Don’t Sleep on this…
Hello, people! Welcome back to a brand new blog for a brand new year! It’s been a tough one for moi thus far, as I got the gift no one wants… covid. It’s been gnarly, but thankfully, I’m starting to feel more like myself again. This week, we’re starting a new series on a very important topic that I hear a lot of complaints about: sleep. Sleep is a vital part of life; we spend up to one-third of our lives doing it, and can’t live without it. It’s a lot like sex… everyone wants it, and some people get more of it than others.
Lots of go getters and workaholics will say “I’ll sleep when I’m dead.” But the problem is that that might be sooner than you want it to be if that’s your point of view. Why is this? Why is sleep so important? What happens in our bodies and brains during sleep? Why is it so hard for some people to fall asleep, while others are out cold before their heads hit their pillows? How can we get better sleep? How does sleep- or lack thereof- affect mental health? One of my patients recently told me about her latest sleepwalking escapades. What’s that all about? These are just some of the questions I’ll be addressing in this series.
We’ll start with the first question: why do we sleep? At the most basic level, it makes us feel better. A sleepless night usually leads to a dull, lethargic day, but a good night of sleep makes us feel more alert, more energetic, happier, and better able to function. It is as necessary as food, and one way to think about the function of sleep is to compare it to that life-sustaining activity, eating. Hunger is a mechanism that has evolved to ensure that we consume the nutrients our bodies need to grow, repair tissues, and function properly, and feeling tired essentially serves the same purpose. Eating and sleeping are not very different, and both are regulated by powerful internal drives. Going without food produces the uncomfortable sensation of hunger, while going without sleep makes us feel overwhelmingly sleepy. And just as eating relieves hunger and ensures that we obtain the nutrients we need, sleeping relieves sleepiness and ensures that we obtain the sleep we need. But the question remains: why is it necessary? What is the function of sleep?
Despite decades of research and many discoveries about other aspects of sleep, the question of exactly why we sleep has been difficult to answer. Scientists have developed several theories, but as is the case with so many human processes, it’s unlikely that a single theory will ever be proven correct, as sleep is necessary for many biological functions.
Inactivity Theory, aka Adaptive Theory
One of the earliest theories of sleep, sometimes called the adaptive or evolutionary theory, suggests that inactivity at night is an adaptation that served as a survival mechanism by keeping organisms out of harm’s way at times when they would be particularly vulnerable. The theory suggests that animals that were able to stay still and quiet during these periods of vulnerability had an advantage over other animals that remained active. For example, they weren’t killed by nocturnal predators and didn’t have accidents during activities in the dark. Through natural selection, this behavioral strategy of inactivity presumably evolved to become what we now recognize as sleep. But for every yin there’s a yang, and a simple counter argument to this theory is that it may be safer to remain conscious in a dangerous environment, in order to be able to react to an emergency. So there doesn’t seem to be any major advantage to being unconscious and asleep if safety is paramount. I mean, yeah, you’re less likely to be run over by a car, but it’s easier to be eaten if you’re just laying there, conveniently waiting for the predator to get you.
Energy Conservation Theory
The energy conservation theory of sleep suggests that a main purpose of sleep is to reduce a person’s energy use during certain periods when it’s inconvenient and less efficient to hunt for food. This is backed up in our biology, as research has shown that our metabolic rate is significantly reduced during sleep, by as much as 10 percent in humans, and even more in other species. According to this theory, sleeping allows us to reduce our overall caloric requirements by spending part of our time functioning at a lower metabolism. Although it may be less apparent to people living in societies in which food sources are plentiful, one of the strongest factors in natural selection is competition for, and effective utilization of, energy resources. The theory supports the proposition that sleep is a process of natural selection; we’ve evolved to sleep to expend less energy for a certain amount of time each day. And in fact, research suggests that humans getting 8 hours of sleep can produce a daily energy savings of 35 percent over complete wakefulness.
Another explanation for why we sleep is based on the long held belief that sleep serves to “restore” what is lost in the body while awake. The bottom line is that sleep provides an opportunity for the body to repair and rejuvenate itself, and many important processes happen during sleep. In fact, many of the major restorative functions in the body- like muscle growth, tissue repair, protein synthesis, and growth hormone release- occur mostly, or in some cases only, during sleep. There is a great deal of empirical evidence collected in human and animal studies to support the restorative theory. For example, studies have demonstrated that animals deprived of sleep entirely lose all immune function and die in just a matter of weeks. All of the “sleep when you die” folks should probably read that.
Other rejuvenating aspects of sleep are specific to the brain and cognitive function. For example, while we are awake, neurons in the brain produce adenosine, which is a by product of cellular activity. As long as we are awake, adenosine accumulates and remains in high concentrations. During sleep, the body has a chance to clear adenosine from the system, and, as a result, we feel more alert when we wake. In fact, the accumulation of adenosine in the brain is thought to be one factor that leads to our perception of being tired; scientists think that this build-up during wakefulness may promote the drive to sleep.
Brain Plasticity Theory
One of the most recent and compelling explanations for why we sleep is based on findings that sleep is correlated to changes in the structure and organization of the brain. This phenomenon is known as brain plasticity, and its connection to sleep has several critical implications. Simply put, this theory says sleep is required for brain function. Specifically, sleep allows your neurons, or nerve cells, time to reorganize. Sleep affects many aspects of brain function, including learning, memory, problem-solving skills, creativity, focus, concentration, and decision making. Ever have trouble remembering today something you did or said yesterday if you didn’t sleep the night before? That’s because sleep contributes to memory function. While you sleep, short-term memories are converted into long-term memories, and information that is not needed is erased, so as not to clutter the nervous system. In addition, when you sleep, your brain’s glymphatic system clears out waste and removes toxic byproducts from your brain which build up throughout the day, and this allows your brain to work well when you wake up. If you don’t sleep, these things don’t happen, so if it seems like your brain doesn’t work properly when you’ve pulled an all-nighter, it’s because it doesn’t… it’s full of waste and useless info!
What else is sleep essential for?
Not only is sleep needed for physical health, sleep is also necessary for emotional health. Sleep and mental health are intertwined: on one hand, sleep disturbances can contribute to the onset and progression of mental health issues, but on the other hand, mental health issues can also contribute to sleep disturbances. I will cover this in more detail in another blog, but during sleep, brain activity increases in areas that regulate emotion, and this helps support emotional stability. One example of how sleep helps regulate emotions occurs in the amygdala. This part of the brain, located in the temporal lobe, is in charge of the fear response- it’s what controls your reaction when you face a perceived threat, like a stressful situation. When you get enough sleep, the amygdala can respond in a more adaptive way, but if you’re sleep-deprived, the amygdala is more likely to overreact.
Sleep affects your weight by controlling the hunger hormones ghrelin, which increases appetite, and leptin, which increases the feeling of being full after eating. During sleep, ghrelin decreases because you’re using less energy than when you’re awake. But lack of sleep elevates ghrelin and suppresses leptin, and this imbalance makes you hungrier, which increases the risk of eating more calories and gaining weight. Research shows that chronic sleep deprivation, even as few as five consecutive nights of short sleep, may be associated with increased risk of obesity, type 2 diabetes, and other metabolic syndromes. In addition, sleep is necessary for proper insulin function and may protect against insulin resistance. Insulin is a hormone that helps your cells use glucose, or sugar, for energy. But in insulin resistance, your cells don’t respond properly to insulin, and this can lead to high blood glucose levels and eventually, type 2 diabetes. Basically, sleep helps keep your cells healthy so they can properly take up glucose.
A healthy and strong immune system depends on sleep, period. Research shows that sleep deprivation lowers immunity and can inhibit immune response, which obvi makes the body much more susceptible to germs. When you sleep, your body makes cytokines, which are proteins that fight infection and inflammation. It also produces certain antibodies and various immune cells during this “down” time, and together, these prevent sickness by destroying harmful germs. This is why sleep is so important when you’re sick or stressed, as during these times, the body needs even more immune cells. Having had covid recently, I can vouch for that.
While the exact causes aren’t clear, scientists have established a link between heart disease and poor sleep. It is associated with risk factors for heart disease, including high blood pressure, increased sympathetic nervous system activity, elevated cortisol levels, increased inflammation, weight gain, and insulin resistance.
The Centers for Disease Control and Prevention says the average adult needs 7 hours of sleep a night. During that time, the body repairs cells and tissues, restores energy, and releases molecules like hormones and proteins, while the brain stores new information and gets rid of toxic waste, and the nerve cells communicate and reorganize. Without these processes, our bodies can’t function correctly. It’s a lot for a body to do, so give it the time it needs to do it!
Next time, we’ll talk about more what happens while you’re sleeping. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Scariest Psych Disorders, the finale
Hello, people… welcome back to the blog! Last week, we talked about more of the strangest and scariest psych disorders, and this week, we’ll finish that off before we take a break for the holidays. Let’s get right to it.
Ever had a food craving? Maybe you want a piping hot pepperoni and mushroom pizza, with extra cheese. Sounds good, right? How about you add some dryer lint? Yum! Or maybe a little shredded phone book? Still sound good? No? How about sex… ever had a craving for that? Of course, everyone has, right? How about sex with a truck? Not in a truck… WITH a truck. Hmmm…. Maybe not so much.
Well, imagine craving the taste of that phone book, or wanting to have sex with a car. It sounds unreal, but those things are reality for people with Kluver-Bucy Syndrome, a very scary neurological disorder associated with damage to the temporal lobes of the brain, resulting in the desire to eat inedible objects, sexual attraction to inanimate objects, and memory loss.
First described by neuropsychologist Heinrich Klüver and neurosurgeon Paul Bucy- hence the name- the story of Klüver-Bucy syndrome begins with a monkey and a cactus. Actually, it begins with mescaline, which is a chemical derived from a cactus, that causes vivid hallucinations. It was studied very thoroughly- and quite personally- by psychologist Heinrich Klüver, who noticed that monkeys that were given mescaline often smacked their lips, which reminded him of behaviors exhibited by patients with seizures arising from the temporal lobe of the brain. Unsure if this was due to mescaline or not, this made the two of them curious as to all of the functions of the temporal lobe, so they designed an experiment on a monkey named Aurora, who happened to be particularly aggressive. They removed a large part of Aurora’s left temporal lobe to investigate it under a microscope, and noted that when she woke, her previously aggressive demeanor had vanished, and she was instead placid and tame.
Apparently, this drew their interest more than the mescaline, so they focused solely on the temporal lobe, performing bilateral temporal lobe surgery on a series of 16 monkeys, and afterwards noted the following symptoms:
Psychic blindness- this indicates a lack of recognition or understanding of a person, place, or thing being viewed. After the surgery, the monkeys would look at the same object over and over again, unable to recognize the form or function of the object. Even things they should fear, like a hissing snake, they didn’t recognize, much less fear.
Oral tendencies- like a very small child, the monkeys evaluated everything around them by putting it all into their mouths, rather than using their hands, as they normally would. They would even attempt to push their heads through the bars of their cages in order to touch things with their mouths, instead of their hands.
Dietary changes- prior to the temporal lobe surgeries, these monkeys usually ate fruit, but afterwards, the monkeys began to accept and consume large quantities of meat.
Hypermetamorphosis- this meant that anything that crossed the monkeys’ field of vision required their full and immediate attention.
Altered sexual behavior- after the procedure, the monkeys become very sexually interested, both alone with themselves, and with others.
Emotional changes- the monkeys became very placid, with reduced or even absent fear. Facial expressions were also lost for several months, but those did return after a period of time.
Not surprisingly, people with Kluver-Bucy syndrome often have the same symptoms: trouble recognizing people and/ or objects that should be familiar to them, and excessive oral tendencies, with the urge to put all kinds of objects into the mouth, whether food items or not. Hypermetamorphosis is also common, the irresistible impulse or need to explore everything that comes into view. Other symptoms include memory loss, emotional changes, extreme sexual behavior, indifference, placidity, and visual agnosia, which is difficulty identifying and processing visual information. A nearly uncontrollable appetite for food is often noted, and there may be dementia type symptoms as well.
Klüver-Bucy syndrome is the result of damage to the temporal lobes of the brain. This can be the result of trauma to the brain itself, or the result of other degenerative brain diseases, tumors, or some brain infections, most commonly herpes simplex encephalitis.
Thankfully, this type of extreme damage is rare. The first full case report of Klüver-Bucy syndrome was reported by doctors Terzian and Ore in 1955, when a 19-year-old man had sudden seizures, behavioral changes, and psychotic features. First the left, and then the right, temporal lobes were removed. After the surgery, he seemed much less attached to other people, and was even quite cold to his family. At the same time, he was hypersexual, frequently soliciting people who happened by, whether they were men or women. He also wanted to eat constantly, regardless if the items were food or not.
Because it is so rare, like many classical neurological syndromes, Klüver-Bucy syndrome is really more important for historical and academic reasons, rather than for its immediate applications to patients. The reports of Klüver and Bucy got a lot of publicity at the time, mainly due to their demonstrating the temporal lobe’s involvement with interpreting vision, and their work added to the growing recognition that particular regions of the brain had unique functions which were lost if that region of the brain was damaged. Science is built on the work of others- the more we know, the more we learn- and while Klüver-Bucy syndrome isn’t very common, the work that went into describing it still has an impact felt in neurology to this day.
To be or not to be… that is the question. At least, that’s one of the many questions someone with aboulomania is likely to ask themselves. From the Greek a-, meaning without’, and boulē, meaning will, aboulomania is a psych disorder in which the patient displays pathological indecisiveness. While many people have a hard time making decisions, it is rarely to the extent of obsession, and that’s exactly the case in aboulomania.
In most people, the part of the brain that is tied to making rational choices, the prefrontal cortex, can hold several pieces of information at any given time. But people with aboulomania quickly become overwhelmed when trying to make choices or decisions, regardless of the importance of that decision. They come up with all the reasons how and why their decisions will turn out badly, causing them to overanalyze every situation critically. It’s a classic case of paralysis by analysis, where a lack of information, difficulty in valuation, and outcome uncertainty combine to become obsession. Often associated with anxiety, stress, and depression, as you can imagine, aboulomania can severely affect one’s ability to function socially.
As for etiology, it’s usually extremely authoritarian or overprotective parenting that leads to the development of aboulomania; when caretakers reward loyalty and punish independence. Sometimes there’s a history of neglect and avoidance of expressed emotion during childhood that contributes to it. If someone is a victim of humiliation or abandonment during childhood, the chances for aboulomania increase, as shame, insecurity, and lack of self-trust can all trigger it. It’s sad to see, when everyday tasks become deciding questions of peoples’ lives. Simple decisions… to see a movie or stay at home, and what movie? Do I want Mexican or Italian food? Should I call John or text him? These are questions that cannot be answered by people with aboulomania without an eternity of dilemmas.
It’s common for people with aboulomania to avoid being alone whenever they know a decision has to be made, or feel like a dilemma might come up. But this doesn’t come from a fear of being alone, it comes from the need to have someone there to make the decision for them, and assume the responsibility for said decision. Here, the fear of being alone isn’t the root of the problem, it’s just a symptom of a bigger issue. It’s important to mention that this dependency on people makes it easier for others to manipulate or lie to people with aboulomania. Some people will take advantage of their indecisiveness and use that, while others will simply leave them for not being able to make choices or ever express disagreement.
Many times, people with aboulomania don’t recognize it, or recognize it but try to play it off, but this is a pathological level of indecision, a mental illness, not just a self-esteem or insecurity issue, so diagnosis is important. Look, being indecisive when having to make an important decision is normal, but when it starts affecting your relationships, and it makes it impossible for you to live your life, it’s a problem, so it’s time for an evaluation. Once diagnosed, the process really consists of dealing with any of the underlying anxiety, depression, or stress that usually goes with it. The idea is to then help the person develop more autonomy, self esteem, and social skills, like assertiveness.
Ah Paris… the beautiful city of lights, croissants, funny mimes, the Champs-Elysées, macarons, the Eiffel Tower, and art at the Louvre. Sounds fabulous. That’s what most people think of, that view that I just described, so the reality can come as a shock… McDonald’s on every corner, crime, graffiti, and rude taxi drivers and waiters, irritated by tourists who don’t speak the lingo. I mean, every place has its pros and cons, but people seem to have romantic expectations of Paris, right? Hence Paris syndrome, an extremely odd, but thankfully temporary, mental disorder that causes one to become completely overwhelmed while visiting the city of Paris. And to be clear, not overwhelmed by the beauty, but rather by the reality of Paris.
Interestingly, Paris syndrome seems to be most common among Japanese travelers. The theory is that they’re used to a more polite and helpful society in which voices are rarely raised in anger, and the experience of their dream city turning into a nightmare can simply be too much. Of the approximately 6 million Japanese visitors to Paris each year, one to two dozen experience overwhelming anxiety, acute delusions, hallucinations, feelings of confusion and disorientation, nausea, paranoia, dizziness, sweating, and feelings of persecution that are Paris syndrome. Researchers really just speculate as to cause; because most people who experience this syndrome have no history of mental illness, the leading thought is that it’s triggered by the language barrier, physical and mental exhaustion, and the reality of Paris as compared to the idealized version.
So what can one do to prevent Paris syndrome? Simple: adjust your expectations. Ultimately, it’s like any modern metropolis- dirty, crowded, loud, and often indifferent… but beautifully so. Just don’t expect the furniture to spring to life and help you get ready for your dance with the Beast, and a trip to Paris will be exciting, and, most importantly, free of debilitating anxiety and hallucinations.
It seems like there have been so many iterations of The Walking Dead, and like every generation sees a new zombie trend, but this isn’t all movie magic. Imagine feeling IRL that you are dead already, that your body and all of your internal organs are rotting, and that you are ceasing to exist. Well, that’s how it is for people with this very strange- and incredibly frightening- neuropsych disorder also known as nihilistic delusion, as well as walking corpse syndrome. Boy, that last one pretty much says it all, right? Named for neurologist Jules Cotard, who first described it in 1880 as “The Delirium of Negation,” Cotard delusion typically occurs in conjunction with severe depression, some psychotic disorders, and other neurological conditions.
One of the main symptoms of Cotard delusion is nihilism- the belief that nothing has any value or meaning- but can also include the belief that nothing really exists. And in fact, in some cases, people with Cotard delusion feel like they’ve never existed, never lived. But it does have a flip side, the feeling of being immortal. As for other symptoms, depression is numero uno, with anxiety a close second. Hello, I think I’d be depressed and anxious too if I thought I was rotting and my very soul didn’t exist. But depression is in fact very closely linked to Cotard delusion, with a review indicating that 89% of documented cases cited depression as a symptom. Aside from anxiety, other common symptoms include hallucinations, hypochondria, guilt, and a preoccupation with hurting oneself or with death.
Researchers aren’t sure what causes Cotard delusion, but there are a few potential risk factors. Being female is one, as women seem to be more likely to develop Cotard delusion. Age is a factor. Several studies indicate that the average age of people with Cotard delusion is about 50, but it can also occur in children and teenagers. Interestingly, people with Cotard delusion that are under the age of 25 tend to also have bipolar depression, so that’s a risk factor. In addition, Cotard delusion seems to occur more often in people who think that their personal characteristics, rather than their environment, cause their behavior. People who believe the opposite- that their environment causes their behavior- are more likely to have a related condition called Capgras syndrome. That should sound familiar from the first installment of this series, as the syndrome causes people to think their family and friends have been replaced by imposters. Notably, Cotard delusion and Capgras syndrome can also appear together. Imagine that… believing that your body is rotting away, you are ceasing to exist, and all of the people and places in your life have been replaced by imposters! Jump on the empathy train, people.
In addition to bipolar disorder, other mental health conditions that might increase one’s risk of developing Cotard delusion include postpartum depression, psychotic depression, schizophrenia, catatonia, and dissociative disorder. Cotard delusion also appears to be associated with certain neurological conditions, including dementia, brain infections, brain tumors, multiple sclerosis, epilepsy, migraines, stroke, traumatic brain injuries, and Parkinson’s disease.
As you can imagine, feeling like you’re ceasing to exist- or like you’ve already died- can lead to some gnarly complications. For example, some people stop bathing or taking care of themselves, which can lead to skin and dental issues. All of that can cause people around them to start distancing themselves, which then usually leads to additional feelings of isolation and depression for the patient. Others stop eating and drinking because they believe their body doesn’t need it, and in severe cases, this can lead to malnutrition and starvation, even death by starvation. Unfortunately, suicide attempts are very common in people with Cotard delusion. Some see it as a way to prove they’re already dead by showing they can’t die again, while others simply feel trapped in a body and life that feels hopeless and doesn’t seem real. They hope that their life will get better or that their condition will stop if they die again.
Fortunately, Cotard’s delusion is very rare, with about 200 cases known worldwide, and while the symptoms are extreme and it can be hard to get the right diagnosis, most people get better with treatment. That generally entails a mix of therapy and medication, often a combination of meds to find something that works. If nothing seems to work, ECT- electroconvulsive therapy- may be used as a last resort. Done under general anesthesia, ECT passes small electric currents through the brain; this induces a generalized seizure and causes changes in brain chemistry that may quickly reverse or resolve symptoms of certain mental health conditions. While it sounds horrifying, ECT is not the procedure depicted in old B movies, and it can be a real game changer for some people with refractory conditions… I’ve seen a single ECT session change a person’s life.
There are descriptions of several Cotard’s cases available on the interwebs. One of the earliest recorded cases occurred in 1788, when an elderly woman was preparing a meal and felt a sudden draft, and then became totally paralyzed on one side of her body. When feeling, movement, and the ability to speak eventually came back to her, she told her daughters to dress her in a shroud and place her in a coffin. For days, she continued to demand that her daughters, friends, and maid treat her like she was dead. They finally gave in, putting her in a shroud and laying her out so they could mourn her. Even at the “wake,” the lady continued to fuss with her shroud, and even complained about its color. When she finally fell asleep, her family undressed her and put her to bed. After she was treated with a “powder of precious stones and opium,” her delusions went away, only to return every few months.
Some 100 years later, Cotard himself saw a patient he called Mademoiselle X, and she had an unusual complaint. She claimed to have “no brain, no nerves, no chest, no stomach and no intestines,” yet despite this predicament, she also believed that she “was eternal and would live forever.” Since she was immortal, and didn’t have any innards, evidently she didn’t see a need to eat, and soon died of starvation. Cotard’s description of the woman’s condition spread widely and was very influential, and the disorder was eventually named after him.
But Cotard’s delusion isn’t strictly confined to the history books. In 2008, a New York psychiatrist reported on a 53-year-old patient who complained that she was dead and smelled like rotting flesh. She asked her family to take her to a morgue so that she could be with other dead people. Thankfully, they dialed 911 instead, and the patient was admitted to the psychiatric unit, where she accused paramedics of trying to burn her house down. After a month or so on a strict drug regimen, her symptoms were greatly improved, and she was well enough to be released to her loving family.
That seems like a good place to stop. We’ll be taking a break for the holidays, so the next blog will be in 2022! I hope you enjoyed this week’s blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Happy holidays! Be well people!
Hello, people! Welcome back to the blog. Hope everyone had a great weekend. I’ll tell you, anyone who doesn’t believe in global warming doesn’t live here in SoFla, because it was a warm one. It sure doesn’t feel like two weeks until Christmas. Anyway, I guess we should get to the shrinky stuff. Two weeks ago, I introduced you to some of the scariest mental disorders out there, and we talked about apotemnophilia, where people have the desire to amputate a healthy, functional limb, Capgras delusion, where people believe that the people in their lives have been replaced with duplicate imposters that are hell bent on harming them, Diogenes syndrome, better known as hoarding, and factitious disorder, where people go to great lengths to fake symptoms of real illness. This week, we’re going to continue the discussion, and things are going to get way weirder- and scarier- so buckle up, folks.
