adams, and I had psychiatry training at Institute of Psychiatry in London from Professor Dr. Aubrey Lewis.  Both of these people had a sense that psychiatry had to develop a coherent and comprehensive structure that relating, but ultimately to find a way to understand the nature of the disorders, I think that is what they were trying to work towards and  it seemed to me the problem between neurology and psychiatry  is neurologists had a clear idea of what their disorders were in nature, they were after all in some ways injuries to brain and they could take the form of any pathology,  whereas the psychiatrists were uncertain, we used words like “endogenous” and “exogenous”  conditions and things of that sort,  these were unsatisfactory concepts to people like Dr Aubrey Lewis, he thought you cannot tell these from the presentations of depressed patients, so that is how I came to be thinking about what was fundamental to psychiatry mainly, what is the nature of mental illness and that is what I came up.

Dr. Camsari:   When you started to write the Perspectives Book, were you at Hopkins or was that before?

Dr. McHugh: No, I and Dr Phillip Slavney started working on the Perspectives when we were at University of Oregon actually. We decided that we would write a book but we were not exactly certain about what kind of a book that we would write to present our point of views, we at first decided to write a small textbook that we would write a little about our method but one day he and I agreed on what we should be doing , we would be talking about how in a methodological way emphasis on method of assessment we might be able to differentiate the families of mental disorders and thus come to say what we believe mental illness is.

Dr. Camsari: Dr McHugh, I know that you were a chairman at Hopkins for 26 years, between 1975 and 2001. Did this revolutionary idea of Perspectives  play a role in your being appointed as a chairman in Psychiatry at Hopkins in 1970’s?

Dr. McHugh: No, not really, but it [being at Hopkins] gave a me a better forum and more support fundamentally for the enterprise of brainstorming, after all, I had very good students and very good colleagues and I could share with them and get back from them and also of course working with Dr. Timothy Moran in laboratory studying a basic behavior, food intake,  I was extending my understanding of behavior and its controls.

Dr. Camsari:  Did you face any resistance while implementing this idea which was new?

Dr. McHugh: I was experiencing resistance in 1970’s from the psychoanalytic community.  Most of the issues of resistance were more resistance to my teaching in general to medical students than specifically to the perspectives, even though I was making the point to the psychoanalysts that after all, the way to understand their work was to appreciate that life story of the patient was important to understand the mental disorders.

Dr. Camsari:  So your work actually also included psychodynamic knowledge?

Dr. McHugh: It was intended to  encompass what they had accomplished. The things what they had accomplished, I believe, could be encompassed within this. They, on the other hand felt that it was replaced through out the perspectives. In fact one said, “when I read the first page it gets my dukes up”

Dr. Camsari: Have you seen over the years that this idea was spread out of Hopkins as well?

Dr. McHugh: The idea  first  went out with Dr. Robert Robinson at University of Iowa, Dr. Marshall Folstein at Tufts Medical School. The real problem for us, if we talk about the acceptance of the Perspectives  Model, it appeared at the time exactly when DSM III appeared, and they were out of the gates together and DSM was the hare and we were the tortoise.  And now we are kind of catching up. The DSM approach to ignoring all aspects of generation or cause, only looking at symptoms is beginning to reach its 30th year.  And now people are wondering and we think, look, it would not be odd now to bring our thoughts up for psychiatrists that are acquainted with DSM III or IV, and they  would not find it hard now to begin to think with the perspectives, particularly if we could persuade the APA that instead of axis organization they have that maybe they could have the idea, axis I included only the conditions you could think of were likely to be brain diseases, axis II could continue as it is, personality and all indeed the dimensional perspective, axis III could be now put aside and replaced with the behavior perspective, and axis IV could again be the life story and it would not be all that much of a change, we could keep axis V as GAF and then maybe people would begin to see that instead of everything being axis I with modifications out of the other axes, that some of our patients are axis II, III,IV, now identifying them with the dimensional, behavioral and lifestory perspective and I think that what is going to probably happen.

Dr. Camsari: Dr McHugh, I know that you have been in touch with DSM committees, do you think they are convinced with this idea?

