Personality Disorder Part 3

Personality Disorders, part 3

Hello, people! In last week’s blog, we talked about the cause of personality disorders, sort of the nature versus nurture debate, and how both genetics and environment play a role in developing these disorders. We also discussed some of the requirements for diagnosis: how the maladaptive behaviors or personality traits must be relatively stable over time and consistent across situations; that they must cause significant impairment in self and interpersonal functioning; and that they cannot be a result of the direct effects of a substance or general medical condition. Each of the ten disorders has its own set of diagnostic criteria based on the various signs and symptoms typically exhibited. And that’s what we’ll be getting into today- the signs and symptoms of personality disorders.

As I mentioned before, the DSM-5 allocates each of the ten personality disorders to one of three groups or clusters, A, B, or C, based on similar characteristics and symptoms. Many people with one personality disorder also have signs and symptoms of at least one additional personality disorder, and it is usually within the same cluster. I should note that it’s not necessary to exhibit all the signs and symptoms listed for a disorder to be diagnosed. So let’s get started on the first cluster.

Cluster A Personality Disorders

These are characterized by odd, eccentric thinking or behavior. They include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Paranoid Personality Disorder

PPD is defined by mistrust and suspicion so intense that it permeates thought patterns and behavior, interfering with daily functioning. A person with PPD feels very wary of others, believing that they want to harm them. They are always on guard for signs that someone is trying to threaten, mistreat, or deceive them. No matter how unfounded their beliefs, they may repeatedly question the faithfulness, honesty, or trustworthiness of the people around them, whether they are friends, family, spouse, and/ or lovers. They may be defensive or sarcastic, which may elicit a hostile response from others. This response, in turn, then seems to confirm their original suspicions, reinforcing their beliefs. When they perceive they’re being persecuted, rejected, or slighted, they’re likely to respond with hostility, angry outbursts, and/ or controlling behavior; and they often deflect any blame onto others. Their fearful and distrustful perceptions make forming and maintaining close relationships very difficult. In addition, they’re often able to find and exaggerate the negative aspects of any situation or conversation, which also strains relationships. These qualities affect their ability to function at home, work, and school. Because of these symptoms, the condition often results in social withdrawal, tenseness, irritability, and lack of emotion.

Common PPD symptoms include:

-Suspecting, without justification, that others are trying to exploit, harm, or deceive them.

-Doubting or obsessing on the lack of loyalty or trustworthiness of family, friends, and acquaintances.

-Refusing to confide in people for fear that any information they divulge will be used against them.

-Becoming detached or socially isolated 

-Interpreting hidden, malicious, demeaning, or threatening subtext or meanings in innocent gestures, events, or conversations.

-Having trouble working with others, being argumentative and defensive.

-Being overly sensitive to perceived insults, criticism, or slights. 

-Quickly feeling anger, snapping to judgment, and holding grudges.

-Responding to imagined attacks on their character with anger, hostility, or controlling behavior.

-Repeatedly suspecting, without basis, their romantic partner or spouse of infidelity.

-Having trouble relaxing due to an inability to let their guard down.

PPD affects approximately 1 to 5 percent of people worldwide, though I’ve seen estimates of up to 10 percent. It often first appears in early adulthood, and is more common in men than women. Research suggests it may be most prevalent in those with a family history of schizophrenia. Despite being one of the most common personality disorders, PPD can be difficult to detect until symptoms progress from mild to more severe. This is because most people behave in mistrustful, suspicious, or hostile ways at some point in their lives without warranting a diagnosis of PPD. Spotting the signs can be further complicated as it often occurs with another mental health problem, such as an anxiety disorder, obsessive-compulsive disorder (OCD), substance abuse, or depression. When people with PPD have other diagnoses, it can compound their PPD symptoms. For example, depression and anxiety affect mood, and shifts in mood can make someone with PPD more likely to feel paranoid and isolated.