Alice in Wonderland Syndrome
Alice in Wonderland is total fantasy, but one of Alice’s more bizarre experiences shares its characteristics with a very scary and all too real neurological disorder. Also known as Todd Syndrome, Alice in Wonderland Syndrome (AIWS) is characterized by transient, episodic distortions of visual perception, phenomena known as metamorphopsias. There’s a scrabble word for you. Just as Alice grows too tall for the house in Wonderland, people with AIWS may see their body parts or other objects as larger or smaller than they really are, hear sounds louder or quieter than they actually are, and even lose their sense of time and velocity. They may also experience derealization and depersonalization, which are shrinky terms for mental states where you feel detached from your surroundings and where you lose your sense of self identity, respectively.
There are three main types of AIWS, which are divided according to how the person’s perception is distorted.
Type A involves sensory distortion of oneself, and in this type, the most common issue is people feeling as though their body parts are changing size.
Type B causes more visual distortions of the surrounding environment, and includes episodes of micropsia, where objects appear too small; macropsia, where objects appear too big; metamorphopsia, where height and width of objects appear inaccurate; pelopsia, where objects appear too close; and teleopsia, where objects appear farther away than they actually are.
Type C is a mix of types A and B. A person with Type C AIWS can perceive both the image of their own body, and that of other people or things around them, to be changing.
AIWS can affect perception of every sense: sight, hearing, touch, and time. As you can imagine, it’s a terrifying disorder, sort of like an LSD trip without the euphoria, but thankfully it’s considered fairly rare, with fewer than 200 “clinical” cases described in the literature, meaning cases requiring medical attention. That said, I also read that “non-clinical” AIWS- meaning fleeting, transient cases not requiring medical attention- have been described in up to 30 percent of the general population. That doesn’t sound so rare to me, right? And by the way, anytime I see my body parts changing size right before my very eyes, I think I’d require medical attention. Just sayin.
While the exact cause or etiology is still unknown, it’s most often associated with migraine, head trauma, brain tumor, fever, drug use, certain types of epilepsy, and certain infectious diseases, especially Epstein-Barr virus and varicella-zoster virus. It’s also theorized that it can be caused by abnormal amounts of electrical activity, resulting in abnormal blood flow to those parts of the brain that are responsible for visual perception and processing. Encephalitis, which is inflammation of the brain, often caused by infection or an allergic reaction, is the most common cause of AIWS in children, while in adults, migraine is the most common cause. Prognostically, AIWS in and of itself is generally considered relatively harmless, but clearly that depends on the underlying pathology.
Alien Hand Syndrome
Any South Park fans here? If so, you may recognize this syndrome… Cartman claimed he suffered from this in the episode with Pancake Head. But true alien hand syndrome is a frightening neurological disorder where a discrepancy develops between one’s intentions and actions of a hand or limb, causing that hand to seemingly act on its own free will. Sometimes one leg is affected, though this isn’t as common. During these episodes, the affected hand feels foreign to its owner, as it carries out its unintentional tasks. Sometimes referred to as Dr. Strangelove syndrome, Strangelovian hand, or anarchic hand, alien hand can affect children, but usually occurs in adults.
Alien hand syndrome can be caused by several factors. Some people develop this after a stroke, brain trauma, or tumor. It’s sometimes associated with cancer, neurodegenerative diseases like Alzheimer’s Disease and Creutzfeldt-Jakob Disease, and brain aneurysms as well. It’s often linked to anything that separates or affects communication between the two hemispheres of the brain, usually a division or an issue with the corpus callosum, which divides the brain hemispheres and allows for communication between the two sides. Surgeries to treat epilepsy sometimes affect the brain in this way. Lesions have also been found in the anterior cingulate cortex, posterior parietal cortex, and supplementary motor cortex areas of the brain in people with alien hand, which would affect intentional planning systems and could cause spontaneous movements.
Alien hand can be like a bad B movie… sufferers have reported their alien hand attempting to choke either themselves or others, ripping clothing, and scratching to the point of drawing blood. Yikes. Unfortunately, no cure exists for alien hand syndrome, and it’s best that those affected by it keep their hands constantly occupied, and use their other hand to control the alien hand. It’s used in some terrifying plot twists, but alien hand syndrome is hardly limited to the fictional world.
Boanthropy is a rare and serious psychological disorder in which a human being experiences a mental metamorphosis, believing they are a cow, and go so far as to behave as such. Sometimes people with boanthropy are found in fields with “other” cows, walking on all fours and chewing grass as if they were a member of the herd. This is actually how they’re identified, as a result of their behavior. But people with boanthropy not only walk like a cow, they often “talk” like a cow… they stop talking like human beings, using language, and instead prefer mooing. They often stop eating people food and develop a taste and craving for grass… they graze like a cow, eating whatever plants they see “the other” cows eating.
Boanthropy isn’t new. It’s even referred to in the Bible, with King Nebuchadnezzar. He was king of the Neo-Babylonian Empire from 605 BC to 562 BC, the dude who conquered Judah and Jerusalem, and sent the Jews into exile. He was also credited with building the Hanging Gardens of Babylon. But he was constantly babbling about his great achievements, so he was humbled by God for being boastful. In the Book of Daniel, he basically lost his sanity, and lived like an animal for seven years. It says that he “was driven from men and did eat grass as oxen.” Lucky for him, God took pity on him and later restored his sanity, so he then praised and honored God.
The cause of boanthropy is still unknown. Many link it with religious perceptions, while others think it’s related to witchcraft and black magic. Most likely, it’s an additional aspect of another psychological disease, such as schizophrenia. The person is probably experiencing severe delusions, and that affects their sense of self, their belief that they exist as a human being. But since the causes of boanthropy aren’t well understood, treatment isn’t exactly defined. That said, if a human is seen grazing and mooing, they clearly need help. Now, I’ve never had a patient with boanthropy, but I can tell you that some serious psychotherapy and pharmacotherapy would be in order, and the primary goal would be to treat the underlying condition, to help the individual give up the state of delusion and realize they’re human.
I read an account online of a person suffering from boanthropy. Apparently he had stopped eating people food, despite his family’s increasingly frantic attempts to get him to do so, and he was dying. I mean, hello, malnutrition, he was only eating grass. Anyway, he was so sickly and weak, he begged to be butchered, so the villagers called the butcher, who was clearly really smart. When he came, he appraised the man’s body condition as he would any animal, and said that the man was too thin, that he must be fattened up with milk and meat for at least one year before he could be butchered. The man heard this and began to take the milk and meat, and started gaining weight. Eventually, this apparently helped him realize his delusion, and he stopped behaving like a cow and started acting like a human again. This wasn’t in a journal, just a random account on the interwebs, so I can’t vouch for the veracity of the story, but thought it was interesting.
Ultimately, they don’t seem to realize what they’re doing at the time, but everything they do, from their behavior, to their diet, to the sounds they make, people with boanthropy moooove through life like a cow. Ha!
Like people with boanthropy, people with clinical lycanthropy also believe they can become animals, but in this case, it’s wolves and werewolves, or lycanthropes. Isn’t that a great word? Fun fact, the word lycanthrope comes from the Greek words lykos, meaning “wolf,” and anthropos, meaning “human being.” So everyone knows the legend of the werewolf, right? It’s the fearsome creature who only takes the form of a human until the night of the full moon, at which point they become a bloodthirsty beast… blood curdling scream!!!!
Clinical lycanthropy is actually another very rare and scary psychiatric syndrome involving a delusion that the affected person can transform into, or has transformed into, a wolf. Basically, these people claim that they can physically shapeshift into wolves and werewolves, and often, the symptoms include them relaying their “transformation experience” during a moment of clarity. I guess other symptoms would include howling at the moon? I joke, but this is a real thing, although exceedingly rare. Since 1850, there have been 56 original case descriptions of people who believed they were metamorphosing into an animal, 13 of which met the criteria for clinical lycanthropy. Once again, the cause is unknown, but several theories exist. Aside from being a garden variety delusion, another potential cause involves lesions or other physiological issues within the cerebral cortex, which is responsible for a person’s perception of their own body. Interestingly, studies have actually shown that when sufferers of clinical lycanthropy undergo a “transformation,” they display unusual levels of brain activity in these regions, suggesting that they may genuinely perceive themselves as other than human. It’s interesting that we’ve actually done imaging studies on people as they “transformed.” I guess it’s become a real phenomenon.
If you search it, there are all sorts of forums and discussions on the interwebs about being a werewolf, the differences between werewolves and vampires, and how to get volunteers to “donate” their blood to lycanthropes. I remember seeing a guy on some tv show saying he had like five people that allowed him to drink their blood- he kept them in circulation- so he didn’t take too much from any one. Get it? Drank blood in circulation. Ha! He really did say that, but not as a joke. Anyway, he seemed perfectly rational as he talked about it. Again, it’s most likely a delusional state, secondary to another psych disorder, like schizophrenia or even bipolar disorder, though I’m sure he- and all those other werewolves out there- would disagree.
Also known as Shrinking Penis or Genital Retraction Syndrome- yikes- Koro syndrome is a delusional disorder in which a person feels that his genitals are retracting into his abdomen, and that they may totally disappear one day, and even possibly kill him… all of this without any physical proof of the retraction. It primarily strikes males, but females occasionally suffer from a variation of koro in which they believe that their nipples are retracting. Interestingly, koro often appears as an epidemic in which multiple cases are reported simultaneously within a specific geographic area. That should give you an idea of an underlying issue associated with koro… mass hysteria.
First identified in ancient China, koro almost always follows an identical pattern: the sufferer first experiences a tingling sensation in the genitals, followed by a rapid onset panic attack, which quickly leads to a sudden and pervasive fear that the genitals are disappearing. In Asia, this fear is almost always accompanied by an imminent fear of death, although interestingly, this element is often missing from reports in other parts of the world.
Koro is clearly heavily influenced by cultural beliefs, which also helps explain why epidemics are common. Outbreaks may be blamed on any number of things, including an invading force, an individual rival, or extramarital affairs. I read that in some West African outbreaks, sufferers believed that their genitals were being stolen for occult reasons, rather than retracting into their bodies. In most cases, indigenous treatment is recommended, and that might include an exorcism, rest, herbal treatments, or other healing practices. “Defeating the foe” is sometimes the recommended treatment in some koro outbreaks. That sounds cool. Doctor, what should I do? Defeat the foe! Apparently, koro sufferers often ask friends or relatives to physically manipulate their genitals to stop them from retracting, which sometimes leads to injury. Ouch! Thankfully, the anxiety and hysteria from koro generally subsides very quickly when a culturally acceptable treatment is used.
Koro happens around the world, including the Western world. Here, koro is treated as a specific phobia, with psychotherapy and antidepressant medications commonly prescribed. Clearly, it’s important to rule out physical causes for the koro symptoms, as pain, tingling, and similar physical symptoms that are common in koro could also indicate an underlying physiological condition. Captain Obvious says that here in the west, we would perform a full workup to determine exactly which factors are in play. Captain Obvious also says that it’s a good idea to first visit the urologist if you’re experiencing these symptoms. That’s my PSA for the day: see a urologist if your genitals are tingling.
That’s a good place to stop for today. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in officeand on Amazon.
Thank you and be well people!
The Scariest Mental Disorders of All Time
Hello, people! I hope everyone had an excellent Thanksgiving! Is everybody on tryptophan overload? I know I am, but man was the turkey great this year! And the stuffing, the mashed potatoes, the gravy, the pineapple casserole… you get the idea. Anyhoo, last week and 5 pounds ago I finished up our series on the dark side of ADHD. I hope everyone learned something. Squirrel!! Again, if you don’t get that joke, check out the series. This week, I want to talk about the weirdest and scariest psych disorders out there. I remember this section from med school- it really caught my attention- you’ll see why shortly. Imagine suffering from a mental illness that causes you to believe your significant other is an imposter, hell bent on harming you, or one that convinces you that books are for eating, not reading. Or that your genitals are shrinking? YIKES!! Or the ultimate… that you have somehow become the walking dead. Pretty scary, right?
While a very small percentage of people are forced to live with these unusual disorders, 450 million people worldwide suffer from mental illness. In the United States alone, one in four families is affected. While some mental disorders, like depression, usually occur naturally, others are the result of brain trauma or other injuries. Although it’s certainly fair to say that any mental illness can be scary for those suffering from it- as well as their families- there are a few rare disorders that are especially terrifying. Those are what I’m going to talk about this week, so jump on the empathy train and buckle up, people… it’s about to get wild.
Also known as Body Integrity Disorder or Amputee Identity Disorder, Apotemnophilia is a disorder that sort of blurs the lines between neurology and psychiatry- we aren’t certain of the origins- so I’ll call it a neuropsych disorder. Whatever it is, apotemnophilia is typically characterized by the overwhelming desire to amputate or permanently damage healthy, functional parts of the body. More rarely, affected individuals have the express desire to be paraplegic, and in some exceptionally rare cases, they seek sensory deprivation, such as blindness or deafness. Oddly enough, the first description of this condition traces back to a series of letters published in Penthouse magazine in 1972, but the first scientific report of this disorder came about in 1977 with the medical description of two cases. As happens, two have become many, and now there may be thousands of people with apotemnophilia desiring amputation. They seem to gather on the interwebs, and some even have their own websites seeking support or pleading their cases. I mean, Captain Obvious says that the vast majority of surgeons won’t just amputate healthy limbs upon request… hello, Hippocratic Oath… so some sufferers of apotemnophilia feel forced to perform amputations on their own. DIY surgery? That’s a very dangerous scenario to be sure. But there have been some cases who have had a limb removed by a doctor, and most are reportedly very happy with their decision.
Since little was known about it, one American shrink made an attempt to further illuminate the disorder by surveying 52 volunteers desiring amputation. Thanks to his work, a number of key features were identified: there seems to be a gender prevalence, as most individuals are men, as well as a side preference, with left-sided amputations being most frequently desired. He also found that there was a preference toward amputation of the leg versus the arm. Until recently, the explanation for apotemnophilia has been in favor of a psychiatric etiology; it was thought to be a pathological desire driven strictly by a sexual compulsion. But a neurological explanation has recently been proposed, in the form of damage to, or dysfunction of, the right parietal lobe, thereby leading to a distorted body image and subsequent desire for amputation. In order to investigate this potential etiology, recent studies have utilized electrophysiological and neuroimaging techniques in an attempt to identify neurological correlates of body representation impairments. That work is ongoing. What’s interesting is that, in my experience, most of these folks seek limb amputation primarily to “feel complete” as they put it, as opposed to wanting to satisfy any sexual proclivities, but the debate about the reasons behind the desire rage on as studies continue. Sounds a little oxymoronic, to remove something to feel more complete, but that’s apotemnophilia.
Also known as imposter syndrome or Capgras syndrome after Joseph Capgras, a French psychiatrist who was fascinated by the illusion of doubles, Capgras is a debilitating mental disorder in which one irrationally believes that the people and/ or things around them have been replaced by identical imposters. Sort of like Leonardo Di Caprio in Inception, but without a totem to tell if you’re in the real world. Whether it’s a close friend, spouse, family member, pet, or even a home, people suffering from Capgras feel that their reality has been altered, that the real thing has been substituted for a fake. And if that weren’t bad enough, even worse, the imposters are usually thought to be planning to harm them. Capgras is usually transient, ranging from minutes to months, but unfortunately, also usually recurrent.
Capgras syndrome is most commonly associated with Alzheimer’s disease or dementia, both of which affect memory and can alter one’s sense of reality. Schizophrenia, especially paranoid hallucinatory schizophrenia, can cause episodes of Capgras syndrome, as this also affects one’s sense of reality and can cause delusions. In rare cases, a brain injury that causes cerebral lesions, especially in the back of the right hemisphere, can also cause Capgras syndrome, as that’s the area of the brain that facilitates facial recognition. Rarely, people with epilepsy and migraine may also experience temporary Capgras syndrome as well. There are several theories on what causes the syndrome. Some researchers believe that it’s caused solely by a problem within the brain, by conditions like atrophy, lesions, or cerebral dysfunction, while others believe that it’s a combination of physical and cognitive changes, causing feelings of disconnectedness. Still others believe that it’s a problem with processing information, or an error in perception which coincides with damaged or missing memories. For all we know about the brain, there is still so much we don’t. Occurring more commonly in females than males, Capgras is relatively rare, and is most often seen after traumatic injury to the brain. No matter the how and why, Capgras is upsetting for both the person experiencing the delusion and the person who is accused of being an imposter, and it’s easy to see why it’s one of the scariest disorders of all time.
Diogenes Syndrome is more commonly referred to as simply hoarding, and is one of the most misunderstood behavioral disorders. Named after the Greek philosopher Diogenes of Sinope- who was, ironically, a minimalist- this syndrome is usually characterized by the overwhelming desire to collect seemingly random items, to which an emotional attachment is then formed. In addition to uncontrollable hoarding, people with Diogenes syndrome often exhibit extreme self neglect, apathy towards themselves or others, social withdrawal, and no shame for their habits. It is very common among the elderly, those with dementia, and people who have at some point in their lives been abandoned, or who have lacked a stable home environment. Occurring in both men and women, people with Diogenes syndrome often live alone, tend to withdraw from life and society, and are seemingly unaware that anything is wrong with the condition of their home and lack of self-care. The conditions they live in often lead to illnesses like pneumonia, or accidents like falls or fires, and in fact, it’s often through these situations that the person’s condition becomes known.
Diogenes syndrome is often linked to mental illnesses such as schizophrenia, obsessive compulsive disorder, depression, dementia, and addiction, especially to alcohol. While there are defined risk factors for developing Diogenes, having one or even more doesn’t necessarily mean it will occur. In many cases, a specific incident becomes a trigger for the onset of symptoms. This can be something like the death of a spouse or other close relative, retirement, or divorce. Medical conditions may also trigger symptom onset: stroke, congestive heart failure, dementia, vision problems, increasing frailty, depression, and loss of mobility due to any number of reasons are the most common medical triggers.
This condition can be difficult to treat, and it can be very frustrating to care for people who have it. While Diogenes syndrome is sometimes diagnosed in people who are middle aged, it usually occurs in people over 60. Symptoms usually appear over time, and in early stages, generally include withdrawing from social situations and avoiding others. People may then start to display poor judgment, changes in personality, and inappropriate behaviors. Due to the associated isolation, people typically have this condition for a long time before it’s diagnosed. Warning symptoms in an undiagnosed person may include skin rashes caused by poor hygiene, fleas or lice, matted, unkempt hair, overgrown toenails and fingernails, body odor, unexplained injuries, malnutrition, and dehydration. The person’s home generally exhibits signs of neglect and decay, with possible rodent infestation, overwhelming amounts of garbage in and around the home, and an intense, unpleasant smell. Despite all of these factors, people with Diogenes syndrome are typically in denial of their situation and usually refuse support or help.
Most people cringe at the first sniffle that may indicate a potential cold or illness, but not people with Factitious disorder, as this scary mental disorder is characterized by an obsession with being sick. Factitious comes from the Latin word meaning artificial, so as the name suggests, people with factitious disorders will present artificial symptoms of real medical conditions. They will often go to incredible lengths to imitate symptoms of a real medical condition, and some will go so far as to intentionally harm themselves to feign symptoms. I’ve seen people inject bacteria into their bodies, intentionally contaminate lab tests, and take hallucinogenic drugs to feign symptoms of whatever illness they’re aiming for, and they’re often willing to be hospitalized and even undergo unpleasant or painful medical tests in order to further their efforts. I should note that factitious disorders are similar to hypochondriasis, in that the symptoms or complaints are not the result of having true, tangible medical conditions, but there is one key difference between factitious disorders and hypochondriasis: people with hypochondriasis believe that they are ill, whereas people with factitious disorders know that they are not.
There are basically three types of factitious disorders. The first is Munchausen syndrome, where people will repeatedly fake symptoms of medical problems. The symptoms will usually be exaggerated, and they tend to go to great lengths to convince others that those symptoms are real. Munchausen syndrome patients have been known to undergo multiple unnecessary medical procedures, even surgeries, and they tend to go to different medical facilities so as not to be detected. The second is Munchausen by proxy, which is like Munchausen, but when by proxy, the person suffering from factitious disorder will force someone else into the patient role. Most commonly, it is the parent(s) or caregiver(s) forcing children into the proxy role, putting them through various medical procedures, making up symptoms that the child has, encouraging the child to lie, falsifying medical reports, and/or altering tests to give the appearance of a sick child. The third is Ganser syndrome, which is a rarer factitious disorder that mostly occurs amongst prisoners, whereby they’ll display faked psychological symptoms such as psychosis. At times, they know they’re not going to get anything out of it, but they’ll give it a try anyway. Psychological testing and sharp shrinks usually tell the true tale with Ganser syndrome.
It can be difficult to identify factitious disorders because the perpetrators are often very adept in feigning symptoms, and they may go to great lengths to physically cause symptoms. I had one case where a woman was admitted to a hospital complaining about vomiting blood, and she insisted on receiving surgery. When an endoscopy didn’t show any stomach bleeding or other source of blood, she shoved her fingers up her nose to make it bleed down her throat. The ruses almost always include elaborate stories, long lists of symptoms, and jumping from hospital to hospital. As you can imagine, it’s incredibly difficult to get an accurate depiction of how prevalent factitious disorders are, because many people are so masterful at faking their symptoms. The estimated lifetime prevalence in clinical settings is 1.0%, and in the general population, it is estimated to be approximately 0.1%, but it ranges widely across different studies, from 0.007% to 8.0%. In one study of patients in a Berlin hospital, it was shown that approximately .3% of hospitalized patients had a factitious disorder. I suspect that whatever the actual number is, these disorders may be much more common than previously thought. Since people with factitious disorders can be very persistent, physicians have to carefully monitor people for it.
Experts have not identified one solid cause of factitious disorders. Some experts believe that these people suffer from a sense of inadequacy or unstable self worth, and use the factitious behaviors to get attention and sympathy, and this essentially defines their self worth. Most likely, they’re caused by a combination of emotional aspects. Such an obsession with sickness often stems from past trauma or serious illness, and it can be linked to a history of hospitalization or sickness during childhood which the patient tries to recreate, in order to return to normalization. Another possible cause is that someone close to the person really was chronically ill, and the person became jealous of the attention, and began to feign symptoms in order to get that same attention. People with factitious disorders will almost always insist that their symptoms are real, even despite clear medical evidence to the contrary, and this makes them very difficult to treat. Unfortunately, most factitious patients will steadfastly deny it and refuse any sort of treatment, but when help is sought, it’s often able to be at least limited with psychotherapy.
That’s a good place to stop for this week. Next week, we’ll talk about more weird and scary psych disorders. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
The Dark Side of ADHD
Hello, people, welcome back to the blog! This week, we’re continuing our discussion on the dark side of ADHD, with a look at gender differences within the disorder.
Before we get to that, I want you to imagine this: Little Janie sits quietly at her desk in second grade. She isn’t talking and she isn’t acting out. That’s great, but she also isn’t learning… anything. Her inattention and inability to focus are obvious every time her teacher asks her a question, which isn’t very often. Teachers like Miss Jones like interaction; they tend to shy away from vacant stares like the one that usually occupies Janie’s face. So Miss Jones’ gaze moves to Barbara, who’s listening attentively- she’s not a “space cadet”- she’s clearly keeping up with what’s going on. So once again, Janie is overlooked, passed over…
Janie’s fraternal twin brother, Johnny, on the other hand, gets lots of attention… though not always for the best reasons. Diagnosed with ADHD last year, he has a reputation for being a bright kid, even if he’s usually hyperactive. Treatment for his ADHD has helped him; he’s a better student than he was, and he gets along better with the other kids. He has some behavior problems, but his natural charm keeps him from getting into too much trouble. But Miss Jones can tell immediately if he’s missed his medication, because it makes all the difference in the world for Johnny. It’s been a total lifesaver. Good for Johnny. But meanwhile, Janie is in her own little world, drowning in inattention. And no one is any the wiser… especially Janie.