Dr. McHugh: No, I do not believe at this moment they are convinced. They are hare and we are the tortoise. They have to complete and finish their run, even discipline itself will see the ultimate need to replace the symptom descriptive mode of classification and takes on a generative and causal mode. All fields go through a descriptive phase and that is only critiscism you can offer them is that they stay in the descriptive phase longer than they should. And we are thinking that now psychiatry has come to the end or should have come to the end of its descriptive phase alone and right now thinking in terms of generative likelihood that schizophrenia is a different kind of disorder than PTSD which is also a different kind of disorder than alcoholism or addiction which is also a different kind of disorder than histrionic personality and we psychiatrists are taking care of all those kinds of patients and would like not only to understand why the therapy needs to be different for each one of those conditions but also research domains and research directions  will be different and then we would have a heuristic classification and not the field guide which is only useful for reliability of diagnosis.

Dr. Camsari:  Dr McHugh, thanks to the Hopkins approach to psychiatry, during my psychiatry training at Hopkins, I started to again feel like that I am a doctor who is practicing a field of medicine. So is that kind of a feedback that you always get from your trainees?

Dr. McHugh: I hope that all of my trainees feel that way. It is our intention to point that we are medical people. We want to be sure that medical people see the domain of psychological life is a domain unplummeted by biology and has a biological domain itself though has its own rules and ways of going awry.  You and I have talked about this before, we need to persuade them mental life is an emergent property of the brain, like any other emergent property, in science, it has its own features of action and features of disorder, you know, if people did not see that point, they would think that in the physical domain, study of hydrodynamics is the study of hydrogen and oxygen rather than fluidity of water itself  which emerges from those two elements.

**This interview was conducted with the full consent and cooperation of the interviewee on July 28, 2012 at the Johns Hopkins Hospital, Baltimore, Maryland.  Additionally, the interviewee has given explicit permission for the publication of this interview. 

Welcome to our in-depth discussion on pornography addiction with Dr. Ulas Camsari, Addiction Medicine and Psychiatry double boarded Psychiatrist and the director of Cognitive Works in Twin Cities, Minnesota. Dr. Camsari is also licensed to practice medicine in New Jersey and Florida.*

Cognitive Works: Dr. Camsari, thank you for joining us today. To start, could you explain the etiology of pornography addiction?

Dr. Camsari: Certainly. Pornography addiction is a complex condition that arises from a combination of factors. It's often linked to brain chemistry changes, emotional struggles, past traumas, relationship issues, and the easy access to online pornography. These elements work together to create a habit that initially feels rewarding but can lead to significant problems over time.

Cognitive Works:  And what can you tell us about the physiopathology involved in this addiction?

Dr. Camsari:  Research indicates that persistent consumption of pornography is associated with physical changes in the brain, particularly in areas related to motivation and reward. For instance, frequent users may experience reduced gray matter in the striatum and weaker responses to sexual stimuli, affecting decision-making skills and potentially leading to a search for more novel or extreme content.

Cognitive Works: Moving on to prevalence, how common is pornography addiction in the United States?

Dr. Camsari: It's more widespread than many realize. Studies suggest that the prevalence of hypersexual disorders, which can include pornography addiction, may be about 3–6% among the general population. However, these rates have been challenging to determine due to a lack of formal classification.

Cognitive Works: That's quite significant. Could you outline the symptoms as per the DSM criteria?

Dr. Camsari:  While pornography addiction is not officially recognized in the DSM-5, addictive behaviors are characterized by repeated engagement despite negative consequences, a preoccupation with the behavior, and an escalation over time. These are common patterns we see in individuals struggling with pornography addiction.

Cognitive Works: Lastly, what are the current approaches to treatment and management?

Dr. Camsari: Treatment for pornography addiction includes cognitive-behavioral therapy, support groups, 12-step programs, medication, and counseling. These methods aim to address the underlying causes, provide support for recovery, and help individuals develop healthier coping mechanisms. It's crucial to tailor the treatment to the individual's needs, as each case can be quite unique.

Cognitive Works: Dr. Camsari, thank you for sharing your expertise with us today.