Professional treatment can help someone with PPD manage symptoms and improve their daily functioning. But due to the very nature of the disorder, most people with PPD don’t seek help, as they don’t see their suspicious behavior as unusual or unwarranted. Rather, they see it as rational. They are defending themselves against the bad intentions and deceptive, untrustworthy activities of those around them. As far as they’re concerned, their fears are justified, and any attempts to change how they think only confirms their suspicions that people are “out to get them” in some way. In addition, their intense suspicion and mistrust of others often includes mental health professionals. They question their motives in trying to help, and it can take a fair amount of time to build enough trust so they feel comfortable confiding in them and following their advice. 

Schizoid Personality Disorder

The term “schizoid” indicates a natural tendency to direct attention toward one’s inner life and away from the external world. Please note that while their names sound alike, and they might have some similar symptoms, schizoid personality disorder is not the same thing as schizophrenia. People with schizoid PD tend to be distant, detached, aloof, and more prone to introspection. They often choose to be alone, and have little to no desire for social or sexual relationships. In addition to being indifferent to other people, they are also indifferent to social norms and conventions. They seem to not care about external praise or criticism, and commonly demonstrate a lack of emotional response. They are generally “loners” who prefer solitary activities. Many people with schizoid personality disorder are able to function fairly well, although they tend to choose jobs that allow them to work alone, such as night security officers, library, or lab workers. 

A competing theory about people with schizoid PD is that they are in fact highly sensitive with a rich inner fantasy life. That they experience a deep longing for intimacy, but find initiating and maintaining close relationships too difficult or distressing, and as a result, choose to retreat into their inner world, which they create with vivid detail. 

Common Schizoid PD symptoms include:

-Lack of interest in social or personal relationships, preferring to be alone

-Limited range of emotional expression

-Inability to take pleasure in most activities

-Inability to pick up normal social cues

-Difficulty relating to others

-Appearance of being cold or indifferent to others

-Little or no interest in intimacy or in having sex with another person

-May commonly daydream and/or create vivid fantasies of complex inner lives.

-Often reclusive, organize life to avoid contact with other people

Available statistics suggest that between 3 to 4 percent of the general population has schizoid PD, though it’s very difficult to accurately assess the prevalence, because people with schizoid PD rarely present for medical attention. This is because they generally function so well, and their preferences have few or no negative legal or societal consequences. Schizoid PD usually begins in late adolescence or early adulthood, affects men more often than women, and is more common in people who have close relatives with schizophrenia.

Schizotypal Personality Disorder

STPD is characterized by oddities of appearance, behavior, and speech, unusual perceptual experiences, and anomalies of thinking similar to those seen in schizophrenia. People with STPD have a higher than average probability of developing schizophrenia, and the condition used to be called “latent schizophrenia.” Their anomalies of thinking can include odd beliefs, suspiciousness, obsessive ruminations, and magical thinking, which is being overly superstitious or thinking of themselves as psychically powerful. An example may be believing that they have a “sixth sense” or thinking that speaking of the devil can make him appear. This may lead them to develop what are called ideas of reference- the false belief or intuition that occurrences, events, or details in the world relate or refer directly to themselves. People with STPD generally don’t understand how relationships form, or the impact of their behavior on others. They may react oddly in conversations, not respond, or talk to themselves. They have difficulty with responding appropriately to social cues, often misinterpret people’s motivations and behaviors, and develop significant distrust of others. This can cause excessive social anxiety, and can lead them to fear social interaction, thinking that other people are harmful. While people with STPD and people with schizoid PD both avoid social interaction, people with STPD do so because they fear others, whereas people with schizoid PD do so simply because they have no desire to interact with others, or find interacting with them too difficult. 