Unfortunately, scenarios like this play out day in, day out, all across the globe. Why? Because the vast majority of people diagnosed with ADHD are male. In fact, according to the CDC, boys are three times more likely to receive an ADHD diagnosis than girls, but I’ve seen that number quoted as double that. Statistics say that during their lifetimes, an average of 13 percent of men will be diagnosed with ADHD, while just 5 percent of women will be diagnosed. Girls aren’t any less less susceptible to the disorder than boys, so why are boys three times more likely to receive a diagnosis? That’s what we’ll talk about today.
In a nutshell, it’s because ADHD symptoms present differently in girls and boys. Boys tend to show more obvious externalized symptoms, such as hyperactivity and impulsivity, while girls’ often display the inattentive aspects of the disorder, with symptoms that are more internalized and much more subtle. In general, boys’ symptoms are typically simply more pronounced and extreme as compared to girls. Captain Obvious says that hyperactive characteristics are obviously much easier to spot than more subtle symptoms like inattention. Some ADHD signs in girls can be very difficult to identify. When girls have primarily inattentive type ADHD, without hyperactivity, research indicates that up to 75 percent are undiagnosed. Ultimately, it takes a higher burden of risk factors for symptoms to be recognized in girls- the threshold for referral and diagnosis seems to be much higher than for boys- so girls are less often referred to behavior specialists for evaluation, and this leads to fewer girls being diagnosed.
There are other theories as to why it’s more commonly diagnosed in boys. One is that there may be actual neurobiological differences. Some researchers think that girls may have a protective effect at the genetic level, that they are in some way “protected” from developing ADHD, though the jury’s still out on that.
Another reason why boys are much more commonly diagnosed with ADHD than girls is because boys with ADHD have been found to have more obvious co-existing disorders, like conduct disorder and oppositional defiant disorder, whereas girls do not. The girls’ internalized symptoms are less disruptive in the classroom than the aggression and rule breaking typically exhibited by boys, so this results in fewer referrals, diagnoses, and treatment in girls. The ole “squeaky wheel gets the grease” kind of thing.
Why else? Well, yes, girls are less likely to exhibit hyperactivity, but even when they do, they’re more likely to “just” be over-talkative, or maybe a little rebellious, more of a “wild child,” so the symptoms aren’t recognized for what they are, as being caused by ADHD. Also, girls with ADHD might get noticed in school for being overly chatty, but we expect girls to be more sociable than boys, so teachers might chalk this up to the girls being immature, rather than possibly having ADHD. And girls with primarily inattentive type ADHD, who don’t have hyperactivity, might just be described as distracted or “daydreamy” or overly emotional or “sensitive.” For some reason, we just seem to attribute these behaviors in girls to other things first, whereas with boys, if they’re running around, the first thought is usually ADHD. It’s nearly automatic, and that’s a problem for both the boys and the girls.
Another contributing factor to why so many more boys get diagnosed is that girls are better at compensating for their ADHD symptoms than boys are. Girls develop better coping strategies to make up for their ADHD-related difficulties than boys, such as working harder to maintain classroom performance. As a result, they can better mitigate or mask the impact of their diagnosis. This is similar to how girls with autism “mask” their symptoms. At one time, it was theorized that autism was strictly a “boy disorder,” but of course that’s not the case. It’s a similar situation. Girls simply tend to adapt better. Even if they are hyperactive, girls are less likely to blurt things out in class or shove the kid next to them. This is where the social or societal aspect comes in. A girl that runs around and acts aggressively would be criticized more harshly by her peers. It’s much harder for girls to behave that way, to get away with it, so they tend not to.
All of these behaviors I’ve mentioned are signs of ADHD, but people react to them in different ways, for lots of reasons. Ultimately, not only are teachers and families less likely to notice signs of ADHD in girls, but they may even be more accepting of the signs girls often show. Parents and teachers either don’t notice girls’ inattentive behaviors and/ or seem to down play girls’ hyperactive and impulsive symptoms, while playing up those same types of behaviors in boys. Seems to be a much bigger issue when it’s a boy.
Since girls with ADHD often display fewer behavioral problems and have less noticeable symptoms, their difficulties are often overlooked and/ or mislabeled. Many times, the behaviors are wrongly attributed to anxiety or depression. Even when girls are properly diagnosed, it happens an average of five years later than boys. This can lead to serious problems in the future, as girls with undiagnosed and late diagnosed ADHD are more likely to have problems in school, social settings, and personal relationships than other girls. Research indicates that this can have a very negative impact on girls’ self-esteem, and can even affect their long term mental health. Boys with ADHD typically externalize their frustrations, but girls with ADHD usually turn their pain and anger inward- they tend to blame themselves- and this puts them at an increased risk for depression, anxiety, panic disorders, eating disorders, chronic sleep deprivation, and substance abuse. This doesn’t just impact them long term, as adults, these things can affect them even as they enter their teenage years.
Many late diagnosed adult women with ADHD show symptoms similar to those found in post-traumatic stress disorder, PTSD, where the coexisting panic and anxiety are the result of the classroom trauma they experienced during childhood from the undiagnosed ADHD. For example, if the woman dealt with low self-esteem from attention problems back in grade school, returning to school later in life may trigger those same emotions. Some women aren’t diagnosed until much later in life, around their 30s and 40s, when one of their children is diagnosed with ADHD. This happens more than you’d imagine… when undergoing the process with their children, they recognize the symptoms in themselves. Being diagnosed much later in life can lead to problems, such as the woman blaming herself for things going wrong, or believing that she cannot achieve higher goals, especially if her symptoms interfered in her school or work performance. Studies have indicated that these women are prone to financial problems, underemployment, divorce, and/ or lack of education. It’s a sad situation, and they blame themselves, as though at age seven they should’ve known they had ADHD. That’s why it’s important that everyone recognize the signs in girls and boys.
Recognizing ADHD in Girls
As I mentioned above, girls with ADHD often display the inattentive aspects of the disorder, whereas boys usually show the hyperactive characteristics. These hyperactive behaviors are easy to identify at home and in the classroom, as the child usually can’t sit still and behaves in an impulsive or dangerous manner. The inattentive behaviors are generally more subtle and can be difficult to spot. That child is unlikely to be disruptive in class, but they will miss assignments, will be forgetful, or just seem “spacey,” and this can be mistaken for laziness or even a learning disability. It’s important to know about the different ways kids can act out, and which behaviors tend to get overlooked. That awareness can help girls with ADHD get the help they need sooner, and that definitely makes for a better long term outcome.
Girls’ symptoms typically include:
-Inattentiveness or a tendency to “daydream”
-Appearing not to listen
-Verbal aggression, such as teasing, taunting, or name calling
-Difficulty with academic achievement
Recognizing ADHD in Boys
Though ADHD is often underdiagnosed in girls, it can be missed in boys as well. Traditionally, boys are seen as energetic, so if they run around and act out, it may be dismissed as simply “boys being boys.” But it’s a mistake to assume that all boys with ADHD are hyperactive or impulsive; some boys display the inattentive aspects of the disorder, and they may not be diagnosed because they aren’t physically disruptive.
Boys with ADHD tend to display the symptoms that most people think of when they imagine ADHD behavior. These include:
-Impulsivity or “acting out”
-Hyperactivity, such as running and hitting
-Lack of focus, including inattentiveness
-Inability to sit still
-Frequently interrupting other peoples’ conversations and activities
While the symptoms of ADHD may present differently in boys and girls, it’s critical for them to be treated. While the symptoms of ADHD usually lessen with age, they still tend to have adverse effects. People with ADHD often struggle with school, work, and relationships- even as adults- and they’re also more likely to develop other conditions, including anxiety, depression, and learning disabilities. If you suspect your child has ADHD, take them to a doctor for an evaluation as soon as possible. Getting a prompt diagnosis and treatment will not only improve symptoms, but it can also help prevent other disorders from developing in the future.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
The Dark Side of ADHD, part deux
Hello, people, welcome back to the blog! Hope everyone had a great weekend. Last week, we started a series on the dark side of ADHD. Squirrel!! If you don’t get that, check out last week’s blog. This week, we’re going to continue the discussion, but we’re going to focus on what it’s like to have ADHD, from that person’s perspective. I’ve made a little list of things patients have told me, and I want to share that, because they tell it best; far better than I can.
First, I just want to bust a couple more myths. Someone asked me about sugar causing ADHD, and that really put a bug in my bonnet about myths and misconceptions. There’s still so much misinformation out there, so I want to stamp it out.
“ADHD is a learning disability.”
Wrong. ADHD symptoms can definitely get in the way of learning, but they don’t cause difficulty in specific skills like reading, writing, and math, as a true learning disability does. That said, some people can have ADHD and a learning disability, but it is not one itself. Now, just because ADHD isn’t a learning disability doesn’t mean that kids can’t get help in school. And for that matter, adults with ADHD can often get support at work as well.
“People with ADHD can’t ever focus.”
Wrong. While it’s true that people with ADHD can have trouble focusing, they can actually experience hyperfocus. If they’re very interested in something, they may focus on it very intensely, to the exclusion of everything else, even to the point that they cannot pull themselves away. That’s hyperfocus. Some kids with ADHD are very easily distracted in class but a bomb could go off when they’re playing a video game, and it wouldn’t faze them. Adults might have trouble focusing on the parts of work they find boring, but they totally pour themselves into the aspects they really enjoy.
“People with ADHD would be more successful if they tried harder.”
Wrong. ADHD isn’t an issue of laziness or lack of motivation. A person is considered lazy if they have the ability or capacity to do something, but they just don’t want to exert the effort to do it. People with ADHD are often trying as hard as they can to focus and pay attention, and they exert as much effort to get things done as those without it- and often more- but their condition keeps them from getting to the finish line because they’re so easily distracted along the way. They’ll eventually get there, it just may take a little longer. And btw, telling someone with ADHD to “just focus” is like asking someone who’s nearsighted to just see farther. It doesn’t fly. If they could, they would. The reason they struggle with attention has nothing to do with attitude… it’s due to differences in the way their brain is structured and how it functions.
“People with ADHD aren’t smart.”
Wrong. ADHD isn’t related to lower IQ. People with ADHD may be perceived to have lower intelligence because they work differently than everyone else. But the truth is, most people with ADHD are highly intelligent and creative… even more creative than their non-ADHD counterparts. They’re also more intuitive thinkers and better at managing crises. Tell Albert Einstein (yes, the theoretical physicist) that people with ADHD aren’t smart. Or Sir Richard Branson, the billionaire business mogul. Or John F. Kennedy, the 35th president of the United States. Or actor/producer/rapper Will Smith. Or actor/comedian/producer Jim Carrey. Or Michael Jordan, the greatest basketball player of all time. They all seem to do just fine. People with ADHD aren’t dumb, and kids with ADHD can grow up and be just as successful as anyone else. The factors that contribute to the success of a child with ADHD are mostly related to how their parents and teachers react. If they take the time to understand what’s going on, embrace the learning process, and help the child find ways to manage it, they greatly increase that child’s chances of success.
So what’s it like to have ADHD? Here’s what I’ve been told…
It’s rarely feeling like you really enjoy anything, because you’re always so distracted by something else.
It’s constantly coming up with great ideas, but failing to focus or work efficiently on any one of them long enough to make it a reality.
It’s knowing how long it takes to get ready in the morning, but not being able to tell how quickly time is passing until you’re already late.
It’s being able to note every single detail of a classroom, but being unable to pay attention to the one thing you’re supposed to be looking at.
It’s struggling in every aspect of your life, but feeling that other people don’t recognize your suffering as a legitimate disorder.
It’s feeling exhausted at the end of a hectic day, but too overwhelmed with thoughts to actually fall asleep.
It’s having a conversation in a public place and hearing every noise around you… except for the voice you’re supposed to listen to.
It’s being barely focused on everything around you, or so hyperfocused on one thing that the world around you ceases to exist.
It’s hearing all the instructions, but not being able to hold them in your brain long enough to actually use them.
It’s remembering that you always need your phone, keys, and wallet before you leave the house, but still having to play hide and seek for them every single time.
It’s knowing you need to switch to another task on your to-do list, but being too hyperfocused on what you’re doing to disengage from it.
It’s being completely bored with what’s in front of you, but totally restless and jittery with excitement about all the abstract thoughts circling in your head.
It’s always trying to do too many things at once, and not multitasking efficiently enough to finish any one of them.
It’s believing you can succeed in your career, while also fearing that your ADHD will cause you to fail.
It’s knowing you need to reach a long-term goal, but lacking the planning strategies to take the right short-term steps to get there.
It’s wanting to control your intense emotions, but not realizing you need to until after you’ve had the uncontrollable outburst.
It’s having a brilliant answer to a question in the back of your head, but taking too long to communicate it, so someone else answers.
It’s knowing you’re smart, but feeling stupid all the time, because you have trouble putting your thoughts into words.
It’s knowing that you shouldn’t interrupt someone, but not being able to stop yourself from speaking out loud.
It’s working twice as hard for twice as long as everyone else, but to get just half as much done.
It’s knowing that you need a particular environment to be productive, but not wanting to ask for special accommodations.
It’s being excited to make plans with someone you love, but forgetting about them because you didn’t write them down.
It’s being focused on everything and nothing at all, which makes it feel like you’ll never get anything done.
It’s wanting to take control of your life and achieve your dreams, but feeling like ADHD will always have control over you.
As you can imagine, ADHD can cause a great deal of frustration. People can feel hopeless at times, and feeling misunderstood makes it that much worse. Misconceptions propagate in silence, and ultimately can prevent people from seeking help. By taking the time to learn more about ADHD, you’re already making an effort to beat that, so be sure to share what you’ve learned.
That’s a good place to stop for this week. Next week, we’ll talk about gender differences in ADHD. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
The Dark Side of ADHD
Hello, people, welcome back to the blog! Last week, I told you all about SAD, seasonal affective disorder, a depressive disorder that exhibits a seasonal pattern, usually late fall through spring, though it can have a spring/ summer pattern. I thought it was timely, since we were approaching its usual start point; symptoms seem to begin shortly after we “fall back” and winter arrives. Speaking of which, we had our first hint of winter this weekend- or at least what passes for winter here in SoFla- as temps dipped below 60 late Saturday night…. brrrrr! Sunday was kind of gray outside, but temps were really nice. Anyhoo, this week, I’m starting a new series on the dark side of ADHD, attention deficit hyperactivity disorder.
When you think about ADHD, you probably think of a 9 year old boy running around in circles, laughing his head off, totally out of control. While that certainly can be the case, the real faces of ADHD may surprise you. Think of your boss, your mail carrier, or your kid’s teacher… anyone has the potential to have ADHD, even if you don’t see what you think of as the classic symptoms. What most people know about ADHD comes from pop culture… they hear ADHD and think of that 9 year old boy, or maybe Dug the talking dog from the movie Up. Remember him? He couldn’t even complete a sentence without being distracted by an imaginary squirrel. Squirrel!! It was funny, right? Squirrel!! Maybe you’ve made a joke about being ‘sooo totally ADHD’ after you’ve gotten distracted and lost your train of thought? Hey, you’ve got to have a sense of humor to get through this life, and psych disorders sometimes make easy punchlines. But ADHD is a real disorder, and it affects real people in real ways, so it’s important that you’re informed about it, that you understand it, as that’s the basis of empathy. Empathy is where it’s at, and that’s the true point of this blog, to understand what people with ADHD experience on the daily. That’s not to say we can’t laugh about it, because sometimes it’s funny. Squirrel!! But if you understand it, you’re much more likely to laugh with, and not at, and that’s the ultimate point here.
So, what is it? ADHD is a neurological disorder, typically characterized by difficulty in sustaining attention, a lack of impulse control, and impaired working memory. There are three forms of ADHD: inattentive, hyperactive-impulsive, and combined types. By the way, ADHD is the official, medical term for the condition, regardless of whether a patient demonstrates symptoms of hyperactivity. We used to call that condition, having an attention deficit but without hyperactivity, ADD- actually some people still do- but that’s now technically considered to be an outdated term for describing inattentive type ADHD. So they’re all called ADHD now, no more ADD, and just the type or form varies. Inattentive type ADHD is characterized by a lack of attention to details, an inability to follow or remember instructions, and getting distracted easily. Hyperactive-impulsive type is marked by the stereotypical symptoms, things like fidgeting, running around, and talking too much. And shockingly, combined type is a combination of inattentive and hyperactive-impulsive ADHD types, and people with this type can exhibit both types of symptoms. Regardless of type, ADHD symptoms impact every aspect of a person’s life, and can seriously limit a person’s ability to study or work, and this can lead to stress, anxiety, and depression.
Prevalence statistics for ADHD vary widely, but it’s considered the most common childhood neurodevelopmental disorder. The symptoms of ADHD typically first appear between the ages of 3 and 6, and the average age of diagnosis is 7 years old. Squirrel!! According to the American Psychiatric Association, 5 percent of American children (ages 4 to 17) have ADHD, but the Centers for Disease Control and Prevention puts the number at more than double that, stating that 11 percent of American children carry the diagnosis. In my opinion, the actual number is closer to the CDC’s statistic, but may actually be higher still. And contrary to what some people believe, ADHD isn’t just a childhood disorder. Today, about 4 percent of American adults over the age of 18 deal with ADHD on a daily basis.
People with ADHD experience hyperactivity, impulsivity, and inattention in varying degrees. Not everyone with ADHD is noisy and disruptive. A child may be quiet in class, for example, while facing severe challenges that they do not express. The effects of ADHD features vary widely from person to person and even within a person, as they may find that their experience of ADHD changes over time. Squirrel!! Features and behaviors also seem to vary by gender; females with ADHD tend to have more difficulty paying attention, while males tend to have more hyperactivity and impulsivity. Depending on the type a person has, ADHD will have a predominantly inattentive presentation, a predominantly hyperactive and impulsive presentation, or a combined presentation that includes both types of behaviors.
This can manifest in innumerable ways, many you might not even realize unless you experience them. Some behaviors related to inattention might include daydreaming, being easily distracted, squirrel!, having difficulty focusing on tasks, making “careless” mistakes, appearing to not listen while others are talking, being late, having difficulty with time management and organization, difficulty completing projects, frequently losing everyday items, avoiding tasks that need prolonged focus and thought, and difficulty following instructions.
Hyperactivity and Impulsivity
Hyperactivity presents in any number of ways, and can vary widely, especially depending on the person’s age. In children, impulsivity often presents as conduct issues, so we think of a child “running amok” around a classroom. With age, overt behavioral symptoms usually become less conspicuous, as adults have generally learned to restrain themselves from these telltale behaviors. But they may manifest conduct issues in other ways, like blurting out things they didn’t mean to say. Some other behaviors related to hyperactivity and impulsivity include restlessness, the person seeming to be unable to sit still, being constantly “on-the-go,” running or climbing at inappropriate times, having difficulty taking turns in conversations and activities, constantly fidgeting or tapping the hands or feet, excessive talking and/or noise making, workaholism, and taking unnecessary risks.
Causes and Risk Factors
We don’t know exactly what causes ADHD, but we do know that a large component is genetic. About 85% of people diagnosed with ADHD have someone in their family who also has it. We have identified some risk factors, and these include brain injury, fetal exposure to stress, alcohol, or tobacco during pregnancy, fetal exposure to environmental toxins during pregnancy, or from a young age, low birth weight, and preterm birth. Diet may play a role, and some factors are random, just down to an individual brain’s wiring.
One question that’s asked a lot is if kids can outgrow ADHD. The answer is yes, but it rarely happens. That said, at one time, it was suggested that up to 40 percent of children outgrow their diagnosis, but recent research has proven this is wrong. Unfortunately, fewer than 10 percent actually outgrow it; the rest still meet the clinical definition of the disorder. Generally, what actually happens is that the presentation of symptoms changes as the person ages, but the underlying disorder remains. As the person matures and enters adulthood, overt behavioral symptoms usually become less conspicuous, and excessive motor activity becomes less common. Squirrel!! Hyperactivity is usually changed from being an external behavior to an internal state, so it can appear to others that the person’s ADHD has gone away, along with its most obvious symptom. But in reality, only the presentation has changed.
In other words, a 35 year old can’t get away with the same behavior that a 9 year old can, so instead of being a 9 year old running around willy nilly, laughing maniacally, the now 35 year old has an inner restlessness, and channels that into something else, like becoming a workaholic or an adrenaline junkie. Many adults with ADHD become workaholics, they like to keep their brains in overdrive. ADHD symptoms can also change for the better depending on stress levels, environment, and the amount of support a person receives. For example, establishing a routine and having understanding family members, friends, co-workers, and colleagues that can assist or help compensate for certain issues as needed are two ways to make symptoms seemingly decrease or disappear. In addition, the person may develop coping skills that address their symptoms well enough to prevent ADHD from interfering with their daily lives. Some do it so well that it appears as though they’ve outgrown it, but in reality, they’ve found working solutions. It’s sort of like watching a duck on a pond. Or maybe a squirrel! The duck looks still and serene on the surface, everything under control, but beneath the water, its little feet are paddling furiously.
I’ve seen many patients create their own little systems and methods to cope and compensate for their symptoms, to varying levels of success. I remember an ADHD patient that was very forgetful and terrible with time management especially. She had alarm clocks set to go off to remind her to set other alarm clocks, and her life was all color coded post its in strategic places to remind her to do whichever thing. I couldn’t understand it to save my life, much less keep up with it, but it worked for her. Pretty darn well, actually. But if the batteries in one alarm clock died- this was years ago, when people used alarm clocks, and they were radios too, imagine that- her entire life unraveled. She would get behind and it was like dominoes. But if her alarm clocks went off properly and her post its didn’tblow away, you’d be hard pressed to know she had ADHD. On the surface, she looked like she had it all under control, no problem, but below, her feet were constantly paddling, she was working overtime to keep it all together.
The term “attention deficit hyperactivity disorder” wasn’t used in medicine until the 1980s, although symptoms of the disorder were discussed in the early 1900’s. Back then, the diagnosis was typically thought to relate to the child having family members with psychiatric disorders, or the result of poor parenting. Squirrel! Strangely enough, some of these myths and stereotypes persist even today. We’ve busted some of those today, and next week, we’ll talk about what it’s really like to have ADHD, how it affects someone’s day to day life.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Hello, people… welcome back to the blog! Last week, we finished our two part series on phobias, and it seems everyone enjoyed it. I got a lot of great feedback on it, and people have been sharing their weird phobias with me even more than ever… I’ve really added to my list of doozies! This week, I wanted to talk about a topic I ran into recently, seasonal affective disorder, or SAD.
What is SAD? In the shrink bible, the DSM-5, it’s identified as a type of mood disorder. It’s not a standalone, but is specified as a major depressive disorder with a seasonal pattern, meaning that it happens every year at the same time, typically starting in fall or early winter and ending in spring or early summer. Because of this, some people call SAD the “winter blues,” but this is misleading, as there is a rarer form of seasonal depression known as “summer depression” that begins in late spring or early summer and ends in fall. And while the two types obviously share many symptoms, interestingly, their profiles are slightly different. More on that in a moment.
First, let’s talk statistics. In the United States, the percentage of the population affected by SAD is about 5%, but varies widely based on geographical location, from 1.4% of the population in Florida, to 9.9% in Alaska. This should give you a clue about one of the main factors associated with SAD, the amount of available sunlight. SAD may begin at any age, but it typically starts between the ages of 18 and 30, and as with other types of depression, SAD is much more common in women; they are three times more likely to be affected than men.