*This interview has been edited for clarity and brevity. For those seeking help or more information on pornography addiction, resources are available through healthcare providers and addiction support organizations.*

*Please note that the image accompanying this discussion is a creative representation and not an actual photograph.*

---

References:
: Medical News Today
: Valley Spring Recovery
: The Healthy by Reader's Digest
: Cognitive Works Mental Health

Understanding the Intersection of Depression and Anxiety: A Comprehensive Overview

Depression and anxiety are two of the most common mental health disorders that can significantly impact an individual's quality of life. Often, these conditions can occur simultaneously, a phenomenon known as comorbidity. This comprehensive overview will delve into the DSM-5 criteria for diagnosis, the latest research findings, prevalence rates, treatment modalities, medications, their mechanisms of action and side effects, and psychotherapy models.

DSM-5 Criteria for Depression and Anxiety

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is a critical resource used by healthcare professionals for the diagnosis of mental health conditions. Within its pages, the criteria for Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) are meticulously outlined, providing a framework for understanding these complex conditions.

Major Depressive Disorder (MDD) is more than just a fleeting sadness; it is a profound and persistent state that can significantly impair an individual's ability to function. The DSM-5 outlines that for a diagnosis of MDD, a person must experience a consistent feeling of sadness or a marked disinterest in almost all activities for a minimum of two weeks. This period must reflect a noticeable shift from their previous level of functioning. Additionally, at least five of the following symptoms must be present during the same two-week period, with at least one of the symptoms being either a depressed mood or loss of interest or pleasure:

- Depressed mood most of the day, nearly every day.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
- Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day.
- A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
- Diminished ability to think or concentrate, or indecisiveness, nearly every day.
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Generalized Anxiety Disorder (GAD), on the other hand, is characterized by an excessive and persistent worry that is difficult to control. This worry pertains to a variety of events or activities and occurs more days than not for at least six months. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):

- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

It is important to note that these disorders are not just extreme versions of normal emotions; they are serious conditions that require a professional diagnosis and often, a comprehensive treatment plan. The DSM-5 criteria serve as a guide to help professionals distinguish between normal psychological states and those that warrant clinical attention.

Understanding these criteria is crucial for those seeking help, as it provides insight into the symptoms and duration required for a formal diagnosis. It also underscores the importance of seeking professional support, as these conditions can profoundly affect one's quality of life. If you or someone you know is experiencing symptoms of depression or anxiety, it is important to reach out to a healthcare provider for a proper assessment and to discuss potential treatment options. Mental health is a critical component of overall well-being, and the DSM-5 serves as a valuable tool in safeguarding it.

Recent Research on Comorbidity

Recent studies have shown that nearly half of those with a diagnosed depressive disorder also meet the criteria for an anxiety disorder. Research suggests that these conditions may share common genetic vulnerabilities and similar disruptions in brain chemistry and circuitry, which could explain their frequent co-occurrence.

Prevalence of Anxiety and Depressive Disorders

In the United States, it is estimated that 18.4% of adults have received a diagnosis of depression at some point in their lives. Globally, the number of people living with anxiety and depressive disorders rose significantly due to the COVID-19 pandemic, with depressive symptoms increasing from about 193 million to 246 million worldwide.

Treatment and Management

The management of depression and anxiety often involves a combination of psychotherapy and pharmacotherapy. Cognitive Behavioral Therapy (CBT) is one of the most effective psychotherapy treatments, focusing on changing thought patterns and behaviors associated with these disorders. Medications typically include Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), which have been shown to alleviate symptoms of both depression and anxiety.

Medications Commonly Used
Common medications for treating both conditions include SSRIs like sertraline (Zoloft) and escitalopram (Lexapro), which work by increasing levels of serotonin in the brain. SNRIs such as venlafaxine (Effexor) and duloxetine (Cymbalta) also increase norepinephrine alongside serotonin, which can be particularly effective in cases of severe depression or anxiety.

Mechanisms of Action and Side Effects
Antidepressants typically work by altering neurotransmitter activity in the brain to regulate mood and reduce symptoms. For instance, SSRIs block the reuptake of serotonin, increasing its availability. However, these medications can come with side effects ranging from nausea and headaches to more serious risks like increased suicidal thoughts, particularly in young adults.