Schizotypal personality disorder typically includes five or more of these signs and symptoms:

-Being a loner and lacking close friends outside of the immediate family

-Limited or inappropriate emotional responses, “flat emotions”

-Persistent and excessive social anxiety, tendency to be stiff and awkward when relating to others

-Very uncomfortable with intimacy

-Commonly misinterpret events, ie feeling that something has a direct personal offensive meaning, when it is actually harmless or inoffensive 

-Distorted perceptions or odd perceptual experiences, ie mistaking noises for voices, hearing a voice whisper their name, or sensing an absent person’s presence

-Peculiar, eccentric, or unusual thinking, beliefs, or mannerisms

-Suspicious or paranoid thoughts and constant doubts about the loyalty of others

-Belief in special powers, such as mental telepathy or superstitions

-Dressing in peculiar ways, such as wearing oddly matched clothes or appearing unkempt

-Peculiar style of speech: highly variable, this may include unusual patterns of speaking, rambling oddly during conversations, vague speech, or speaking in excessive detail, in metaphors, or in an overly elaborate manner. 

The prevalence of STPD ranges from approximately 1 to 4 percent of the population, and is more common in men than in women. STPD occurs more often in relatives of patients with schizophrenia or another Cluster A personality disorder. In fact, people that have an immediate family member with STPD can be as much as 50 percent more likely to develop it, as compared to people without that family history. People with STPD typically disagree with the suggestion their thoughts and behavior are disordered, and seek medical attention for depression or anxiety as opposed to the disorder. While it is typically diagnosed in early adulthood, some signs and symptoms, such as increased interest in solitary activities, or a high level of social anxiety, may be seen in the teen years. These children may also underperform in school, or appear socially out of step with peers, and this may result in teasing or bullying. STPD is likely to endure across the entire lifespan, though treatment, such as medications and therapy, can improve symptoms. Without treatment, individuals with STPD are at high risk for having major difficulty with work and relationships. 

That’s the end of Cluster A personality disorders. Next week, we’ll cover Cluster B.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Personality Disorders part 2

Welcome back to the blog, people. Last week we started a new series on personality disorders, which are one of the most common of the severe mental disorders. A personality disorder is marked by rigid patterns of thoughts and behaviors that cause significant life impairment, and deviate from what is generally expected, or considered “normal” by society. There are four core defining features that are common to all personality disorders. They are distorted thinking patterns, problematic emotional responses, impulse control issues, and interpersonal difficulties. In order for a diagnosis to be made, a person must demonstrate significant and lasting difficulties in at least two of those four areas. We’ll talk more about diagnosis later; first let’s talk about what causes personality disorders.

As we talked about last week, personality is the combination of thoughts, emotions and behaviors that makes you unique. It’s the way you view, understand, and relate to the outside world, as well as how you perceive yourself. Your personality forms during childhood, and it’s shaped through an interaction of your genetics and your environment, often referred to as nature and nurture. Have you ever been told ‘You remind me of Uncle Jimmy, the way you do xyz.’ This may be because certain personality traits can be passed on to you by your parents through inherited genes. That is to say, these natural traits may be heritable. The nurture refers to your environment, the surroundings you grew up in, the events that occurred, and your relationships with family members and others.

The exact cause of personality disorders isn’t known. Just as personalities are shaped by genetics and environment, personality disorders are thought to be caused by a combination of these genetic and environmental influences. It’s thought that your genetics may make you prone to developing a personality disorder, and then something in your environment- some life situation- may trigger the actual development. In other words, the tendency to develop a personality disorder can be inherited, but not the disorder itself. The disorder only arises if/when something interferes with the development of the healthy personality. For most personality disorders, levels of heritability are about 50 percent, which is similar to, or even higher than, that of many other major psychiatric disorders. There’s no clear reason why some people develop the feelings and behaviors associated with personality disorders, while other people don’t. The social circumstances we grow up in and the quality of the care we receive greatly affect the way our personality develops, so they seem to be part of the equation. 