Calling SAD the “winter blues” makes it sound like no big deal, but people with SAD experience serious depression- the mood changes and symptoms are very similar to chronic depression- and these symptoms can have a major impact on their lives for 40% of the year, as symptoms usually occur during the fall and winter months and typically improve with the arrival of spring, with January and February being the most difficult months in the US. While temporary, SAD symptoms can be overwhelming, and in some cases, it can seriously interfere with daily functioning. Thankfully, it can be treated, and that’s why I decided to cover this topic. Recognizing the disorder is very important because it can cause such serious psychosocial impairment, but it’s not just important to recognize it… getting help is key, because acute treatment can be very effective, and maintenance treatment can actually prevent future episodes.
People with SAD experience mood changes and symptoms similar to depression, and these can vary from mild to severe. Everybody gets bummed out from time to time, those everyday feelings of sadness or fatigue brought on by life’s ups and downs- even during the holidays- but depression is a different animal.
Seasonal depression is marked by some specific symptoms, and these may include:
-Sleeping more than usual and still feeling drowsy and fatigued during the day
-Loss of interest in activities that once brought you joy
-Increase in purposeless physical activity, like pacing and hand wringing; an inability to sit still
-Slowed movements or speech, severe enough to be observable by others
-Feeling irritable and anxious
-Feeling guilty, worthless, hopeless, sad, tearful
-Desire to isolate, not wanting to see people
-Difficulty thinking, concentrating, or making decisions
-Increased appetite, overeating, and weight gain
-Cravings for carbohydrates
-Physical symptoms, such as headaches
-Thoughts of suicide or death
Clearly you don’t have to have every one of these to have SAD, and as with anything else, symptoms occur on a spectrum. Some people with SAD have mild symptoms and basically feel out of sorts or cranky, while others have symptoms that totally interfere with relationships and work. As I mentioned earlier, spring and summer SAD is much less common, but still occurs. The symptom profile is a little different; instead of people eating their way through it as a result of increased appetite, it’s difficult to get summer SAD people to eat at all, as they tend to have zero appetite. In my experience, it also seems to feature more agitation, almost manic type behavior.
What causes SAD? Like so many disorders, the cause isn’t completely understood, but we know that the body uses sunlight to regulate sleep, appetite, and mood. It’s believed that the decreased sunlight in the fall and winter months disrupt the body’s circadian rhythm. Lower light levels in winter disrupt the body clock, leading to depression and tiredness. As seasons change, people already naturally experience a shift in their biological internal clock that can cause them to be out of step with their daily schedule, so people may be more vulnerable during this time. The change in season, with shorter daylight hours, can lead to a biochemical imbalance in the brain, specifically in levels of serotonin and melatonin, two hormones that affect sleep and mood. SAD has been linked to this imbalance. There are risk factors involved as well. You’re more likely to develop SAD if you have an existing form of depression, or a relative with SAD or another form of depression. And Captain Obvious says that SAD is much more common in people living far from the equator where there are fewer daylight hours, so living somewhere where you expect months of darkness during the year isn’t the best plan if you have any of the risk factors.
The main feature of SAD is that your mood and behavior shift along with the calendar. So how do you know if you have it? If for the past 2 years, you:
-Had depression or mania that starts as well as ends during a specific season
-You didn’t feel these symptoms during your “normal” seasons
-Over your lifetime, you’ve had more seasons with depression or mania than without
I should note that sometimes it takes a while to diagnose SAD, because it can easily mimic so many other other conditions, like chronic fatigue syndrome, underactive thyroid, low blood sugar, viral illness, and/ or other mood disorders. If you suspect that you or a loved one may have it, the best course of action is to see a physician. There are online resources available as well, from the Center for Environmental Therapeutics, at cet.org. More on that at the end of this blog.
Clearly, you can’t stop the changing of the seasons, but there are some things you can do to combat SAD, including light therapy aka phototherapy, antidepressant medications, talk therapy aka cognitive behavioral therapy, or a combination of all three. Meds are usually brought in as adjuvants if light therapy is insufficient in reducing symptoms. Wellbutrin XL was the first drug approved specifically for SAD in the United States, and I’ve seen some success with it. Symptoms will generally improve on their own with the change of season, but it happens far more quickly with treatment. Treatment course differs depending on how severe your symptoms are, and of course, depending on whether you have another type of depression or bipolar disorder. For some people, simply increasing exposure to sunlight can help improve symptoms of SAD, and it’s recommended that people get outside early in the morning to get more natural light. If this is impossible because of the dark winter months, then phototherapy is key.
As I mentioned, light affects the biological clock in our brains that regulates our circadian rhythm, a physiological function that may induce mood changes when there’s less sunlight in winter. We know that natural or “full-spectrum” light can have an antidepressant effect. In phototherapy, you mimic that by sitting about 2 feet away from a light box, usually a 10,000-lux light box specifically, so that full spectrum bright light- about 20 times brighter than normal room lighting- shines directly upon you, but indirectly into your eyes. You do this for 15 minutes per day to start, and the times are increased as necessary with a max of 30 to 45 minutes a day, depending on your response. If using a weker lightbox, such as those that emit 2,500 lux, it will require much longer, about two hours of exposure per day.
Light therapy should be done in the early morning, upon waking, to maximize treatment response. Morning therapy also helps to specifically correct any sleep-wake cycle issues contributing to the symptoms. Please people, don’t look directly at the light source of any light box, to avoid possible damage to your eyes. I’ve heard of some practices that provide light boxes for patients with SAD. Again, the Center for Environmental Therapeutics has info on this. I’m sure you can also rent light boxes, and I know you can purchase them, but they’re expensive, and health insurance companies don’t usually cover them. But if you have SAD and live in a “dark” winter area, they can be worth their weight in gold.
Optimum dosing of light is crucial, since if done wrong it can produce no improvement, or partial improvement, and that can potentially lead to worsening of symptoms. I read some research that found that even a single, one hour light session can improve symptoms of depression in people with SAD. It varies; some people recover within days of using light therapy, most see some improvement within one or two weeks of beginning, but a few take longer. To maintain the benefits and prevent relapse, light treatment is usually continued through the winter, until you can be out in the sunshine again in the springtime. Because of the anticipated return of symptoms in late fall, I highly recommend that SAD patients begin phototherapy when fall first starts, even before feeling the effects of SAD. If the SAD symptoms don’t go away, your physician may increase light therapy sessions to twice daily. While side effects are minimal, be cautious if you have sensitive skin or a history of bipolar disorder. Common side effects of light therapy include headache, eyestrain, nausea, and agitation, but these effects are generally mild and transient, or disappear with reducing the dose of light.
Cognitive behavioral therapy or CBT can also be an effective treatment for SAD, particularly if it’s used in conjunction with light therapy and/ or medication. CBT involves identifying negative thought patterns that contribute to symptoms, and then replacing these thoughts with more positive ones. For many of my patients, I utilize all three modalities for treating SAD, as this has shown the most benefit.
… is worth a ton of cure in this case. So what can you do to avoid SAD?
Get out! Get as much natural sunlight as you can. Spend some time outside every day, even when it’s cloudy, as the effects of daylight still help. If it’s too cold out, let the sunshine in… open your blinds, and sit by a sunny window, even at work. If trees block the sunlight, trim them. I have a SAD patient that has her trees pruned way down in early fall so she can get as much light in the house as possible.
Eat a healthy, well-balanced diet. Our diets do more than provide us with energy, they also impact our mental health. A healthy diet rich in fruits and veggies and low in processed garbage can help curb feelings of depression by reducing inflammation in the body, which is a big risk factor for depression. Pass up all those sweet starchy “foods” in favor of lean proteins and veggies. This will help you have more energy, even if you’re craving carbs bigtime. If you recall the blog on Vitamin D, research has found that people with SAD often have low levels, so people with SAD are also often encouraged to increase their intake of Vitamin D through supplementation, in addition to diet and sunlight exposure.
Stay Active! Exercise is a great way to naturally combat the imbalance of brain neurotransmitters like serotonin, norepinephrine, and dopamine that can contribute to depression. When you exercise, your body produces endorphins, the mood boosting hormones that counteract serotonin and dopamine deficiencies that can bring you down. Exercise for 30 minutes a day, five times a week. That doesn’t have to mean you’re tied to the gym pumping iron all the time… Do something structured, but also pick an activity you enjoy and do it. Gardening, walking, dancing, and even playing with your kids can all be good forms of exercise.
Stay Connected! Social connections can be a great defense against depression. Whether you talk on the phone, video chat, or better yet, meet in person, keep in regular contact with friends and family for a healthy and happy mind. Experiencing depression of any kind isn’t a sign of weakness and shouldn’t be dealt with alone. Social support is very important, so stay involved with your social circle and regular activities. If you’re experiencing symptoms of depression that keep you in, seek help. Ask your physician what treatment options are available.
When should you call your physician? If you feel depressed, fatigued, and cranky at the same time each year, if it seems to be seasonal in nature, you may have a form of SAD. Talk openly with your physician, and follow their recommendations for lifestyle changes and treatment.
The Center for Environmental Therapeutics, CET, is a non-profit organization that provides information and educational materials about SAD, along with free, downloadable self-assessment questionnaires and interpretation guides, to help you determine if you should seek professional advice. All of that can be found on their website, cet.org.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Freaky Phobias, part deux
Hello, people- I hope everyone had a great weekend! Last week, I introduced the subject of phobias, and we’ll continue that discussion today. Fear is an important evolutionary tool, allowing humans to survive dangerous encounters and develop appropriate responses to hazardous situations. But when fear becomes debilitating, when it becomes a greater threat than the actual person, place, or thing causing it, it has become a phobia. Phobias are a type of anxiety disorder where a person has a persistent, excessive, unrealistic fear of an object, person, animal, activity, or situation. That leaves the field pretty much wide open, and in fact, a person can have a phobia of almost anything. They’ll try very hard to avoid that thing, otherwise they’re basically forced to white knuckle through it with much anxiety and distress, potentially to the point that it produces physical symptoms like nausea and dizziness, and possibly even a panic attack.
Everyone has something they fear to some extent, and for most people, it doesn’t affect one’s quality of life. But for patients with diagnosable phobias, the level of fear and discomfort when confronted with specific objects or situations can be exceptional, and can significantly impact their daily life. Some phobias are very specific, so this limits the impact the phobia has. As an example, a person may only fear spiders and cats- meaning they have arachnophobia and ailurophobia- and so they live relatively free of anxiety simply by avoiding spiders and cats. But some phobias pose an issue in a wider variety of places and situations, so they affect people’s lives more drastically. For example, symptoms of acrophobia- the fear of heights- can be triggered by looking out the window of a high rise office building, by climbing a ladder, or by driving over a tall bridge, just to name a few. Because it comes into play in so many places and forms, acrophobia has a much greater impact on the person’s life, and it may influence or even dictate the person’s employment type, job location, driving route, recreational and social activities, and/ or home environment.
Cause and Risk Factors
There is always an argument about whether a particular psychological trait or symptom is genetic in origin or a product of one’s environment… the old “nature vs. nurture” debate. Most of the time, the proper answer is “both,” and in fact, that’s the case with phobias. The reasons why phobias develop aren’t fully understood, but research does indicate that both genetic and environmental factors play a role.
Specific phobias tend to begin in childhood, a time when developing brains are still learning appropriate ways to respond to the world around them, and phobias can start in any number of ways. A child may develop a phobia of dogs after being bitten by one, but there are many more subtle ways that a child’s brain can take in information that teaches them to fear something. For example, they could learn to fear a dog by watching a movie that features a scary dog, or by watching a family member respond in fear to a dog’s bark or presence. Ultimately, fear is easily passed from one person to the next, either through watching and learning, or through genetic inheritance.
Certain phobias have been clearly linked to a very bad first encounter with the feared object or situation, though researchers don’t know if this first encounter is required, or if phobias can simply occur in people who are more likely to have them. As to what makes a person more likely to have them, there is no phobia gene- it’s never that easy- but we know that when it comes to risk factors, there is a genetic component. Research and surveys indicate that individuals with a parent or a close relative suffering from a specific phobia are three times more likely to develop that same phobia. That said, more research is needed to elucidate the genes responsible for triggering these phobias.
In addition to a complex interplay of genetic and environmental factors, a person’s temperament can also contribute to risk of developing phobias. A negative affect, meaning a propensity to feel negative emotions such as disgust, anger, fear, or guilt, seems to increase the risk for a variety of anxiety disorders, including specific phobias. Behavioral inhibition, often due to parental overprotectiveness, especially in childhood, is another risk factor for phobia development. A history of physical and/ or sexual abuse also increases the likelihood of an individual developing a specific phobia.
Phobias can be debilitating, but fortunately, there are ways to treat them. One treatment method that’s used very successfully is exposure therapy. We’ve discussed this before in relation to OCD; it’s a type of cognitive behavioral therapy, aka CBT, whereby you are repeatedly presented with your phobic trigger in a controlled manner, and you challenge yourself to get through it. It’s done in the presence of a therapist, and they essentially talk you through it, discussing what you feel, why you feel it, what is happening, and what you fear may happen. Afterwards, there’s usually discussion about feared outcome versus actual outcome, and what thoughts helped you get through the exposure. It’s often done in stages, as opposed to jumping straight in the deep end. For example, let’s say you have an insect phobia; you might start by just thinking about an insect, then move to looking at a picture of one, and then maybe being close to one in a terrarium, and eventually, even holding a living one.
Anxiety reduction techniques may also be helpful in combating phobias, things like yoga, breathing exercises, meditation, and mindfulness. The ultimate goal is to be mindful of the trigger, as opposed to afraid of the trigger. Unfortunately, the majority of patients don’t seek treatment for phobias, and of those who do, many don’t follow through. As a result, only 20% percent of people recover completely from them; the majority of people experience a recurrence of their phobia, which is referred to as a relapse. Captain Obvious says if you have a phobia, your best bet is to get the help of a medical professional for treatment.
It might (but really shouldn’t) surprise you to hear that celebrities have phobias too. Just for funsies, here are a few I found while surfing the interwebs.
Tyra Banks has been very open about her long standing fear of dolphins. She doesn’t swim in the ocean, because she imagines them swimming near her and touching her legs.
Christina Ricci has a fear of indoor plants, botanophobia, and says that touching a dirty houseplant feels like torture.
Khloe Kardashian has a phobia of belly buttons. Her half sister Kendall Jenner revealed that she struggles with trypophobia, an aversion to the sight of holes. She says that pancakes, honeycomb, and lotus heads are too much for her to take.
Nicole Kidman has been deathly afraid of butterflies since childhood, and would do anything to avoid having to go through the front gate of her home if even one butterfly was sitting on it.
Jennifer Aniston has a serious fear of being underwater, due to a traumatic experience she had as a child.
Billy Bob Thornton has a fear of antiques; according to him “…old, mildewy French/English/Scottish stuff, dusty heavy drapes and big tables with carved lions’ heads…” creeps him out.
Oprah Winfrey has an intense dislike for chewing gum that goes back to her childhood days. Growing up poor, her grandmother used to try to save gum to chew more than once, so she put it on the bedpost, or stuck it on the cabinet for later. Apparently little Oprah used to bump into it, and it would rub up against her, and gross her out. Evidently, she even barred gum-chewing in her offices.
Kyra Sedgwick is apparently terrified of talking food. Her husband, Kevin Bacon, actually had to turn down an apparently lucrative offer to be featured in ads for M&M’s for fear that she would leave him.
Katie Holmes has a longtime fear of raccoons, and once barked at one in an effort to scare it away. It worked… it left, but her phobia stayed.
Jake Gyllenhaal developed a phobia of ostriches while filming “Prince of Persia: The Sands of Time” after the animal trainers warned him not to make any noise around them, because “they’ll tear out your eyes and rip out your heart.”
Helen Mirren has a fear of phones, and evidently never returns calls because the phone makes her so nervous.
One of Channing Tatum’s biggest fears is porcelain dolls. Yep, Magic Mike is afraid of dolls.
Tyrese Gibson has no problem performing stunts in action movies, but he won’t get near an owl for any amount of money.
Singer Adele has a serious fear of seagulls after a scary incident in her childhood, when one flew in and swiped an ice cream she was eating. Its claw scratched her shoulder, leaving physical- and emotional- scars.
Megan Fox can’t stand the feeling of dry paper, so when she reads through scripts, she constantly licks her finger to keep it wet.
Alfred Hitchcock lived with ovophobia, the fear of eggs. People who worked with him claimed cracking an egg made him gag, and he once told a reporter “…Have you ever seen anything more revolting than an egg yolk breaking and spilling its yellow liquid?”
Actor, producer, and musician Johnny Depp has a phobia hat trick- three phobias- clowns, spiders, and ghosts.
Sean “P. Diddy” Combs has a phobia of people with a long second toe, to the point that it influences his dating life. He must see the toe on the first date… it’s mandatory. He may not go for a kiss, but he’s definitely going to check out that second toe, to see if it’s too long.
Ellen Page has a phobia of tennis balls, and can’t even watch a tennis match on television.
Kristen Bell is afraid of pruney fingers, specifically the feeling of pruney fingers on normal skin, and even wears gloves when she goes in the water to avoid touching herself with her own pruney fingers.
Some fun phobia facts…
In the United States, approximately 19 million people suffer from various phobias, with varying levels of severity.
The prevalence of phobias is approximately 5% in children, 16% in teenagers, and 3% to 5% in adults.
Women are nearly twice as likely to be affected by a phobia as men are, but men are more likely to seek treatment for phobias.
Symptoms of phobias tend to begin in early to mid childhood, with the average age of onset being about 7 years old.
While specific phobias usually begin in childhood, their incidence peaks during midlife and old age.
Phobias can persist for several years, decades, or be present throughout one’s life in 10% to 30% of cases.
The presence of a phobia is strongly predictive for the onset of other anxiety, mood, and substance use disorders.
Specific phobias can and do affect people of all ages, backgrounds, and/ or socioeconomic classes.
A part of the brain called the amygdala is responsible for triggering specific phobias.
There are approximately 400 specific phobias, and new ones are added to the list as necessary. Some are rare, unusual, or downright weird. Here are a few of those.
Ablutophobia, fear of bathing
This phobia can sometimes be the result of a traumatic, water-related incident, especially if it involves bathing during juvenile years, though many sufferers will grow out of this phobia as they get older. This phobia can cause a great deal of social anxiety and friction as it can often result in unpleasant body odor.
Anatidaephobia, fear of being watched by a duck
This is funny, but it’s for real. People with this phobia fear that no matter where they are, or what they’re doing, a duck is watching them. Not a hen, not a rabbit, specifically a duck, like Daffy.
Arachibutyrophobia, fear of peanut butter sticking to the roof of your mouth.
While this may sound like a minor issue, this phobia likely stems from a fear of choking or inability to open one’s mouth. While some sufferers may be able to eat small amounts of peanut butter, especially if it’s not very sticky, many will not eat peanut butter at all for fear of it sticking to the roof of their mouth.
Arithmophobia, fear of math
While plenty of people hated math class, arithmophobia takes this anxiety to the next level. This phobia isn’t so much a fear of numbers or symbols, as it is a fear of being forced into a situation where one has to do math, especially if that person’s math skills are subpar.
Chirophobia, fear of hands
This phobia can be a fear of one’s own hands or another’s. This is often the result of a traumatic event like a severe hand injury, or a persistent condition like arthritis.
Chloephobia, fear of newspapers
This phobia is often connected to the touch, sound, and smell of newspaper. Sufferers may become anxious at the sound of a rustling newspaper, or from the smell of newspaper ink and paper.
Eisoptrophobia, fear of mirrors
Sometimes referred to as spectrophobia or catoptrophobia, sufferers are often unable to look at themselves in a mirror. In more severe cases, this anxiety can even extend to reflective surfaces like glass or standing water. One genesis of this phobia revolves around the superstitions tied to mirrors, the fear of seeing something supernatural or breaking a mirror and being cursed with bad luck. In other cases, this phobia can stem from low self-esteem and an aversion to seeing oneself.
Geniophobia, fear of chins
This one sounds a little unreal, because how can anyone fear a chin, but people with this phobia have an aversion to chins, and cannot interact or look at people whose chins bother them. It’s unclear if this is all chins or Jay Leno chins…
Genuphobia, fear of knees or kneeling
People who have this phobia have a fear of knees, their own and/ or someone else’s. This gives me flashbacks to confirmation classes, with all the kneeling, aka genuflecting.
Globophobia, fear of balloons
This phobia often originates from a traumatic event, often when a popping balloon causes a scare at a young age. Sufferers of this phobia can have varying levels of anxiety, with some casually avoiding balloons, while other, more severe cases are prohibited from being anywhere near a balloon. Globophobia is also often linked to the fear of clowns, coulrophobia.
Hippopotomonstrosesquipedaliophobia- I kid you not- is the phobia of long words. Of course a 15 syllable word represents this fear…can people with it even say what they’re afraid of? Hmmm…
Omphalophobia, fear of belly buttons
Just like Khloe Kardashian! Sufferers will often avoid areas like the beach, where exposed belly buttons are common. This phobia can be the result of a previous infection in the umbilicus, but can also just be random. In severe cases, sufferers may cover up their own belly button with tape or a bandaid. Interestingly, this phobia may be related to trypophobia, the fear of holes that Kendall Jenner, Khloe Kardashian’s half sister has… hello, genetics!
Optophobia, fear of opening your eyes
This phobia is generally the result of a traumatic event, especially during childhood. This phobia can be extremely debilitating, as sufferers will often avoid leaving their homes, and naturally seek out dark or dimly lit areas.
Nomophobia, fear of not having your cell phone
This is an anxiety that so many people feel to varying extents, but it becomes a phobia when the anxiety turns into a consistent fear or panic at the mere thought of being without a mobile phone. This phobia also extends to having a phone with a dead battery or being out of service, thereby making the phone unusable. Someone with nomophobia will feel intense anxiety if they have no phone signal, have run out of data or battery power, or even if their phone is out of sight. Nomophpia is often connected with an addiction to phones and the need to be constantly connected. A recent study showed that many people under the age of 30 check their phone at least once every 10 minutes- 96 times a day- so this is far more common than you can imagine.
Plutophobia, fear of wealth
This phobia deals less with the fear of physical monetary currency and more with the anxiety around wealth or being wealthy. Sufferers dread the responsibility and weight that accompanies wealth, and fear that they will be targeted for their wealth, and subsequently put into danger. They may even sabotage their career or money-making opportunities in an attempt to avoid feeling it.
Pogonophobia, fear of facial hair
This fear is often the result of a traumatic experience with someone who has significant facial hair or a beard. Beards also partially hide someone’s face, creating an additional layer of anxiety for those that struggle in social situations, or reading social cues. In more severe cases, a sufferer of pogonophobia may not even be able to look at a picture of someone with a beard.
Sanguivoriphobia, fear of vampires
Sufferers have a fear of vampires and blood eaters. In fact, the word literally translates to ‘fear of blood eaters’. At least people with this won’t have to sit through the torture of the Twilight movie series.
Somniphobia, fear of falling asleep
While some people just can’t do without their regular eight hours a night, sufferers of this phobia may associate going to bed with dying, or fear losing time while asleep.
Turophobia, fear of cheese
A fear of cheese can often be traced back to an incident with cheese, especially in early childhood. Being forced to eat cheese, especially when lactose intolerant, can create an aversion to, and anxiety towards, cheese. More severe cases can even result in fear just from the sight or smell of cheese.