Psychotherapy Models
Various psychotherapy models are employed to treat depression and anxiety, including CBT, Interpersonal Therapy (IPT), and Psychodynamic Therapy. CBT, in particular, is effective in addressing the cognitive distortions that contribute to both conditions.

Conclusion

The intersection of depression and anxiety presents a complex challenge in mental health care. A multifaceted approach that includes a thorough understanding of the DSM-5 criteria, awareness of the latest research, and knowledge of effective treatments and medications is crucial for managing these conditions. It is essential for healthcare providers to stay informed about the evolving landscape of mental health treatment to provide the best care for their patients.

---

References:
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- Anxiety and Depression Association of America. (n.d.). Understanding Anxiety and Depression: Facts & Statistics. Retrieved from [ADAA](^24^).
- World Health Organization. (2022). Mental disorders. Retrieved from [WHO](^27^).
- Verywell Mind. (2023). Types of Psychotherapy for Depression. Retrieved from [Verywell Mind](^29^).
- Mayo Clinic. (2023). Selective serotonin reuptake inhibitors (SSRIs). Retrieved from [Mayo Clinic](^35^).
- Psych Scene Hub. (2023). Simplified Guide to 21 Common Antidepressants – Mechanisms of Action, Side effects and Indications. Retrieved from [Psych Scene Hub](^34^).

Substance addiction is a complex and often misunderstood condition that affects millions of individuals and their families. To shed light on this issue, we had the privilege of interviewing Dr. Ulas Camsari, a psychiatrist and an expert in the field of addiction.

Cognitive Works: Dr. C, could you explain what substance addiction is and why it's considered a chronic disease?

Dr C: Substance addiction, or substance use disorder (SUD), is a medical condition characterized by an uncontrollable urge to use substances despite harmful consequences. It's considered a chronic disease because it involves changes to the brain's wiring, affecting an individual's behavior and decision-making abilities. Like other chronic diseases, it requires ongoing management and can be relapsed.

Cognitive Works: What are the most common misconceptions about substance addiction?

Dr C:  One of the most prevalent misconceptions is that addiction is only a choice or a moral failing. This view oversimplifies the profound challenges individuals face when dealing with addiction. It's crucial to recognize that addiction also falls into the disease model, and it does have a disease component from a medical and psychiatric standpoint; it is not merely a matter of choice. Another common misconception is that detoxification alone is sufficient for recovery. While detox is an essential first step, signaling the body's physical separation from substances, it must be followed by comprehensive treatment and support. Recovery is a multifaceted process that often involves therapy, medication, lifestyle changes, and ongoing support to prevent relapse.

Cognitive Works: Can you tell us about the treatment and management of substance addiction?

Dr C: Treatment for substance addiction is multifaceted and should be tailored to the individual's needs. It often includes medication-assisted treatment (MAT) to manage withdrawal symptoms and cravings, behavioral therapies, and support groups. Management of addiction also involves addressing any co-occurring mental health disorders, which is crucial for a successful recovery.

Cognitive Works: How can we better support individuals undergoing treatment for addiction?

Dr C:  Support from family, friends, and the community is vital. Encouraging a non-judgmental and understanding approach can make a significant difference. Additionally, advocating for better access to treatment and reducing the stigma associated with addiction can help individuals seek and receive the help they need.

Cognitive Works: Finally, what message would you like to convey to those who are struggling with addiction or know someone who is?

Dr C: You are not alone, and there is hope. Addiction is a treatable condition, and with the right support and treatment, recovery is possible. Don't hesitate to reach out for professional help, and remember that it's a sign of strength, not weakness.

We thank Dr. C for his insights and dedication to improving the lives of those affected by substance addiction. His expertise underscores the importance of understanding, treating, and managing this condition with compassion and evidence-based practices.

For more information on substance addiction and recovery, visit the CDC's page on the treatment of substance use disorders or the National Institute on Drug Abuse's guide to treatment and recovery.

To schedule an Addiction Diagnostic Assessment with Dr. Camsari please call us at 952-300-6277 or send an email to This email address is being protected from spambots. You need JavaScript enabled to view it.