Xanthophobia, fear of the color yellow
This is a difficult phobia to deal with, as some things in nature and many man made things are yellow. Sufferers may fear something seemingly benign like a flower, school bus, or wheel of cheese. This phobia could be an artifact, originating from survival-based evolution, as animals that are brightly colored, like frogs or snakes, are sometimes poisonous or venomous.
That’s a good place to end for this week, before everyone develops bibliophobia, the fear of reading! I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in officeand on Amazon.
Thank you and be well people!
Hello, people… welcome back to the blog! Last week, we finished a two part series on N-acetyl cysteine, the latest and greatest amino acid supplement that’s showing major promise in helping to treat some heavy hitting psych disorders, especially bipolar depression. This week, I want to talk about a very intriguing topic… phobias.
What is a phobia? A phobia is an irrational fear of something that’s unlikely to cause you any harm. I want to highlight the most important point here: irrational fear. Irrational, without rationale. What does that mean exactly? It generally means not thinking, but sometimes it means thinking, but without logic. So a phobia is when you’re afraid of something, often without even thinking about it, sometimes despite thinking about it- which just causes more anxiety btw- and the thing that you’re afraid of is usually nothing to be afraid of in the first place. But despite that fact, the fear can be intense. The word phobia comes from the Greek word phobos, which means fear or horror. Generally, the name of the phobia is a telling label, one basically made up as the need arises, typically by combining a Greek (or sometimes Latin) prefix that describes the phobia, along with the -phobia suffix. For example, the fear of water is named by combining hydro (water) and phobia (fear), so you end up with hydrophobia.
When someone has a phobia, they experience very intense fear of a certain object, thought, or situation. This fear is more extreme than fear in the normal everyday sense, and it develops when a person has an exaggerated or irrational perception of danger about a particular thing. But where’s the line? Being a little wary of spiders isn’t the same as being arachnophobic, right? And btw phobias aren’t always entirely irrational… some spiders ARE dangerous- they can kill you- so they should be avoided. But a phobia will assume that ALL spiders- even a teeny tiny harmless house spider- is a real threat. That’s how phobias are a little different than regular fears, because they cause significant distress, potentially enough to interfere with life at home, work, and/ or school. You’re afraid of serial killers, I’m afraid of serial killers, I imagine everyone is afraid of serial killers. Actually, are serial killers afraid of serial killers? Hmmm… don’t know. Anyway, is this a phobia? Not for most folks, but it sure is for some. What’s the difference? It has to do with interference. Why and how does that phobia, that thing, interfere with your life? Because people with phobias actively avoid the phobic object or situation- that’s another difference- they’ll do nearly anything to avoid it- or else they’ll just white knuckle through it with super intense fear and anxiety. Are you so afraid of serial killers that you avoid going to a nearly deserted truck stop diner at midnight, or so afraid of them that you refuse to leave your house… ever? If you’re the latter, you might have foniasophobia, fear of dying at the hands of a serial killer.
Ultimately, phobias are a type of anxiety disorder. Anxiety disorders are very, very common- I see them all day long- and they’re estimated to affect more than 30 percent of U.S. adults at some point in their lives. Specific phobias affect fewer people, with an estimated 12.5 percent of American adults experiencing one at some time in their lives. You can have a phobia without having a true anxiety disorder, and you can have an anxiety disorder without having a phobia, though I can’t think off the top of my head of a patient with a generalized anxiety disorder that hasn’t told me about a specific phobia, though I’m sure there are some.
In the shrink bible, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, aka the DSM-5, it outlines several of the most common phobias, and they typically fall within five general categories:
-Fears related to animals, like spiders, dogs, and insects
-Fears related to the natural environment, like heights, the dark, and thunder
-Fears related to blood, injury, or medical issues, like injections, blood draws, and medical catastrophes, like falls and broken bones
-Fears related to specific situations, like flying, riding in an elevator, being on an escalator, and driving over bridges
-Fears of other more random things like loud noises or choking
The thing is, these categories encompass an infinite number of specific objects and situations. A person can conceivably be afraid of anything they can physically do, think about, or feel. And let me tell you, I’ve heard some doozies. Some people are genuinely afraid of some weird stuff! Not even making fun… most of the time, they’ll even tell you it’s weird too. One of my patients that I’ve treated forever has a wind phobia, anemophobia, or sometimes called ancraophobia. Whatever it’s called, she hates wind… anything more than a light breeze is like nails on a chalkboard for her. What’s really wild is that this very specific, and fairly rare phobia appears to be genetic for her- it runs in her family- and she never even knew that until they all “hurricaned” together several years ago. She, her father, who evidently never really admitted it, and her aunt on her father’s side… all three of them were climbing the walls together during the hurricane. And apparently she always hated wind. As a kid, she would get up in the middle of the night… even if, maybe even especially, when it was storming… and hello, windy… and climb up on a barstool to take down her mom’s windchimes! Every one of them, and evidently she had a lot. Why? Because they drove her looney, listening to the wind blow them around… ding!! Ching ching bing!!! Ding ding da ding!!! She told me that they all made different noises, varying tones, high and low, and she said that every one of them just reminded her how bloody windy it was. For her mom, that sound was relaxing, but for her… not so much! Now, was she actually worried that the wind would blow her away, like Dorothy, off to Oz? Nope. She always knew that wouldn’t happen. She knew she was perfectly safe in her concrete block constructed house, but nonetheless, the wind made her beyond anxious. That, my friends, is a phobia. Totally irrational. And she’d tell you so herself.
Phobias come in all shapes and sizes, and because there really are an infinite number of objects and situations, the list of specific phobias is very, very long. Did you know that there’s even such a thing as a fear of fears? Phobophobia. How about that? And it’s actually more common than you might imagine. That’s one of the problems with fear, it often begets itself. If you have a panic attack because you go sailing in a 28 foot sloop in 12 foot seas, you may end up with not just a phobia about sailing, but a phobia of water and waves. And because the impact of the fear was so intense that it produced physical symptoms of a panic attack, you can even wind up with a phobia of having a panic attack. Yep, and you can be so afraid of having a panic attack that you can cause yourself to have one. Kid you not.
While there are potentially hundreds, maybe even thousands of different types of phobias, there are some that affect the population at much higher rates than others. Here are a few of the most commonly diagnosed phobias, along with some interesting points on each.
The fear of spiders, or arachnids, is possibly the most well-known of all phobias, and it’s estimated that arachnophobia affects roughly 1 in 3 women and 1 in 4 men.
Ophidiophobia is the fear of snakes. Interestingly, both ophidiophobia and arachnophobia are thought to be rooted in human evolution, meaning we evolved to fear these critters. It was a matter of survival, so humand learned it generation over generation, to the point it stuck in our DNA. Pretty amazing, no?
This is the fear of heights, which affects over 20 million people. Acrophobia can affect a person in a variety of situations, including air travel, crossing bridges, and even travelling up an escalator. It can be extremely limiting, because this fear in particular is frequently associated with anxiety attacks as well as avoidance of the phobia trigger, and this often prevents people with acrophobia from participating in activities that most of us take for granted.
This is the fear of dogs, and unfortunately, often stems from a personal traumatic experience in the patient’s past, maybe a bite or an attack. I’m a dog lover, and have never had a negative experience with a dog, so while I can’t understand it from an experiential standpoint, I have great empathy for people that are so afraid of dogs for whatever reason that they miss out on the love and companionship they can provide. Cynophobia is an interesting one to me, because it is one of the most commonly treated phobias. In fact, 36 percent of all patients who seek phobia treatment actually do so for cynophobia, which gives you an idea of how much it impacts their lives.
Social phobia involves fear centered around social situations and interactions. Among the most common symptoms of social phobia is fear of public speaking, but it can center on any number of situations, like starting conversations, speaking on the phone, meeting new people, speaking to authority figures, and even eating and drinking in front of others. Social phobia typically first appears during puberty, and it can be lifelong if not properly treated.
Agoraphobia is the fear of entering open or crowded places, of leaving one’s home, or of being in places or situations that trigger a feeling of helplessness, or where a quick escape would be difficult, such as being on public transportation, like an airplane. Agoraphobia is its own unique diagnosis, and is often associated with panic disorder and panic attacks; roughly one-third of patients with an existing panic disorder will also go on to develop agoraphobia as a comorbidity. Statistically, it’s more prevalent in women than men, with two-thirds of patients being female.
Speaking of being on airplanes, aerophobia is the fear of flying, and it affects an estimated 8 million people. Given today’s world of travel and transportation, this one can be particularly difficult to avoid, but it can be addressed with various techniques, like exposure therapy. More on that next week.
That’s a good place to stop. Next week, more on freaky phobias; among other things, we’ll talk about how to rid yourself of them. Because while you might assume that once a person gets to the other side of their phobia and knows they lived through it, that it would go away all by itself… you’d be wrong most of the time. Wah wah waaaah. We’re going to talk about just why the hell that is.
Thank you and be well people!
N-acetyl Cysteine… New Miracle for Bipolar?
Hello, people… hope everyone is well! In last week’s blog, I introduced you to N-acetyl cysteine, or NAC, an amino acid supplement that’s garnering some serious attention in shrinky circles, as it has shown major potential to help treat multiple psych conditions. Recall from last week that NAC is most renowned for its ability to replenish levels of the body’s strongest antioxidant, glutathione, while it also regulates the very important neurotransmitter, glutamate, acta as an anti-inflammatory, and assists the body’s detoxification system.
The rationale for administering NAC for psych conditions is based on those roles: being a precursor of glutathione, as well as its action as a modulating agent of glutamatergic, dopaminergic, neurotropic, and inflammatory pathways. Those are the mechanics of NAC, the how and why it’s beneficial for brain function: NAC helps to produce glutathione, which, being the chief free radical scavenger, takes up all those nasties, reducing cellular damage. NAC also acts as an anti-inflammatory, so it decreases the blood levels of molecules that cause inflammation in the body and brain, such as interleukin-6, which incidentally may play a role in the pathogenesis of schizophrenia, bipolar disorder, and depressed mood. A third mechanism of action that has been proposed for NAC involves the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine. Let’s talk about those two for a moment.
As the most abundant neurotransmitter in the brain and CNS, glutamate plays an important role during brain development, as well as helping with learning and memory. Glutamate is an excitatory neurotransmitter. What is that? Excitatory neurotransmitters have excitatory effects on the neuron, meaning that they increase the likelihood that the neuron will fire a signal- called an action potential- in the receiving neuron. Because neurotransmitters can increase action potential, you can then probably imagine why neurotransmitter levels are very important. At high concentrations, glutamate can overexcitenerve cells and cause more neuronal firing. Prolonged excitation is toxic to nerve cells, and causes damage over time. So having excess glutamate, as an excitatory neurotransmitter, causes more neuronal firing, and you can actually damage cells this way. In fact, you can excite cells to death… a process referred to as “excitotoxicity.” Having too much glutamate in the brain has been associated with neurological diseases such as Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, stroke, and ALS, amyotrophic lateral sclerosis or Lou Gehrig’s disease. Problems in making or using glutamate have also been linked to a number of mental health disorders, including autism, schizophrenia, depression, and obsessive-compulsive disorder, OCD. Glutamate is also a metabolic precursor for another neurotransmitter called GABA, gamma-aminobutyric acid. GABA is the main inhibitory neurotransmitter in the central nervous system- the flip-side of the coin- which decreases the likelihood that the neuron it acts upon will fire. That’s why glutamate is so important, it’s the dominant neurotransmitter used for neural circuit communication, and it’s estimated that well over half of all synapses in the brain release glutamate.
Dopamine is the “feel good” neurotransmitter that’s strongly associated with pleasure and reward. It’s a contributing factor in motor function, mood, and decision making, and is also associated with some movement and psychiatric disorders. Dopamine is released when your brain is expecting a reward; when you come to associate a certain activity with pleasure, just the anticipation alone can be enough to raise dopamine levels. It could be a specific food, sex, shopping, or just about anything else that you enjoy. If your go-to comfort food is homemade chocolate chip cookies, your brain may increase dopamine levels when you smell them baking or see them come out of the oven. Then when you eat them, the flood of dopamine you receive acts to reinforce the craving, causing you to focus on satisfying it in the future. Dopamine is all about the cycle of motivation, reward, and reinforcement. Now imagine that you’ve been jonesing for those cookies all day, but your co-workers scarfed them all down while you were sidetracked by a conference call. Your disappointment might well lower your dopamine levels and dampen your mood. It might also intensify your desire for chocolate chip cookies, making you want them even more. Dopamine plays the main role in all of that, but keep in mind that dopamine doesn’t act alone. It works with other neurotransmitters and hormones, things like serotonin and adrenaline. Aside from its “feel good” function, dopamine is involved in many body functions, including blood flow, digestion, memory and focus, mood and emotions, motor control, pain processing, sleep, stress response, heart and kidney function, pancreatic function, and insulin regulation. Once again, as with all neurotransmitters, levels are important… theright amount of dopamine generally equates to a good mood. Ultimately, dopamine contributes to feelings of alertness, focus, motivation, and happiness, and a flood of dopamine can produce temporary feelings of total euphoria.
Those mechanisms I mentioned- glutathione reducing cellular damage, anti-inflammatory action, and the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine- are the proposed how NAC works, but why does NAC help people with varying psych diagnoses? Why might it work across so many conditions? This is the most intriguing thing to me. First and foremost, it seems to target biological pathways that are common across many mental disorders. For example, we know that patients with bipolar disorder have significantly higher levels of oxidative stress, and higher glutamate concentrations in their brains, especially during acute mania. It’s been suggested that people with schizophrenia may have the same, and that this may predispose them to changes in neuronal cell membranes and mitochondrial function that later manifest as symptoms of schizophrenia. It appears that NAC supplementation, by increasing CNS glutamate levels and reducing overall oxidative stress, may reduce the severity of these psychotic symptoms.
A meta-analysis and systematic review of placebo-controlled studies on NAC as a stand-alone treatment of depressed mood in people diagnosed with major depressive disorder, bipolar disorder, and other psychiatric disorders, found evidence for “moderately improved” depressed mood and improved global functioning. In a four-month, double-blind study, individuals treated with NAC plus their usual antidepressant improved more than individuals taking a placebo with their antidepressant medication.
In a large, six-month, double-blind study, individuals with schizophrenia who had failed to respond to multiple trials on antipsychotics were treated with 1,000 mg NAC twice daily versus a placebo, while also taking their usual antipsychotic medication. Those taking NAC experienced moderate improvements in symptoms of apathy and social withdrawal, the so-called “negative” symptoms of schizophrenia, as well as improvements in day-to-day functioning, and fewer of the abnormal involuntary movements that are commonly caused by some antipsychotic meds.
NAC has also been investigated as a treatment for substance use disorders, with promising results. The findings of small, placebo-controlled studies suggest that NAC helped heavy Cannabis users to reduce their use, and that it may reduce the intensity of withdrawal and cravings in people in early stages of cocaine recovery. As in mood disorders, the beneficial effects of the NAC may be related to its role in restoring neurotransmitter activity that has been affected by chronic substance abuse.
In addition to its mood-enhancing benefits, there is evidence that NAC may reduce trichotillomania (compulsive hair pulling) and other impulse control disorders, like nail-biting, skin picking, and pathological gambling. There was one eight-week, open-label study on pathological gamblers, and over 80 percent of them responded to NAC. They were then subsequently enrolled in a six-week, placebo-controlled trial, and continued to report “significant reductions” in gambling.
As for potential treatment targets, a systematic review of all of the evidence suggests that NAC may be effective at treating major depressive disorder, bipolar disorder, drug addiction, obsessive-compulsive disorder, impulse control disorders, autism, schizophrenia, Alzheimer’s disease, and even certain forms of epilepsy, specifically progressive myoclonic seizures. NAC has also been shown to potentially reduce the severity of mild traumatic brain injury in soldiers, and animal studies show that it can improve cognition after moderate traumatic brain injury. Other disorders such as anxiety and ADHD have some interesting preliminary evidence, but require larger studies.
The jury’s still out as to the mechanism, whether NAC’s benefits are the result of glutathione reducing cellular damage, the anti-inflammatory action, or the actions on glutamate and dopamine. Even though we don’t know exactly why yet, on a clinical level, NAC seems to help with ruminations, the difficult to control, extreme negative self-thoughts. These thoughts are very common in depression and anxiety disorders, and also in eating disorders, schizophrenia, and OCD. NAC seems to help some patients when other modalities, even meds and psychotherapy, haven’t helped much. It doesn’t always work, but when it does, irrational thoughts seem to gradually decrease in intensity and frequency. Negative thoughts, like “I’m a bad person,” “Nobody likes me,” or ruminations about other people or other issues that can’t seem to be quieted by reasonable evidence to the contrary- those really pesky negative thoughts that keep intruding on someone’s awareness, hour after hour, day after day, despite all efforts to control them- seem to decrease with NAC. If they do continue to occur, they’re less distressing, and can be observed from more of a distance, and are less likely to trigger depression or other negative effects.
Overall, NAC seems pretty special. Its ability to successfully cross the blood-brain-barrier to increase CNS glutathione levels, while reducing glutamate and overall oxidative stress, in addition to its anti-inflammatory properties- all conditions linked to depression and other mental health disorders- makes it an interesting treatment candidate for many psych conditions. If you take NAC, you’re basically giving your body an efficient way to soak up excess glutamate, an excitatory neurotransmitter that’s not good in excess concentrations. You’re also reducing oxidative stress and inflammation by giving it glutathione. As a result, this seems to help alleviate a number of different mental health conditions: depressed mood, schizophrenia, impulse control disorders, and substance use disorders. Studies indicate that people benefit from taking anywhere between 250 mg to 500 mg daily. Lower doses are better because high doses of NAC can sometimes redistribute heavy metals into the brain… this is not a good thing, so you obviously want to avoid that. You can take NAC with leucine, another amino acid, as taking leucine with it prevents mercury from being reabsorbed into the central nervous system. As always, please bear in mind that large placebo-controlled studies are needed to confirm the beneficial effects of NAC in mental health care, and to determine safe, optimal dosages for standalone or adjunctive treatment. But if you think it might be helpful, talk to your physician to determine if NAC is a good supplement choice for you.
Thank you and be well people!
Hello, people! Last week, we finished up our discussion on the darker side of OCD and talked about the most difficult subtype to deal with, the pure hell of pure obsession OCD, aka Pure O. As promised, we’re back this week with a new topic, N-acetyl Cysteine, or NAC. NAC is an amino acid used by the body to build antioxidants. Antioxidants are vitamins, minerals, and other nutrients that protect and repair the body’s cells from damage, usually referred to as oxidative stress. Historically, NAC has been used mainly in emergency rooms to treat people who overdose on acetaminophen… I’ve ordered it innumerable times for this very purpose. These days, it can be purchased as a supplement OTC, and new studies have begun investigating its effectiveness as both a stand-alone and adjunctive treatment for depressed mood associated with depression, bipolar disorder, schizophrenia, OCD, and trichotillomania, as well as abuse and dependence on nicotine, Cannabis, and cocaine. And it has shown some promising results.
Before we get to that, let’s talk about some things NAC does in the body.
1. NAC is essential for making the body’s most powerful antioxidant, glutathione. Along with two other amino acids- glutamine and glycine- NAC is needed to make and replenish glutathione, which helps neutralize free radicals that can cause oxidative stress- damage to cells and tissues in your body. It’s essential for immune health and for fighting cellular damage, and some researchers believe it may even contribute to longevity. Its antioxidant properties are also important for combatting numerous other ailments caused by oxidative stress, such as heart disease, infertility, and some psychiatric conditions. More on those later.
2. NAC helps detoxify the body to prevent or diminish kidney and liver damage, helping to prevent deleterious side effects of drugs and environmental toxins. This is why doctors regularly give intravenous NAC to people with acetaminophen overdose. It’s usually organ failure that gets you in acetaminophen overdose, and NAC helps to prevent or reduce damage to the kidneys and liver, increasing the chances of survival. NAC also has applications for other liver diseases due to its antioxidant and anti-inflammatory benefits.
3. NAC helps regulate levels of glutamate, the most important neurotransmitter in your brain, and this may improve some psych disorders and addictive behavior. While glutamate is required for normal brain function, excess glutamate paired with glutathione depletion can cause brain damage. This state- excess glutamate with glutathione depletion- is commonly seen in certain psych disorders; specifically, it’s thought to contribute to bipolar disorder, schizophrenia, obsessive-compulsive disorder, and addictive behavior.
For people with bipolar disease and depression, NAC may help decrease symptoms and improve overall ability to function, and research suggests that it may also play a role in treating moderate to severe OCD. In addition, an animal study implied that NAC may minimize the so-called negative effects of schizophrenia, such as social withdrawal, apathy, and reduced attention span. NAC supplements can also help decrease withdrawal symptoms and prevent relapse in cocaine addicts, and preliminary studies show that NAC may decrease marijuana and nicotine use and cravings. Many of these disorders currently have limited or ineffective treatment options, so NAC may be an effective option for individuals with these conditions. More on this in a moment.
4. NAC can help relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in the air passageways. As an antioxidant, NAC helps replenish glutathione levels in your lungs, and reduces inflammation in the bronchial tubes and lung tissue. People with chronic obstructive pulmonary disease (COPD) experience long-term oxidative damage and inflammation of lung tissue, which causes airways to constrict, leading to shortness of breath and coughing. NAC supplements have been used to improve these COPD symptoms, leading to fewer exacerbations and less overall lung decline. In a one-year study, 600 mg of NAC twice a day significantly improved lung function and symptoms in people with stable COPD. But those with chronic bronchitis can also benefit from NAC. Bronchitis is the term for when the mucous membranes in your lungs’ bronchial passageways become inflamed, restricting airflow to the lungs. Not much fun. By thinning the mucus in the bronchial tubes, while also boosting glutathione levels, NAC may help decrease the severity and frequency of wheezing and coughing in respiratory attacks. In addition to relieving COPD and bronchitis, NAC may improve other lung and respiratory tract conditions like cystic fibrosis, asthma, and pulmonary fibrosis, as well as symptoms of garden variety nasal and sinus congestion due to allergies or infections. Ultimately, NAC’s antioxidant and expectorant capacity can improve lung function in everyone by decreasing inflammation and breaking up and clearing out mucus.
5. NAC boosts brain health by regulating glutamate and replenishing glutathione. The neurotransmitter glutamate is involved in a broad range of learning, behavior, and memory actions, while the antioxidant glutathione helps reduce oxidative damage to brain cells associated with aging. Glutamate levels are subject to the three bears law: you need some, but too much isn’t good, as it’s an excitatory neurotransmitter. Because NAC helps regulate glutamate levels and replenish glutathione, it may benefit those with brain and memory ailments. The neurological disorder Alzheimer’s disease slows down a person’s learning and memory capacity, and animal studies suggest that NAC may slow the loss of cognitive ability in people with it. Another brain condition, Parkinson’s disease, is characterized by the deterioration of cells that generate the neurotransmitter dopamine. Oxidative damage to cells, and a decrease in antioxidant ability, contribute to this disease, and NAC supplements appear to improve dopamine function as well as disease symptoms, such as tremor.
6. NAC may improve fertility in both men and women. Approximately 15% of all couples trying to conceive are affected by infertility, and in nearly half of these cases, male infertility is the main contributing factor. Many male infertility issues increase when antioxidant levels are insufficient to combat free radical formation in the male reproductive system, leading to oxidative stress and cell death, culminating in reduced fertility. In some cases, NAC has been shown to combat this, improving male fertility. One condition that contributes to male infertility is varicocele. This is when veins inside the scrotum become enlarged due to free radical damage; surgery is currently the primary treatment. In one study, 35 men with varicocele were given 600 mg of NAC per day for three months post-surgery. The combination of surgery and NAC supplement improved semen integrity and partner pregnancy rate by 22% as compared to the control group with surgery alone. Another study in 468 men with infertility found that supplementing with 600 mg of NAC and 200 mcg of selenium for 26 weeks improved semen quality. Researchers suggested that this combined NAC/ selenium supplement should be considered as a treatment option for male infertility. In addition, NAC may improve fertility in women with polycystic ovary syndrome (PCOS) by inducing or augmenting the ovulation cycle which is altered by the condition.
7. NAC may stabilize blood sugar by decreasing inflammation in fat cells. High blood sugar and obesity contribute to inflammation in fat tissue. This can lead to damage or destruction of insulin receptors, which puts you at a much higher risk of type 2 diabetes. When insulin receptors are intact and healthy, they properly remove sugar from your blood, keeping levels within normal limits. When the insulin receptors are damaged, blood sugar levels are more difficult to control. Animal studies show that NAC may stabilize blood sugar by decreasing inflammation in fat cells, keeping receptors happy, and thereby improving insulin resistance. That said, human research on NAC is needed to confirm these effects on blood sugar control.
8. NAC may reduce heart disease risk by preventing oxidative damage. Oxidative damage is caused by free radicals, and this type of damage to heart tissue often leads to heart disease, causing strokes, heart attacks, and other serious cardiovascular conditions.
NAC may reduce heart disease risk by reducing oxidative damage to tissues in the heart. It has also been shown to increase nitric oxide production, which helps veins dilate, improving blood flow. This expedites circulation and blood transit back to your heart, and this can lower the risk of heart attack. Interestingly, a test-tube study showed that when combined with green tea, another well recognized antioxidant, NAC appears to reduce damage from oxidized “bad” LDL cholesterol, another bigtime contributor to heart disease.
9. NAC and its ability to boost glutathione levels appears to increase immune function, boosting immune health. Research on certain diseases associated with NAC and glutathione deficiency suggests that immune function might be improved, and potentially even restored, by supplementing with NAC.
This has been studied mostly in people with human immunodeficiency virus (HIV). In two studies, supplementing with NAC resulted in a significant increase in immune function, with an almost complete restoration of natural killer cells, the main patrol cells. High levels of NAC in the body may also suppress HIV-1 reproduction. A test-tube study indicated that in other immune-compromised situations, such as the flu, NAC may hamper the virus’s ability to replicate; this could potentially reduce the symptoms and lifespan of the associated viral illness. Other test-tube studies have similarly linked NAC to cancer cell death and blocked cancer cell replication. Great news, but more human studies are needed.
This is a short blog, but that’s a good place to stop for this week. Next week, we’ll talk about how NAC may alleviate the symptoms of multiple psychiatric disorders, as well as reduce addictive behavior; and we’ll talk about some preliminary study findings as well. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
The Dark Side of OCD
Hello, people… welcome back to the blog! We had some bigtime issues with our website, so we had to take a short blog break… but our IT guy got it sorted, so we’re finally back! Our last blog continued the discussion of OCD subtypes, and I went over Scrupulosity OCD, the obsession with morality and good versus evil, and Sexual Orientation OCD, the obsession with one’s “true” sexuality. This week, we’re wrapping up the OCD subtype series with a look at Relationship OCD, or ROCD, and an overview of Pure Obsessional OCD, aka Pure O.
In Relationship OCD, obsessions revolve around one’s feelings of attraction, attachment, and love for their partner. Recall again that OCD is a disorder of doubt, so ROCD presents as a preoccupation with doubting various aspects of the relationship. The person may wonder whether their person is really ‘the one,’ and about the level of sexual attraction or general compatibility; ‘Do they really love me?’ and ‘true love’ versus ‘just lust’ are other common themes. Whatever the doubts may be, they can become so pervasive and consuming that they can easily poison otherwise entirely healthy relationships… it can be exasperating to the person’s partner, and totally devastating to everyone involved. Imagine being married to someone for a number of years, maybe even having children with them, and then one day they tell you they’re not sure if you have sexual chemistry, or are compatible, and they don’t know if you belong together. Yikes! Scary stuff for everyone. It can even be a physical trait they’re unusually drawn to, and unsure if they can live with, or a common habit. Maybe you squeeze the toothpaste from the middle of the tube instead of rolling up the end. Jk on that last one people, though some folks, whether they have OCD or not, can be pretty particular about those kinds of things.
Sometimes people have a hard time understanding the difference between ROCD and more garden variety relationship doubts, and ROCD can even be misdiagnosed by mental health professionals if they misread the symptoms that way. Lots of people doubt their relationships from time to time, and there’s nothing wrong with taking a hard look at things and asking yourself some serious questions when choosing to settle down with a partner. We’re not talking about your usual commitment phobias here… make no mistake, people with ROCD are tortured continuously by their doubting thoughts. But the core issue with ROCD isn’t actually related to compatability or intimacy, once again, it’s about the doubt; specifically, the inability to tolerate that doubt. To draw the distinction, I’ll use a nerd word, people… ego-dystonic. For people with ROCD, the doubts they have are ego-dystonic, meaning that they are inconsistent with their actual feelings. They truly feel that they are attracted to, and compatible with, their partner, it’s just the ROCD causing them to constantly question it. Unfortunately, some clinicians and practitioners who aren’t familiar with ROCD may suggest to a person with it that “maybe you’re just not that into them” or that they “may not be right for you” or “not the one.” Worse yet, they might even tell them, “Well, maybe your gut is trying to tell you something… maybe those are your instincts, and perhaps you should pay attention to them” Alas, no. Telling someone with ROCD to listen to their doubts is the fastest way to send them into a tailspin of panic.
Aas ROCD obsessions center on doubt, the associated compulsions center on being absolutely sure that the relationship in question is right, on ascertaining the justification for entering into or remaining in it. For the person with ROCD, attempting to arrive at this level of certainty is agonizing, and it leads to an intense and endless cycle of anxiety, because it’s impossible to arrive at a definitive answer for any length of time. The doubt can usually be assuaged for a short time by performing various mental compulsions, but it always returns with a vengeance. It’s no picnic for the partner, either. They’re forced to think about what their significant other might be willing to do to reach that goal to be sure, especially the possibility of cheating, which is the usual form it takes. For them, this often leads to constant uncontrollable guilt, fear, and distressing thoughts of what will happen.
As with all forms of OCD, compulsions must be performed in an effort to reduce the anxiety related to the unwanted obsessional thoughts. Some examples of what ROCD might look like may be a married woman who has the obsessional thought, “What if I don’t really love my partner?” so she looks at old pictures and mentally recites her wedding vows until she feels she does. Or a husband who imagines cheating on his wife, and then obsessively fears that because he imagined it, he must secretly want to be with another woman, sso he may test the theory so to speak. Maybe a guy is drawn to his girlfriend’s nose, and obsesses about whether or not he finds her attractive enough to be with her, or if he should break up with her. Whichever way he leans- stay or break up- it causes him huge anxiety, so he compares his girlfriend to other girls he sees on the street to find evidence of sufficient feelings for her. Perhaps a man is attracted to a girl he notices on the street, and he begins to obsess that this must mean that he doesn’t love his girlfriend, so he must be in the wrong relationship. This causes him a lot of distress, because he actually believes he does love her and doesn’t really want to break up with her… but the doubt persists. How about a girl who’s living with her boyfriend, and confesses that sometimes she feels turned off by the thought of having sex with him. She believes that since she’s not 100% attracted to him 100% of the time, this is proof that she’s in the wrong relationship. So she mentally lists all the things she does and does not find aattractive about him in an effort to figure it out.
Notice that these compulsions aren’t very obvious… things like mentally reciting wedding vows and making mental lists and comparisons of people can clearly go unnoticed by others, as opposed to someone washing their hands over and over or unlocking and re-locking a deadbolt 20 times to check it. These are more of a mental obsession game. In fact, all of the subtypes we’ve been discussing in this series are similar in this way- sexual orientation OCD, pedophilia OCD, scrupulosity OCD, emotional contamination OCD, and hyperawareness or sensorimotor OCD- all of these are primarily cognitive in nature. As such, they are loosely categorized under Pure Obsessional OCD, aka primarily cognitive obsessive compulsive disorder, aka Pure O. Though not a true diagnosis found in the DSM-5, Pure O is considered a lesser known manifestation of OCD, and is thought of as one of the most distressing and challenging forms of OCD, as people with it have terribly disturbing and unwanted thoughts pop into their heads very frequently, totally unbidden; and once there, they tend to stick around.
In addition to the types we’ve discussed, some other common themes of Pure O thoughts and obsessions include:
-Responsibility type, which is marked by an excessive concern over someone else’s well-being, and hallmarked by guilt over believing they have harmed them, or might, either inadvertently or intentionally.
-Health type, which is essentially a contamination type, where they have constant fear of having or contracting a disease, generally through seemingly impossible means; for example, by touching an object that has just been touched by someone with a disease. This type can also include obsessive mistrust of the medical establishment and/ or diagnostic testing. It’s important to note that this is not the same as hypochondriasis, which is an illness whereby affected individuals falsely convince themselves they are physically ill, potentially to the point that they may even manifest physical symptoms. Maybe that’s a good topic for another blog.
-Existential type, which involves the persistent and obsessive questioning of the nature and meaning of self, life, reality, the universe, and other philosophical topics… all the deep stuff.
It’s important to distinguish Pure O from a singular fleeting thought. All humans experience unwanted thoughts. However, non-clinical people, or those who don’t have OCD, are able to easily dismiss the thoughts as uncomfortable, weird, or just something their brain does. What distinguishes Pure O from a fleeting unwanted thought is the anxiety that becomes affixed to the thought, which then creates a significant amount of distress to the sufferer. As you’ve probably noticed throughout this series, the nature and type of Pure O obsessions vary greatly, but the central theme is the emergence of a disturbing, intrusive thought or question, an unwanted or inappropriate mental image, or a frightening impulse that causes the person extreme anxiety, because it’s typically oppositional to their religious beliefs, morals, or societal norms. The fears associated with Pure O tend to be far more personal and terrifying for the sufferer than those of someone with traditional OCD… scenarios that they feel would ruin their life or the lives of those around them, the stuff of nightmares. Not to minimize the fears associated with stereotypical OCD, but to illustrate the difference, think about being overly concerned about security or cleanliness, and then imagine being terrified that you’ve undergone a radical change in your sexuality, or that you want to molest your baby nephew, or stab your father. You might be a murderer, you might cause some harm to a loved one, or an innocent person, or to yourself… or maybe you are, or will go, insane. You don’t actually want to do these things, but your brain makes you doubt that, makes you think you might want to. You have to think about it all the time, just to be absolutely sure that you won’t. That’s the pure hell of Pure O.
People with Pure O understand that these fears are probably unfounded, that it’s highly improbable, or even impossible, that they would ever hurt anyone or themselves, but the anxiety they feel will make the obsession seem very meaningful and real. While people wwithout Pure O will usually instinctively dismiss any bizarre, intrusive thoughts as insignificant impulses that are part of the normal variance of the human mind, just doing its thing, someone with Pure O will respond with alarm, followed by a desperate attempt to neutralize the thought and banish it… anything to try to avoid ever having it again. Even though they usually realize that their fear is irrational, a fact which just causes even more distress btw, they’ll constantly ask themselves, “Am I really capable of something like that?” or “Could that really happen?” and they’ll continuously put tremendous effort into resolving or somehow escaping the unwanted thought. It ends up in a vicious cycle, as they mentally search for reassurance, while trying to get a definitive answer to the question(s). This is generally through creating specific mental rituals they must accomplish in order to reassure themselves their intrusive thoughts are untrue, or that they aren’t a bad person. They may repeat specific words, recite special prayers or mantras in their head, or mentally review certain images each time there’s a negative thought, in an effort to neutralize it.
People with Pure O often report that it’s these thoughts that make them incredibly anxious, that they can’t get out of their head. This is an important point: what ignites the symptoms of Pure O isn’t having the experience of intrusive thoughts, but actually the reaction to them. The more they hate the experience of the intrusive thoughts and try to repress, control, or fight them, the greater the frequency of intrusive thoughts they’ll experience. It’s the very act of trying to not have the thought(s) that guarantees they’ll resurface agaain and again. This is because Pure O is rooted in the faulty assumption that as humans, we have control over our thoughts, when in fact, not so much. The human brain has evolved to be constantly searching and seeking, aware and alert, to find interesting problems to solve, and to search for threats to safety and existence. In addition, the brain is hardwired to be particularly interested in thoughts that contain uncertainty, and OCD thoughts are the epitome of uncertainty. When the brain of someone with Pure O lands on a thought or question that’s unacceptable or fearful to the person having the thought, the fear network of the brain is alerted that something is wrong, and that something must be done about it IMMEDIATELY. It comes down to the fight or flight response, and it’s this fight or flight experience that causes the sufferer a great deal of distress.
Remember when I talked about perfectionism being a little unusual because it’s really a subtype of its own, but also a common feature of stereotypical OCD as well as the other OCD subtypes? Many people with Pure O also experience comorbid features of perfectionism. They tend to maintain a high overall standard for what their brain “should” be thinking, and the level of control they “should” have over their thoughts. Individuals living with Pure O will commonly berate themselves, saying things like “I shouldn’t be thinking this,” “These thoughts are wrong or bad,” and “I should be able to control these thoughts.” They spend a great deal of time analyzing why they’re having them, with negative self talk about what the thoughts say about them as a person. Sadly, for many sufferers of Pure O, failing to meet this self-imposed standard of control over their own brain will lead them to conclude that they are a bad person, when the truth is that they are not… their brain may be “disordered,” but this is not, and should not be, a reflection on them as a person. They’re typically their own worst enemy, and they need and deserve our empathy and understanding.
Now you know more about the dark side of OCD- that it’s not all cleaning, straightening, and arranging- and that brings us to the end of this series. Next week, new topic… I’ll surprise you… as soon as I figure out what I’m writing about.
I hope you enjoyed this week’s blog, and found it to be interesting and of course, educational… please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well, people!
Obesity: What Causes it and How to Combat it
We’re nearly six weeks into the new year, and this is right about the time that most people toss their new year’s resolutions out the window. Many of them had resolved to lose weight: surveys have shown that, of the people who make new year’s resolutions, an average of 45% of them resolve to lose weight and get in better shape. So that means that nearly half of resolution-makers are overweight at least. That number seems high, but given that obesity has reached epidemic status, I guess it’s not that surprising.
Obesity is broadly defined as the state of being well above one’s normal weight. Obesity often results from taking in more calories than are burned by exercise and normal daily activities, aka ‘eating too much and moving too little.’ A person has traditionally been considered to be obese if they are more than 20% over their ideal weight. That ideal weight must take into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (NIH) by utilizing a person’s BMI, body mass index. The BMI is a key index for relating body weight to height, and it is formulaic. The imperial BMI formula is weight (in pounds) multiplied by 703, then divided by height (in inches²). If you don’t feel like dealing with the math, you can google a BMI calculator. Having a BMI of 30 and above is considered obesity. Over 70 million adults (35 million men and 35 million women) in the U.S. are obese, while 99 million (45 million women and 54 million men) are overweight and at risk for becoming obese.
What are the causes of obesity? Obesity can be complex, going beyond eating too much and moving too little. Following are some other factors that cause or contribute to obesity.
Obesity has a strong genetic component. Genetic predisposition means that children of obese parents are much more likely to become obese than are children of lean parents. Genetics also affect the rate at which the body uses energy (burns calories) when at rest, which is called the basal metabolic rate. People with higher basal metabolic rates naturally burn more calories than other people, so they are less likely to gain weight. The opposite is also true: people with lower basal metabolic rates burn fewer calories, so they are more likely to gain weight. But these facts don’t mean that obesity is completely predetermined, that there’s no way to change it. What you eat can have a major effect on which genes are expressed and which are not. This is demonstrated when people of non-industrialized societies come to the U.S., begin a western diet, and then rapidly become obese. Obviously, their genes didn’t change, but their diet did; that changed the signals they sent to their genes, which then changed the expression of the genes. Changing the expression of the genes resulted in obesity. The bottom line is that genetics do play a key role in determining susceptibility to gaining weight and obesity, but that is only one factor of many; it is not all genetically predetermined.
Diet: What and How You Eat
Obviously, eating an unhealthy diet is a major contributing factor in obesity. Overeating at meals and snacking throughout the day can also lead to obesity. An unhealthy diet would be high in complex carbohydrates, bad fats, and sugar, and low in fresh fruits, vegetables, and high protein lean meats. There are social factors that affect diet and therefore weight. If you spend a lot of time with overweight friends and family who eat too much of an unhealthy diet, the odds are that you’ll be overweight as well. Economic factors also play a role in obesity. If you can only afford cheap, ready-made packaged foods or fast foods from the dollar menu, you are much more likely to be obese. Economics may force you to eat a diet high in complex carbs like pastas, breads, potatoes and rice just to fill yourself up, because that is all you can afford. That type of diet greatly increases the risk of obesity. Unfortunately, eating unhealthy foods and overeating are easy in our culture today. Many things influence eating behavior, including time with family and friends, the low cost of unhealthy but filling foods, and the access to and expense of healthy foods.
If you have a lifestyle that centers on eating and/ or drinking, this can contribute to excess weight. A chef, bartender, or baker, something that requires tasting various dishes and trying new recipes for example. Also, someone who travels a lot for their job so always eats at restaurants, which are notorious for hidden calories and fat; they are more likely to be overweight and at risk for obesity. A sedentary lifestyle, where there is little to no activity or exercise is a huge contributing factor in being overweight or obese. Our modern conveniences- elevators, cars, remote controls- have cut activity out of our lives. The problem is that the less you move, the less active you are, the more likely you are to be obese. Being active helps you stay fit. And when you’re fit, you burn more calories, even when you’re resting, so you’re less likely to be overweight or at risk for obesity.
There are a host of medical issues that can cause or contribute to significant weight gain. Some examples are hypothyroidism, diabetes, Cushing syndrome, polycystic ovarian syndrome (PCOS), menopause, depression, and endocrine dysfunction. Some medical issues don’t cause weight gain in and of themselves, but make weight gain more likely because they limit the person’s activity. Some examples would include conditions like osteoarthritis, uncontrolled rheumatoid arthritis, and chronic pain syndromes.
The list of medications that can cause weight gain is a long one. Everyday medications like corticosteroids (Prednisone, Celestone), diphenhydramine (Benadryl), hormone replacements/ birth control, and even insulin are among the culprits. Sometimes it’s not the drug itself causing weight gain, it’s a side-effect from the drug. Some drugs stimulate your appetite, and as a result, you eat more. Others may affect how your body absorbs and stores glucose, which can lead to fat deposits in your body. Some cause calories to be burned more slowly by altering your body’s metabolism. Others cause shortness of breath and fatigue, making it difficult to exercise, while some drugs cause you to retain water, which adds weight but not necessarily fat. Some medications don’t cause you to gain weight outright, they just make it more difficult to lose excess weight you may already carry. A lot of psychiatric medicines cause weight gain. The worst offenders generally include mirtazapine (Remeron), paroxetine (Paxil), risperidone (Risperdal), aripiprazole (Abilify), and quetiapine (Seroquel). With the exception of Wellbutrin, essentially all classes of psychiatric meds can be associated with serious weight gain. As a psychiatrist, I have to prescribe meds that may cause an unwanted side effect like weight gain. I have to weigh the cost to benefit with each patient. Unfortunately, I have patients who are trapped; they must take certain medicines to remain stable, so they have to severely alter their food intake and diet every day of their lives in an effort to avoid weight gain if possible. That’s the cost to benefit ratio- they pay the cost of a severe diet in order to get the benefit of being stable psychologically.
Why should you care about your weight? What health issues does being overweight cause? The answer is many. Obesity leads to type 2 diabetes. It causes high blood pressure, which can cause strokes. Obesity can increase cholesterol levels and cause coronary artery disease, which is where deposits line the blood vessels that feed the heart and partially or totally block them, so the heart does not get adequate blood supply; this results in a heart attack, aka a “coronary” and this can easily be fatal. Being overweight puts excess weight on the human body, and this commonly causes osteoarthritis of major joints like the knees, the hips, and the ankles. All parts of the body are stressed and strained because they are not designed to carry around that much weight, and this limits the range of motion, mobility, and ability to walk. Obesity increases the risk of cancer to several organs and body parts: the breast, colon, gallbladder, pancreas, kidney, prostate, uterus, cervix, endometrium, and ovaries. Another common medical issue from being overweight is sleep apnea. All the weight on the chest and throat causes you to temporarily stop breathing when sleeping, until you finally noisily gasp for air. Sleep apnea is serious, and very disturbing for anyone that you share your bed with. Obesity causes a fatty liver, which then leads to liver disease and the potential to cause the liver to shut down. Obesity can cause gallstones as well as kidney disease, which can cause your kidneys to stop functioning. Obesity can also cause fertility problems in both men and women. As a psychiatrist, I get obese patients referred to me because obesity can directly cause, or indirectly lead to, various syndromes and other issues, including chronic pain syndromes, depression syndromes, isolation syndromes, social problems, self esteem issues, and difficulty dating. People who develop obesity, especially when it is the result of something beyond their control, like from a medical issue such as hypothyroidism, have all sorts of social interaction issues and work problems, and I can treat them and help walk them through it with psychotherapy.
We defined obesity, discussed the risk factors and what can cause it, and then the issues it can cause. Now let’s discuss how we can lose weight and prevent obesity.
To offset weight gain or to help work off excess weight, consider keeping a food diary tracking what you eat and when you eat. Becoming a mindful and aware eater is a great first step to managing weight.
Another factor which helps with weight loss is eating slowly. It takes some time for your stomach to tell your brain that you’ve had enough to eat. If you mindlessly shovel huge amounts of food into your mouth, you’ll miss your cue and overeat, and that obvi will cause you to put on weight and increase the risk of obesity. Eating slowly also has the added benefit of reducing the chances of having indigestion.
Become more active whenever possible. Instead of meeting someone for coffee or a movie, meet them at a park, beach, or green space and go for a walk. Ideally, you want aerobic activity; that means getting your heart rate up, when it’s harder to breathe. Aerobic activities mean constant motion, like running, biking, swimming, soccer, basketball, anything where you’re moving constantly. Constant activity is aerobic activity, and daily aerobic activity will raise your basal metabolic rate and you’ll burn more calories, even when you’re at rest.
Resistance training is good for targeting fatty areas on the body. Resistance training involves moving a specific muscle against resistance, either using your own body weight or using standard weights. Other activities like lifting weights, doing push-ups, and doing squats are good for reducing body fat.
…and make sure you understand them. If you don’t understand them, do some research, get a library book on nutrition, ask a friend if they understand, or ask your doctor what the values all mean and how much of the various components should be included in a healthy balanced diet or when dieting in an effort to lose weight. Pay close attention to calorie count, fat grams, protein grams, sugar grams, and carbohydrate count. Just because something says “light” doesn’t mean it should be included in your diet. So many people are ignorant about nutrition information on food packaging. Be sure to know what those values mean and how much you should have of each every day.
Know the Fats
Trans fats- Bad fats!
Historically, trans fats are an evil on par with Satan himself, to be avoided at all costs. The worst type of dietary fat, trans fat is a byproduct of the industrial process of hydrogenation, which turns healthy oils into solids to prevent them from becoming rancid. Eating foods rich in trans fats increases the amount of harmful LDL cholesterol in the bloodstream while reducing the amount of beneficial HDL cholesterol. Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions. They contribute to insulin resistance, which increases the risk of developing type 2 diabetes. Even small amounts of trans fats can harm health: for every 2% of calories from trans fat consumed daily, the risk of heart disease rises by 23%. Mind blowing. Though they have no known health benefits, trans fats were found in most pre-packaged garbage foods and were the main component in margarine type spreads. I say ‘were’ because recent science found there is no safe level of consumption of trans fats, and as a result, trans fats have been officially banned in the United States and several other countries.
Monounsaturated fat- Good fats!
Evidence has shown that consuming monounsaturated fats has several health benefits, including reducing general inflammation in the body. Studies have also shown that a high intake of monounsaturated fats can reduce triglycerides, decrease the risk of heart disease, and lower bad LDL blood cholesterol while increasing good HDL cholesterol. A diet with moderate-to-high amounts of monounsaturated fats can also help with weight loss, as long as you aren’t eating more calories than you’re burning. These fats are liquid at room temperature. Good sources of monounsaturated fat include avocados, almonds, cashews, peanuts, cooking oils made from plants or seeds like canola, olive, peanut, soybean, rice bran, sesame, and high oleic safflower and sunflower oils.
Polyunsaturated fat- Good fats!
The two types of polyunsaturated fats (omega-3 and omega-6) are essential fats, meaning they’re required for normal bodily functions, but your body can’t make them, so you must get them from food.
Omega-3 fats are a type of polyunsaturated fat that, like other dietary polyunsaturated fats, can help to reduce your risk of heart disease. Omega-3s can lower heart rate and improve heart rhythm, decrease the risk of clotting, lower triglycerides, reduce blood pressure, improve blood vessel function and delay the build-up of plaque in coronary arteries.
Omega-6 is a polyunsaturated fat that lowers bad LDL cholesterol. Eating foods with unsaturated fat, including omega-6, instead of foods high in saturated fats helps to get the right balance for your blood cholesterol (ie lower bad LDL and increase good HDL). Sources of polyunsaturated fats include oily fish (like salmon, mackerel, sardines), tahini (a sesame seed spread),
linseed (flaxseed) and chia seeds,
soybean, sunflower, safflower, and canola oil, margarine spreads made from those oils, pine nuts, walnuts, and Brazil nuts.
Follow these easy ideas for getting the balance of blood cholesterol (LDL and HDL) right.
– Go nuts! Nuts are an important part of a heart-healthy eating pattern. They’re a good source of healthier fats, and regular consumption of nuts is linked to lower levels of bad (LDL) and total blood cholesterol. So, include a handful (30g) every day! Add them to salads, yogurt, or your morning cereal. Choose unsalted, dry roasted or raw varieties.
– Go fish! Include fish or seafood in your family meals 2 – 3 times a week. Fish are great sources of the good omega-3 fats. If you don’t eat fish, you can take an omega-3 supplement.
– Use healthier oils! Choose a healthier oil for cooking. For salad dressings and low temperature cooking, choose olive, peanut, canola, safflower, sunflower, avocado or sesame oils. For high temperature cooking, especially frying, choose olive oil or high oleic canola oil, as they are more stable at high temperatures. Store oils away from direct light and heat and don’t ever re-use oils that have been heated before.
Eating polyunsaturated fats in place of saturated fats or highly refined carbohydrates reduces blood pressure, raises good HDL cholesterol, reduces harmful LDL cholesterol, lowers triglycerides, and may even help prevent lethal heart rhythms.
Saturated fat- OK in strict moderation
Saturated fats are common in the American diet, and they are solid at room temperature- think along the lines of cooled bacon grease. Common sources of saturated fat include red meat, whole milk and other whole-milk dairy foods, cheese, coconut oil, and many commercially prepared baked goods and other foods. A diet rich in saturated fats can drive up total cholesterol and tip the balance toward more harmful LDL cholesterol, which can prompt heart disease from blockages formed in arteries in the heart and elsewhere in the body. For that reason, most nutrition experts recommend limiting saturated fat to under 10% of calories a day. Replacing excess saturated fat with polyunsaturated fats like vegetable oils or high-fiber carbohydrates is the best bet for reducing the risk of heart disease.
– Eat plenty of fiber. Fiber fights belly fat. When ingested, fiber goes into your system, binds to and then forms a sort of gel with the food, which slows down the absorption of food in the gut.
– Eat a high-protein diet. Eggs are eggsellent…high in protein and low in fat. Avoid red meat. All meats should be lean and high in protein, like chicken or turkey. Nuts are also good for a protein snack.
– Eat fish, as often as 2-3 times per week for good omega-3’s. As discussed above, oily fish like salmon, mackerel, and sardines are high in omega-3’s which are good for the brain, help to decrease weight, and have numerous other health benefits. If you don’t eat fish, take a good omega-3 supplement.
– Drink green tea; there are reports that it helps with weight loss, and it’s generally just good for you.
– Don’t eat sugary foods or anything with sugar in it: sodas, candies, cakes, cookies, doughnuts; those are the main culprits. It’s a major bummer, but to avoid weight gain in your life, much less to try to lose weight if you’re already overweight, you must avoid sugar like the plague. Wah wah wah…
– Cut out the carbs! To lose weight or just to avoid putting weight on, anything with white flour must go, so say syonara to pasta and most breads. You have to cut way down on starches, if you’re allowed them at all, so there goes rice and potatoes. And while most people consider corn a vegetable, you must count it as a starch when dieting.
– Get on the wagon! If you drink alcohol, you won’t lose weight and keep it off. Won’t happen. When you consume booze of any sort- beer, wine, liquor- the alcohol is immediately converted to sugar, and if you’ve forgotten, see Diet Don’t 1 above. There’s no point in restricting calories, fats, etc by following a diet and also drinking alcohol at the same time, even a small amount.
Go to Bed!
Sleep is critical if you want to lose weight, so aim to sleep at least 7-8 hours each night. If you do not get proper sleep, it will be very difficult (if not impossible) to lose weight, and you will likely gain weight. This is all thanks to brain chemistry and hormones, which get all fouled up with sleep deprivation.
You have to reduce stress if you want to lose weight. When you are stressed, your body produces the stress hormone cortisol, and cortisol increases appetite and increases belly fat by selectively placing fat deposits around the stomach and middle of the body.
A Fast Fast
We’ve always been told that starving ourselves will not result in weight loss, and that it will even result in weight gain because the body goes into ‘starvation mode.’ Well, there are some recent studies out there that conclude that intermittent fasting, 24 hours without eating, once or twice a week, actually helps with weight loss. Very interesting.
So that’s all about obesity: what causes it, what it causes, and how to combat it. We are a fat society, and the number of cases of obesity goes up every day. It’s disturbing because it’s essentially a preventable issue.
For more information and interesting stories on other diagnoses, check out my book, Tales from the Couch, available in my office and on Amazon.com.Learn More
Through the years I’ve had lots of patients ask me how to interact with people and how to be social, the mechanics of it, so I want to give some rules of the road, social skills 101 if you will. First, let’s talk about why social skills are important. Social skills are the foundation for positive relationships with other people: friends, partners, co-workers, bosses, neighbors, on and on. Social skills allow you to connect with other people on a level that is important in life, a level that allows you to have more in-depth relationships with others rather than meaningless surface relationships that have no benefit to anyone. Once you understand the value of having good social skills, you need to want them for yourself and commit to working on them, because that may mean doing new things that may be uncomfortable at first. So, how would you start to improve social skills? Well, socialization is an interaction, so you need at least one other person to socialize with. So the first step is to put yourself among other people. Basically, you have to suit up and show up to socialize. You might feel wierd or shy at first, but don’t let anxiety stop you. If you’re not around other people to socialize with, you’re obviously not going to improve your social skills. So take a breath and dive in.
Step number two, put down the electronics. If you’ve put yourself in a social situation, you may be tempted to fiddle with your phone to avoid the awkwardness of just standing there, but when you’re around people, turn the phone off. You shouldn’t be disrupted, you can’t be distracted, and you can’t be checking email, messages, notifications, etc. Those things will get you to exactly nowhere. When you’re distracted, you won’t pay proper attention to the social setting you’re in, and since that’s kind of the whole point, put it away and keep it there.
So you’re in a room with plenty of folks to socialize with, your phone is tucked away, so what’s next? Well, if you want to interact with people, socialize with people, you have to look like it. You can’t put yourself in a corner with your arms crossed and a disinterested look on your face. Step three is to demonstrate an open, friendly posture. You need to be inviting to others who may want to talk to you. Put on a friendly face – you’ll be surprised at how many people approach you when you look approachable.
As they say, the eyes are the entries to the mind. Step four is to always maintain good eye contact. This is hugely important when conversing, but fleeting eye contact also comes in handy when you’re just circulating in a room or looking for someone to strike up a conversation with. Eyes can entirely change a facial expression and easily convey mood and interest. Without eye contact, there is limited communication, and social skills are compromised without appropriate eye contact. Eye contact is so integral to communication that some people say they can tell if someone they’re talking to is being honest or lying by their eye contact, or the lack thereof.
To communicate well, you must pay attention to your equipment…your speech. So step five is remember your speech: the tone, the pitch, the volume, the tempo, the accent. Right or wrong, people will judge and label you by your voice. A man’s voice that’s too loud is a turnoff, he comes off as a blowhard. A woman’s voice that’s too soft is annoying because people have to try too hard to hear her, and people may say she’s a sexpot, a la Marilyn Monroe. If she speaks at too high a pitch, she’s a bimbo. To some, a southern accent means you’re dumb and a northern accent means you’re a hustler. Speaking too slowly or too fast is annoying, too monotone and you’ll put people to sleep. On the flip side, a singer or actor with perfect pitch or an especially unusual or dulcet tone can build a legacy based just on their voice, a voice that will be instantly recognized for all time. When it comes to the way you speak, be aware and make alterations to be distinct and easily understood. Remember voice inflection, because monotone is a tune-out and turnoff. Speech should be like a story, with highs and lows, ups and downs to hold people’s interest.
After reading step five above, you might think that developing good social skills hinges on everything you say, but that leaves out a key factor…listening. Step six on the path to developing good social skills is to be a good listener. Just listen. Eazy peazy lemon squeazy. Now, if you’ve ever in your entire life enjoyed speaking to someone who clearly wasn’t listening to anything you said, raise your hand. Any takers? Anyone? I thought not. It is annoying AF when it’s so obvious that someone’s not listening to you speak. And you don’t want to be annoying AF, do you? I thought not. Social skills aren’t just about what comes out of a person’s mouth, so listen.
A great way to deal with nerves that may accompany you when you put yourself in a social situation and talk to people is to find commonality, so this is step seven. When you first meet someone, a sense of commonality is a great way to establish a quick rapport with them. Commonality is something you share. It could be something as simple as going to the same school, a shared interest in sports, same places where you’ve lived or hobbies in common. Step seven is to find commonality with someone; something simple to break the ice and establish a conversation.
Once you’ve begun a conversation with someone and you want to further it, you need to go beyond just commonalities. You need to relate to the person on a deeper level. How do you do that? Through step eight, empathy. Empathy is the ability to relate to someone by putting yourself in their position in order to understand them better. If someone has a dying parent, has just lost their job, if someone is lonely, has ended a relationship, didn’t get a promotion, or experiences anything that elicits an emotional response, being empathetic is the ultimate understanding of their pain, their sorrow, or their disappointment. Step eight in improving social skills is the ability to put yourself in someone else’s shoes in order to have genuine empathy for that person. A key word here is genuine. As a general rule, good social skills are genuine. Lip service is not part of good social skills.
Step nine is a pretty simple concept, though not so much in practice. Respect. In order to learn good social skills (and have anyone to practice them on) you must respect what other people say. I did not say agree. You can completely disagree with their opinion, but step nine is that you must respect their right to have it and include it in the conversation.
While in theory you have the right to say anything you want in your social circle, you should watch what you say. Step ten is to consider the content of your conversation. There are certain things that shouldn’t be brought up in some situations. As they say, religion and politics are big no no’s for sure. Gossiping is also on the no list, because it’s really toxic to a conversation and leaves people scratching their heads. If you’re talking about Mary to Connie, Connie’s bound to wonder what you say about her when you’re speaking to Shelly. So it’s best to just not talk about people. But I think it was First Lady Dolly Madison who said “If you don’t have anything nice to say, sit next to me” Some people do like gossip, the jucier the better. But you have to be prepared to pay the piper. A conversation can be like a minefield, with certain subjects as the mines. You have to navigate through the whole conversation without blowing yourself to smithereens.
In order to have appropriate social skills, you must consider the non-conversational parts of social interaction. If you’re so drunk that you can’t speak or no one can understand what you’re saying, obviously you can’t use good social skills. Same goes for drugs. If you take a Xanax to calm your nerves before the company mixer, you will not have appropriate social skills. You may not think people can tell, but you’d be wrong. Step eleven is about intoxicants like alcohol, marijuana, benzodiazepines, and Adderall… they all make you act weird and affect your social interactions, and people pick it up right away. They may not know what drug you’re on, but they’ll know you’re on something for sure, because your social interactions will be inappropriate. Rule eleven: you cannot interact appropriately when using drugs or alcohol, so cut both out if you want to have good social skills.
If you follow these steps, you’ll definitely learn better social skills. And a breath mint wouldn’t hurt. Like with anything else, practice makes perfect when it comes to social graces. Be positive, open, honest, empathetic, clear, respectful and sober, and you’ll never be at a loss for people to talk to. You’ll navigate the waters of conversation deftly with give and take, and all included will come out feeling positive about the interaction.Learn More
Couples and Conflict
One of my foremost jobs as a psychotherapist is to be a listener. All day, every day people come to me to talk about their problems. As you can imagine, many times patients want to talk about their spouses, specifically how they fight with them. So I want to talk a little bit about couples and fighting. Whether it’s about money, children, career, housework, all couples fight. Nobody gets along 100% of the time without some conflict. It’s all a matter of how you resolve that conflict. I had a patient named Roxanne come in for her session yesterday, and she told me that she and her husband Bill fight all the time. One yells at the other and the other yells back louder until it reaches a terrible crescendo and both storm off in opposite directions. She said she had no choice in this, he just made her so angry and they just didn’t get along. I told her that the first thing that had to happen for the relationship to move forward was to decide that it wasn’t his fault and wasn’t her fault, it was both of them. She immediately recoiled and told me I was dead wrong. That it was all Bill’s fault. He was never home, he didn’t want to be a part of the family, he this, he that, ad nauseum. I asked her about how they fight, her yelling and screaming…was it working? Was it resolving anything? She launched in again, saying it wasn’t her fault, it was his fault because he made her yell. He antagonized her. I told her that she didn’t have to go to every fight he invited her to, she had the choice. This is a point that I think a lot of couples miss. Just because your spouse may be baiting you, looking for a fight, it doesn’t mean you have to give them what they’re looking for. You don’t have to respond at all. You have a choice in how you behave.
I explained to Roxanne that the only way to start to resolve an issue is to not yell and scream, not raise a voice. Once you express anger, you’ve made the situation worse. I suggested to her that the only way to make the situation better when Bill is yelling and screaming is to fall silent. Until the yelling stops, nothing productive can be accomplished. A conflict cannot be resolved through warfare. Once people raise their voice, no interaction happens. For instance, if you raise your voice at a child, they shut down. They will hear nothing you say. The same happens in couples. If one raises their voice at the other, from that moment forward, nothing constructive happens. So, if you’re married or in a relationship and you find you are having problems or there is fighting, and yelling, you are responsible for your response, and your response should be to not yell back, fall back. All yelling does is put fuel on the fire. If you fall silent, eventually they will stop yelling, and once the yelling stops, resolution can start. You can begin a conversation by discussing what the problem is, why you keep arguing, and what you can each do to make things better. That’s the only way these things will really be resolved. But you have to be willing to change how you respond to conflict and how you fight. Learn to fall back if baited. Talk should replace screaming matches.
I hear so often in my office “it’s not me, it’s him, it’s her, they’ll never change, we tried that” blah, blah, blah, blah. If you really want to effect change in your relationship, change your own behavior and then the reaction you get back from your spouse or partner will change. Stop yelling and start conversing. Focus on what you can each do to make the relationship better. To resolve conflict, cooler heads should always prevail over heated emotions.Learn More
Hello people, I hope everyone had a great holiday weekend! Did everyone set off a bunch of fireworks? Did you grill some burgers or dogs, have some baked beans, and a scoop of potato salad? Top it off with some apple pie? Me neither. Can I just ask, why do people shoot off fireworks on Saturday day, like before the sun sets? Are they testing them to see if they’re loud enough? Just wondering. Maybe they can’t wait. Anyhoo, last week, we talked about Antisocial Personality Disorder, the first Cluster B personality disorder, the dramatic and erratic disorders. If you recall, ASPD is the official diagnostic term for the colloquial terms sociopathy and psychopathy. That’s the big takeaway. So this week, we’ll be continuing with the Cluster B’s with Borderline Personality Disorder.
Borderline Personality Disorder
BPD is also sometimes called Emotionally Unstable Personality Disorder, or EUPD, but I prefer Borderline. It always reminds me of that 80’s song. BPD is the most commonly diagnosed personality disorder, and was so called, because it was thought to lie on the “borderline” between neurotic disorders (meaning anxiety disorders) and psychotic disorders, such as schizophrenia and bipolar disorder. BPD is characterized by difficulties in regulating emotion. People with BPD experience big mood swings, and they feel a great sense of instability and insecurity. They feel emotions very intensely, often for extended periods of time, and it’s generally harder for them to return to a stable baseline after an emotionally triggering event. This difficulty can lead to impulsivity, poor self-image, and intense emotional responses to stressors. Struggling with self regulation and having a poor self-image essentially equates to a lack of a sense of self, and as a result, they often experience feelings of emptiness and extreme fears of abandonment, whether these are real or just perceived. They generally have a pattern of instability in their relationships, and there can be violence involved, especially in response to criticism. These unstable personal relationships often involve “splitting,” where the person alternates between idealization “I’m so in love!” and devaluation “I hate him!” Suicidal threats and acts of self-harm are common, and this is how and why many people with BPD frequently come to medical attention. Extreme stress responses can lead to dissociative feelings, meaning they feel disconnected from their thoughts or themselves, have “out of body” type feelings, potentially even psychotic episodes. They basically check out, and may not remember these events well afterwards.
BPD signs and symptoms may include:
-Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, reckless driving, gambling, overuse of substances, and binge eating
-Distorted and unstable self-image affecting moods, values, opinions, goals, and relationships
-Wide mood swings, often as a reaction to interpersonal stress
-Unstable and intense relationships
-Suicidal behavior or threats of self-injury
-Intense fear of being alone or abandoned, may be real or imagined
-Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days
-Ongoing feelings of emptiness
-Frequent, intense displays of anger, often followed by shame and guilt
-Stress-related paranoia that comes and goes; when stress is severe, it can lead to brief psychotic episodes
It has been suggested that BPD often results from childhood sexual abuse, and that it is more common in women, in part because women are more likely to suffer sexual abuse. However, some argue that BPD is more common in women simply because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behaviors tend instead to be labeled with ASPD, Antisocial PD. More recent research seems to back this up. Women are more likely to receive the diagnosis, because it is commonly thought of as a “female” disorder, even though there’s no such thing. In fact, of the estimated 1.4 percent of the adult U.S. population with BPD, nearly 75 percent of them are women.
Histrionic Personality Disorder
HPD is characterized by a pattern of excessive emotion and attention seeking. People with HPD generally like to be the center of attention at all times, and may actually be uncomfortable when they’re not. They often use physical appearance to draw attention to themselves, are often flirtatious, and can employ exaggerated or rapidly shifting emotions as a means to reach this goal. The surprise is that they usually lack a sense of self-worth, and they depend on attracting this attention to seek the approval of others in order to boost their wellbeing. They often seem to be dramatizing or playing a part in a bid to be seen and heard. The word “histrionic” is derived from the Latin histrionicus, meaning “pertaining to the actor.” People with HPD may take great care of their appearance, and behave in a manner that is overly charming or inappropriately seductive. Because they crave excitement, they tend to act on impulse and are easily suggestible, and they may place themselves at risk of an accident, or fall prey to exploitation. Their dealings with others often seem insincere or superficial, and in the long term, this can adversely impact their social and romantic relationships. They find this to be especially distressing, as they are very sensitive to criticism and rejection, and they react very poorly to loss or failure. It can result in a vicious cycle in which the more rejected they feel, the more histrionic they become, and the more histrionic they become, the more rejected they feel. Achieving any emotional or sexual intimacy may be difficult, and they may play a victim role, potentially without being aware of it. They may also try to control their partner using seduction or emotional manipulation, while becoming very dependent on them. They tend to be too trusting, especially of authority figures who they think may be able to solve all their problems. They often think relationships are closer and more intimate than they really are. They crave novelty and tend to bore easily, so they may change jobs and friends frequently. Delayed gratification is very frustrating to them, so their actions are often motivated by obtaining immediate satisfaction.
HPD signs and symptoms may include:
-Constantly seeking attention
-Into instant gratification
-Excessively emotional, dramatic, or sexually provocative to gain attention
-Excessive concern with physical appearance
-Speaks dramatically with strong opinions, but few facts or details to back them up
-Makes rash decisions
-Easily influenced by others
-Shallow, rapidly changing emotions
-Believes relationships with others are closer than they really are
-Gullible and easily influenced by others
-Excessively sensitive to criticism or disapproval
-Low tolerance for frustration, easily bored by routine, often beginning projects without finishing them or skipping from one event to another
-Self-centered, rarely showing concern for others
-Good social skills, but use them to manipulate others, to be the center of attention
The estimated prevalence of HPD is less than 2 percent of the general population. It is usually evident by early adulthood, and is diagnosed more often in women than in men, but this may simply reflect the higher prevalence of women in clinical settings. There is a clear tendency for HPD to run in families, which suggests a genetic susceptibility, but the child of a parent with the disorder might simply be repeating learned behavior. Other environmental factors that might be involved include a lack of criticism or punishment as a child, and unpredictable attention given to a child by his or her parent(s), which tends to lead to confusion about what types of behavior earn parental approval.
Narcissistic Personality Disorder
NPD is characterized by an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. The person is envious of others, and expects them to be the same of him. They typically lack empathy, and readily lie, exploit, or take advantage of others to achieve aims. To others, they may seem self-absorbed, controlling, intolerant, selfish, and/ or insensitive. If they feel ridiculed or obstructed, they can become very angry and even vengeful. Fueled by a belief that they’re special, and more important than others, they can have a reaction called “narcissistic rage,” which can have disastrous consequences for all involved. It’s human nature to be aware of and express our own needs, as well as want others to be aware of our abilities and achievements. These aren’t bad things, but people with NPD take this to the extreme. At the heart of it, they have fragile self-esteem, so they rely on others to recognize their worth and their needs. They are generally unhappy and disappointed when they’re not given the praise or special favors they believe they deserve. This can cause problems in all areas of life, work
school, and relationships. People with NPD usually put themselves on a pedestal, where they can look down on others and direct them, as they believe they are better than. They exaggerate their own talents and accomplishments, while downplaying those of others. They are usually preoccupied by power, success, and beauty, and may engage in impulsive behaviors, such as risky sex and gambling, in their pursuits of these goals.
NPD signs and symptoms may include:
-Fantasies about power, success, and attractiveness
-Entitled, conceited, snobby
-Exaggeration of achievements or talents
-Expectation of constant praise and admiration
-Exaggeration of intimacy with others, especially those with wealth or VIP status
-React negatively to criticism
-Show great charm but quickly become irritated or angry
-Talking at length about their own concerns but lacking interest in those of others
-Show aggression when faced with a threat to their ego
-Resent the successes of other people
-Arrogant, dismissive, or unaware of other people’s needs
-Perceived superiority that covers a deep seated insecurity
-Unreasonable expectations of favors and advantages
-Envy of others accompanies belief that others envy them
-Unfulfilling relationships; become unhappy, angry, and confused when things don’t go their way
-Typically have ongoing issues with work, school, relationships, finances, alcohol, substances
Research indicates that NPD affects 6.2 percent of the U.S. population, and is much more common in men than women, affecting 7.7 percent of men and 4.7 percent of women. There may be cultural influences associated with NPD, but this may be a stereotype. Diagnosing NPD specifically can be challenging, as the features tend to have so much overlap with other disorders. In addition, a person with NPD may not recognize that problems in their life stem from their own behavior, and they may blame others instead. Narcissists can be especially difficult to deal with. I’ve done a lot of family counseling for it, but the person with the diagnosis must accept it to make headway. Some NPD traits may appear similar to confidence, but healthy confidence and NPD aren’t the same thing. People who have healthy self-esteem are usually humble, while people with NPD, by definition, never are. It takes a lot of work on the patient’s part to modify behavior, but it can be done with sufficient motivation.
That’s the end of Cluster B Personality Disorders. Next week, we’ll tackle Cluster C disorders.
Thank you and be well people!
Hello people! Last week was a light one on dark chocolate (ha ha?) but as promised, today marks the start of a new series on thyroid disease. If you’re wondering why I, a shrink, would care about the thyroid, the answer’s simple: because when it’s a problem, it’s a real problem, because it can affect nearly every aspect of your life, including your mental health. But when it comes to the thyroid, you’re about to find out that that’s where the simplicity ends.
Before we can talk about how the thyroid can affect you, first we have to talk about what it is. The thyroid is a butterfly-shaped endocrine gland that’s found in the forward aspect of the middle of the neck, just below the larynx, or voice box. Its two lobes, left and right, lie on either side of the windpipe, and are each about the size of a halved plum. These lobes are analagous to the wings of the butterfly, and they are joined by a small bridge of thyroid tissue called the isthmus.
Notice I said it was an endocrine gland? The endocrine system is made up of glands that make hormones, which are the body’s chemical messengers- they carry information and instructions from one set of cells, glands, and organs to others. In doing so, the endocrine system influences almost every cell, gland, organ, and function of the body. That’s what makes the thyroid so important- because it’s a big part of the endocrine system, along with the other major glands, including the hypothalamus, pituitary, parathyroid, adrenal, pineal, and the ovaries and testes.
The hormones made by the various glands of the endocrine system are released into the bloodstream, and they travel to cells in other glands and organs where they help control organ function, mood, growth and development, metabolism, and reproduction. The amounts of hormones produced and released is highly regulated, and depends on levels of other hormones already in the blood, other minerals like calcium in the blood, the blance of water and other fluids in the body, and external factors such as stress and infection, just to name a few. Because hormone production and levels are all interlinked- one dependent upon another- it’s important that these levels remain normal. Too much or too little of any one hormone affects production and release of multiple others, so it can affect several organ systems, and cause nearly endless physical and emotional symptoms. This can make you feel very ill, a little “off,” or anything in between.
The Pituitary Gland
Even though this series is on the thyroid, I can’t rightly talk about it, or the endocrine system, without mentioning the pituitary gland. The pituitary is a pea sized gland located at the base of the brain, but don’t let its size fool you, because mighty things can come in small packages. In fact, the pituitary is often called the “master gland,” because the hormones it makes control many of the other endocrine glands. The pituitary also happens to be one of my faves- and it should be one of yours too- because it secretes endorphins, the body’s natural feel good chemicals, the ones that act on the nervous system to produce feelings of pleasure and reduce feelings of pain.
The pituitary gland makes many other hormones, including growth hormone, which stimulates the growth of bone and other body tissues; prolactin, which activates milk production in breastfeeding women; corticotropin, which stimulates the adrenal gland; antidiuretic hormone, which helps control the balance of body water through its effect on the kidneys; and oxytocin, which triggers uterine contractions during labor. But the pituitary hormone that’s most germaine to today’s topic is thyrotropin, more commonly known as thyroid-stimulating hormone, or TSH. Once secreted by the pituitary, TSH, as its name suggests, stimulates the thyroid to synthesize and release thyroid hormones.
In response, the thyroid produces thyroxine and triiodothyronine, more commonly known as T3 and T4, respectively. These hormones control the rate at which cells burn fuels from food to make energy. They basically regulate the body’s metabolism- the rate at which the cells of the body use and store energy. I’ll get into that in a moment, but because they control such a basic function, you can clearly see that thyroid hormones are essential for all the cells in your body to work normally. If that weren’t enough, they also play a role in bone growth and development, as well as that of the brain and nervous system. Just to add another level of complexity, there are also four other tiny glands attached to the thyroid gland called the parathyroids. They release parathyroid hormone, which, along with help from another thyroid hormone called calcitonin, controls the level of calcium in the blood. And if you remember, calcium is one of those minerals in the blood that controls the production and release of other hormones. Yikes!
Believe it or not, this is as simplified as the endocrine system- and the thyroid- really gets, people, so if you’re thinking all of this is super complicated, you cannot even imagine if you just go by this! As a matter of fact, there’s an entire (underappreciated) specialty medical field devoted to this alone… so thank you endocrinologists!
Thyroid Function: Metabolism
As I mentioned before, thyroid hormones regulate the body’s metabolism. Many people think that just means how many calories you burn, but metabolism is a complicated process, one that’s happening 24/7, no matter what you’re doing. That’s even reflected in its literal meaning, which is “a state of change.” Your body relies on metabolism to carry out all of its functions, whether it’s storing or burning fat, regulating sugar levels, or keeping your neurons firing; so metabolism has a huge impact on your health. The three main purposes of metabolism are: the conversion of food to energy to run cellular processes, the conversion of food/ fuel to the body’s building blocks, and the elimination of metabolic wastes.
This intricate involvement with such an important, universal bodily process is why diseases of the thyroid have such an extreme and varied impact on human health. But (thankfully) all of it boils down to two basic conditions: having too much thyroid hormone results in a condition called hyperthyroidism, while having too little thyroid hormone is called hypothyroidism. Generally speaking, in hyperthyroidism, when there is too much thyroid hormone, your body processes speed up, and the body uses energy very quickly. And in hypothyroidism, when you don’t have enough thyroid hormone, your body processes slow down, and the body uses less energy.
That’s probably a good place to stop for this week. It’s been a while since I’ve had to write an endocrine overview, people! Next week, we’ll start getting into the meat and potatoes when it comes to thyroid imbalance- how it can affect you. Something to look forward to.
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The Dark Side of OCD
Hello, people… hope everyone had an awesome weekend! Was it perfect? Because last week, we talked about POCD, perfectionism OCD. This subtype is pretty self explanatory; it’s the obsession with being perfect. Perfectionism is a little unusual, as it can exist outside of OCD, underlie many OCD subtypes, and be a subtype all on its own. In people with stereotypical OCD, perfectionism contributes to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, perfectionism can really be thought of as its own OCD subtype. Perfectionists rigidly adhere to the belief that things must be done in a certain way- perfectly- or not at all. It’s a tough way to live, and the pressure to constantly achieve this standard often becomes so great, at times it’s far easier for them to give up on doing something altogether. This week, we’ll be talking about Scrupulosity OCD, which involves obsessions with morality, being good or evil, or sinning; and Sexual Orientation OCD, obsessions involving one’s sexuality.
I love the word scruples… it’s fun to say. Scruupullzzz. Scruples are the moral principles or beliefs that make you unwilling to do something that seems wrong. Having scruples is kind of like having a conscience… when you’re considering doing something shady, that little knot in the pit of your stomach is brought to you courtesy of your scruples. Fun fact, a scruple is also a unit of weight in old school pharmacy- equal to 20 grains- so sometimes “a scruple” means a minute amount. I drink my tea with a scruple of honey. Okay, sometimes maybe a little more.
Scrupulosity OCD is usually thought of as an obsession with sinning or offending God- common concerns include devil worship, blasphemy, and hell- but it’s not always focused on religion. Secular or moral scrupulosity is more about right and wrong, and being a “good” or “bad” person. While research shows it’s common in orthodox Jews and Catholics, up to 25 percent of people with scrupulosity OCD say that they have no religious affiliation at all. It runs the gamut; I’ve seen very pious, religious people with scrupulosity OCD, as well as people who’ve never even gone to a church service.
I recall a patient who was not raised in the church, who thought he was never going to find God. This internal doubt turned into obsession, requiring various rituals he had to complete. It started with conquering fears to prove that he was worthy; he had to challenge himself to conquer any fear that came up in his daily life. Then, he started to worry that he had already done something horribly wrong, something unforgivable, and as a result, God would never reveal Himself to him. To fix it, he had to do everything correctly, to be a good person, if he had any hope of finding Him. He was always scared that he was off “the path” and constantly tried to find ways to prove that he was on the path. He got totally obsessed with it, and every little decision that he made became monumentally important for how to do the right thing and be on the right path. He became so obsessed with getting on, staying on, and proving he was on the right path, his life deteriorated. He couldn’t get his homework done, couldn’t complete tasks or chores, or go out with friends. Eventually, his scrupulosity led to complete avoidance; he stayed away from people, avoided churches like the plague, and would even get scared whenever anyone would mention the devil or say the word ‘Satan.’ Until he started treatment, his thoughts only intensified, and he was sure that he was going to go to hell.
Some other patients I recall include a woman obsessed about whether or not she felt enough empathy for people she saw suffering in fundraising specials on TV. She also obsessed about not recycling every single scrap of recyclable material, thinking it made her a bad world citizen, someone who didn’t care about the greater good. I remember another woman had to imagine the people she loved with a protective halo surrounding them at all times, to prevent them from being harmed. She was convinced that if she imagined them without it, a horrible fate would befall them.
OCD has a knack for latching onto whatever matters to the person, and that’s why scrupulosity can often strike people whose religion matters a great deal to them. And this can also make it hard to design exposures for therapy. The goal isn’t to make someone violate their true religious beliefs; you don’t want to force a kosher person to eat something unkosher. Instead, you challenge them with feelings of doubt; give them something kosher, but don’t allow them to triple check that it is. Or challenge a secular scrupulosity OCD patient from seeking reassurance that they’re not going to hell, or that they’re a good person.
In my research, I read about an exposure for one scrupulosity patient that was interesting to say the least… he had to go into a church, put up his middle finger and say “F@*k you, God.” Clearly, the idea was to do very blasphemous things, completely contrary to everything he was taught as a kid, in order to show him that God wasn’t going to smite him. In the interview, he said that it was extremely difficult for him to do at the time, but it made him realize that the less he let scrupulosity take over, the more faithful he felt. His therapist told him, “Every ritual resisted is an act of faith,” and those are the words he went by to help stop his compulsions. He decided that listening to the therapist, rather than listening to his OCD, was going to better demonstrate the faith that he was brought up with, as opposed to doing his various rituals. He was at a point where he was willing to do whatever it took, and he amazed himself when he lived through the anxiety. Thankfully, now he notices his thoughts, but doesn’t have to act on them. He can let them go, not dwell on the devil or hell, without reacting compulsively to fix the anxiety. Pretty powerful stuff.
Sexual Orientation OCD
SO-OCD is characterized by obsessions and intrusive thoughts revolving around a person’s “true” sexual orientation. It has been referred to as homosexual OCD or H-OCD, but this term is somewhat misleading, and is increasingly discouraged due to its lack of sensitivity. In reality, SO-OCD can happen to people of any sexuality, about any other sexuality. It goes beyond just questioning your sexuality; because sexual desire is such a fundamental issue, and sexual orientation is such a big part of a person’s identity, SO-OCD often causes a great deal of internal distress, and sadly, shame. The truth is that though we’ve come leaps and bounds as far as acceptance goes, we’ve still got some ground to cover there. Constantly questioning, while simultaneously hiding the questioning, of something so fundamental causes a great deal of internal strife and anxiety. Keep in mind that OCD has that penchant for latching on to what a person values, so with SO-OCD, it can feel like there’s nearly endless fuel for these obsessive thoughts and anxieties.
Someone with SO-OCD may experience fears about being perceived or labelled as having a certain sexual orientation, such as gay or straight. Or they might wonder if they’re actually of an orientation other than the one they thought; they may fear they’re in denial of their “true” sexual orientation. Or, they might fear that their sexual orientation could abruptly change, that they could “turn” gay or straight, and worry what this change will mean for their life. For example, will they have to leave their family? Will their relationship end when their partner discovers they’re not who they think they are?
They often constantly assess or question their behaviors and attraction levels to potentially nearly every person encountered, and can be excessively concerned with whether their behaviors align them with a particular sexual orientation. Asking things like: “I was attracted to that guy back there. This must mean I’m gay.” or “He’s attractive. Was I really into that last girl when we dated… or am I more into guys?” or “What if I’m actually straight and I’m not really in love with my partner?” These thoughts can really take hold of a person’s mind, and they won’t let go until they’ve found sufficient proof that their fears are unfounded. But as with all types of OCD, any relief they may find is only temporary, it’s only a matter of time before the cycle begins again. The most common compulsions to quell these anxieties often involve looking at pictures of women or men to see if you’re attracted to them, repeatedly asking people if you seem straight to them, and/ or avoiding people of the same sex altogether to avoid any confusion or complications.
These intrusive thoughts and compulsions can be extremely distressing, and interfere with a person’s relationships bigtime. And we mentioned religion in our discussion of scrupulosity OCD, and it often plays a role in SO-OCD… it’s fairly common for people to fear going against a religion they were raised in or that their family believes in. Remember in the first blog of this series, I explained that OCD is a disorder of doubt? Well, SO-OCD isn’t so much about their actual sexual identity or orientation, it’s about the doubt that’s common among all subtypes of OCD. It’s really the same uncertainty that exists for everyone, that’s part of human nature… multiplied many fold by confusion and divided by doubt. It’s a tough equation. Nearly every SO-OCD patient I’ve treated has been unconcerned with which orientation fits them, they just want to know with 100% certainty what their sexual orientation is, just as everyone else does. This is how and why people of any orientation can have SO-OCD. Because sexual orientation plays such a big part of a person’s life and identity, and because OCD tends to latch on to what an individual values, it can feel like there is endless fuel for the intrusive thoughts and the anxiety that accompanies them. Altogether, it can make for a debilitating and life altering disorder.
Thank you and be well people!
The Dark Side of OCD
Hello, people~ welcome back to the blog! The last few installments, we’ve been talking about some of the more unusual subtypes or presentations of OCD. Last week, I told you about POCD, pedophilia OCD. This is a devastating harm based subtype that causes people to worry that they might be attracted to children, and could potentially act on that attraction. To reiterate, these are not predators that actually want to harm or molest children. They are simply- or not so simply- obsessed with the idea that they could. Somewhere along the line, that becomes locked in their brain due to the OCD, and they worry about it incessantly. As a result, they avoid all contact with children, and this can have a huge impact on family dynamics. It causes a great deal of shame and guilt for the person who has it, as they fear being judged by others, while always judging themselves very harshly. And it can also be very damaging to the children in that person’s life, since they miss out on the time and affection that person would have otherwise devoted to them. As you can imagine, all of these things often lead to a great deal of anxiety and depression, and many times, people with POCD suffer through it alone. This week, we’ll be continuing the series with a look at perfectionism.
Perfectionism is a pretty self-explanatory subtype, the obsession with appearing and being “perfect.” Perfectionism is kind of an unusual trait. It isn’t unique to OCD; not all perfectionists have OCD, and not all people with OCD are obsessed with being perfect. But perfectionism underlies many OCD subtypes, as it can contribute to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, perfectionism can really be thought of as its own OCD subtype; when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, it falls into a class of its own.
Perfectionism can look very different from person to person, but there are some common overarching themes. Perfectionists feel the need to follow rules very rigidly. I’m sure you’ve heard the addage “Anything worth doing is worth doing right.” Some versions end with “well,” but this isn’t strictly true for perfectionists, it must be right. Things must be done in a certain way- perfectly- or not at all. This is tough to live up to at best, and the pressure to achieve this standard can become so great, that at times it’s far easier to give up on doing something altogether. In addition, perfectionists generally need to feel that they are in control of a situation at all times. By definition, they are excessively concerned with making mistakes, especially when other people could potentially see those mistakes. Ultimately, they think that these errors have some bearing on their overall value as a person, that they define them. They also tend to have an overwhelming need to please others. As a result, relationships with authority figures- people like bosses and parents- can be fraught with anxiety. Perfectionists also have trouble with prioritizing. They can’t make a list of five things they want to accomplish, and then decide which to give 100 percent effort to, 80 percent, and 50 percent. That doesn’t work for them, it’s very all or nothing. Every time they came across a task, whether it’s a strength of theirs or a weakness, whether they have expertise in it or not, they always feel like they must perform it at a high level.
There’s nothing wrong with doing things well, or with being very diligent and detail oriented. These are great qualities, and they work well for people, when they’re functional qualities. But when it gets in the way of getting things done- when it becomes dysfunctional- it’s a problem. I had a patient that was a student, a freshman in college, and he loved school. He was all about it, very intelligent, studied a lot, and worked so hard on papers and projects. Too hard as it turns out. He would begin a lab write up or a paper, but would edit as he wrote. He would then write more, then edit that; then he’d try to stitch them together and get frustrated. Ultimately, he’d have to start all over again. It just went on and on in this way, and it took him forever to do a very simple write up. Something that took his peers maybe a couple of hours tops would take him days of work, because it was nearly impossible for him to write it start to finish, then edit start to finish, a reasonable number of times. There was never an end point- he always felt it needed to be better- and was compelled to improve on it, so sometimes he simply couldn’t finish things. His brain just didn’t want to let him.
Many years ago, I worked with young children in a hospital setting, with a wide array of diagnoses. One young girl, about nine years old, would undoubtedly have a diagnosis of perfectionism. I remember her very well, but her parents made an especially unique impression. When I gave them my assessment, it was quite clear that her being a perfectionist wasn’t a problem for them- this was written all over their faces. The mother especially, she had a little smile, almost of satisfaction or even pride. It was like I was telling them it was a good thing, or maybe too much of a good thing, like having too much money. She was a great student, very precocious, and a great kid, very meticulous. But if she did something imperfectly, if it didn’t meet her standards- which I suspect she may have learned from her mom, or her mom had a hand in planting- it was a problem. She would begin something with such enthusiasm, which was so great to see given her anxiety; but once she realized the task wasn’t going to be up to par, she would just give up and shut down. It was like watching a bright beautiful flower wilt and wither right in front of you. A sad thing at nine years of age.
This is basically a form of avoidance, which is a common compulsion for perfectionists. Better to totally blow something off than to not do it perfectly. Another example of this is something my student patient would do. If he was late for class, he couldn’t bring himself to go in. If he could see from the window that the professor had already started lecturing, and the students were all sitting there, facing front and listening, he would imagine how it would feel to open the door, and have all those heads turn to look at him. He couldn’t take that, everyone seeing his screw up, so he just wouldn’t go, he’d skip class. Then the next class, he was so concerned about showing his face after missing the previous one, it had a tendency to snowball. Even though he was smart and worked very hard, between his lack of participation in class and his issues in completing tasks, he ended up receiving poor grades, or even failing classes, with shocking regularity.
Perfectionism is difficult for those with it to gain insight about, because it’s so engrained within their personality. They like to be focused, discerning, fastidious, and detail oriented. Sometimes it works well for them, but when it works against them, it takes much longer to realize it. All of this makes it hard to treat. Despite the suffering it causes, many times, patients initially resist the idea of abandoning their ways completely. And I get that. Some elements of perfectionism backfire, but there are parts that are beneficial, that help people reach their goals. You don’t want to necessarily eradicate it from their lives altogether, throw the baby out with the bathwater. I understand the hesitation. Somewhere in the dysfunction is function. In my student patient’s case, there were times he got A’s on papers. It took him 40 hours instead of two, but the end result was good, no argument there. So how do you find the happy medium, how do you eliminate the dys- from the functional in treatment? We want people to work hard, to be attentive, accurate, and competent. In treating it, and designing exposures, we don’t want to make a person act stupidly or underperform- proofing and editing is good if you don’t want to send out a paper to your professor, or letter to your boss, filled with typos. That would be nearly impossible to get them to do anyway, even if it was designed as an exposure to treat them. We don’t want to weed out the good parts, or necessarily challenge the outcome or the goal, but we need to challenge how they’re getting there. In the case of my student patient, the exposure would be to write without editing, start to finish, one draft, even if there were mistakes. Other ideas would be to show assignments to other people before they’re turned in, as well as to put max time limits on how long a project can take. Practice doing things well, instead of perfectly, to help them see that they can in fact deal with imperfection. That’s the true reality anyway- nothing is ever perfect. If you want perfection, to the point that you reject anything less than that, you’re going to end up rejecting things you shouldn’t, and missing out on a lot in the bargain.
That makes me think of a book about OCD by Judith Rapoport called The Boy Who Couldn’t Stop Washing. It’s about a law school student with contamination obsessions that agonized over cleaning his apartment. He obsessed about how long the cleaning would take, and especially about how quickly it would get dirty again. He eventually started to avoid going home, so that its cleanliness would be maintained; it wouldn’t be disturbed by the messiness of his living in it. This escalated to the point that he wound up sleeping on a park bench, willingly homeless, all to avoid his apartment. This might seem radically counterintuitive. How could a person with contamination obsessions- who’s afraid of germs- stand to sleep outside, in a park, with all the dirt that goes with it, all for the sake of cleanliness? This is the dark side of OCD when you have perfectionism.
I was thinking about positive perfectionism, and out of curiosity, read about the top career choices for perfectionists. Clearly, positive perfectionism can give a person a set of traits that can help them excel in life, especially in certain careers. Accuracy, attention to detail, persistence, conscientiousness, and organization lend themselves well to roles where design, math, and very complex procedures are essential to their tasks. Mechanics, inspectors, accountants, surveyors, tailors, and engineers would be top choices. Artists and creative types seem to suffer the most from perfectionism. Claude Monet, the highly celebrated French Impressionist, was a perfectionist… the perfectionist impressionist! I read that he was set for an exhibition in May of 1908, featuring his newest works, the result of three years of work. But when he took his final look, he decided the paintings weren’t good enough. Amid great protests, he took a knife and a paint brush to the paintings- worth $100,000 at the time- defacing them irrevocably. Today, they would be priceless. His actions prompted all sorts of ethics discussions; should an artist have the right to destroy his own work? Evidently at least one expert thought so, and actually praised him for being a true “arteest” and told the New York Times, “It is a pity, perhaps, that some other painters do not do the same.” A similar, but more tragic story is told in a book from 1886 called L’œuvre, translated as The Masterpiece. It tells the story of another artist who becomes obsessed with creating a large canvas that he worked on incessantly, but it never satisfies him. He kept painting on more and more layers, to the point that the canvas was destroyed. Then he would start over, again and again. He became so distraught and depressed that eventually, he went insane.
So how do you tell the difference between healthy and unhealthy perfectionism? The difference is when you move from a detail oriented, conscientious place, to a rigid and controlling one. When the ideas of perfection prevent you from doing anything at all, a healthy sense of perfectionism has been taken over by a dysfunctional one; putting you in a place where mistakes are catastrophic, where they say something about you, where you have to live up to other people’s expectations. This induces such anxiety that it becomes crippling, because eventually everything needs to be perfect- even things that other people would never even notice start needing to be perfect. Once again, the pressure from that becomes so intense, it’s easier to just forget it, to give in altogether. But in my view, the only way to truly fail at something is to not try at all. If you fail at something, it’s not because you’re not perfect, but because you didn’t try. Most perfectionists don’t subscribe to this; they seem to mostly have a fear of being average. They want to succeed perfectly, but if they’re going to fail, they’re going to do so spectacularly. A healthier point of view is to accept that nothing is ever perfect… but it won’t be anything if you don’t do it in the first place.
Thank you and be well people!