The nurture side of the coin carries a lot of weight in developing personality disorders. Most of the patients I’ve diagnosed had something happen during their childhood. They may have had a chaotic family life, too little parental support, or a history of traumatic event(s). Trauma doesn’t have to mean emotional, physical, or sexual abuse; it may be the loss of a parent, or extreme poverty or neglect. Captain Obvious says that not everyone who experiences a traumatic situation will develop a personality disorder, and not everyone who develops a personality disorder will have had a traumatic experience. People have unique reactions, and develop different coping methods to deal with the situation they’re presented with. That’s often the core of the issue in the way personality disorders can develop; the strategies needed for coping with pain, fear, and anxiety as a child aren’t ones that are helpful or appropriate in adult life, and may in fact be harmful. That should sound familiar, no… perhaps maladaptive? 

Although we can’t label a precise cause, we know that there are certain factors that seem to increase the risk of developing or triggering the condition. In addition to an abusive, unstable, or chaotic family life during childhood, other risk factors seem to include a diagnosis of childhood conduct disorder, and variations in brain chemistry and structure. A family history of personality disorders or other mental illness is another risk factor. We know of some specific links; for example, a family history of depression may increase the risk of developing borderline personality disorder and/ or obsessive-compulsive personality disorder.

Diagnosing Personality Disorders

This can be a difficult diagnosis to make, and it never happens quickly. It involves a thorough medical and social history and multiple assessments, often over an extended length of time. Each of the ten personality disorders have criteria that must be met to qualify for diagnosis. Generally speaking, it requires finding a persistent, inflexible pattern of maladaptive traits across many life circumstances. They must also cause significant distress and impairment in at least two of the four aforementioned core areas: the way you perceive and interpret yourself, other people and events; the appropriateness of your emotional responses; how well you function when dealing with other people and in relationships; and whether you can control your impulses. 

It’s important to remember that everyone can exhibit maladaptive behavior from time to time. In order to meet the diagnostic requirement of a personality disorder, these traits must cause functional impairment and/or subjective distress, and they must be persistent and inflexible; meaning they can be repeatedly observed without regard to time, place, or circumstance. Other considerations are age of onset and the exclusion of other possible causes, like other mental health disorders, substance use, or history of head trauma. 

Next week, we’ll start taking a closer look at the ten personality disorders; we’ll talk about the signs and symptoms for cluster A, the “Odd and Eccentric” disorders: paranoid, schizoid, and schizotypal personality disorder.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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The Cult of Personality…Disorders

The Cult of Personality… Disorders

Hello, people! Last week, we talked about thyroid disease and mental health, how they may exist together, and how some of the symptoms overlap. It’s definitely something to keep in mind when you’re looking for a diagnosis, and even once you’ve been diagnosed with one, as it doesn’t eliminate the other. And that brought the thyroid series to a close. If you remember nothing else, it should be that since the thyroid regulates metabolism- how every cell in the body uses energy from food to do its thing- its function controls literally everything in the body. So when it’s not working properly, the symptoms can vary widely. It may seem subtle at first, but eventually, you’re going to know about it, so the sooner you pick up on it, the better. 

Now moving on to our next topic, personality disorders. What are they? Disorder is fairly straightforward, so let’s talk about personality. Our personality is the collection of thoughts, feelings, and behaviors that makes each one of us the individuals we are. The traits of our personalities represent our patterns of thinking, perceiving, reacting, and relating to people, places, and things in our world. We don’t always think, feel, and behave in exactly the same way- that depends on the situation we’re in, the people we’re with, and all sorts of other interconnecting factors. We’re meant to be flexible to a point, but our personality traits remain relatively stable over time. Are you very talkative or very quiet? Are you constantly moving or are you a couch potato? A social butterfly or a bookworm? Are you a worry wart, always anxious, or laid back and unconcerned? These fundamental patterns make up our personality traits, and they imply consistency and stability. 

Personality disorders exist when these traits become so pronounced, rigid, and maladaptive that they impair interpersonal function. Maladaptive is such a great shrinky word. It just means more harmful than helpful, as opposed to adaptive, more helpful than harmful. Fun fact: every living organism, from bacteria to humans, displays maladaptive and adaptive traits, though they don’t pertain to behavior or personality in every case. In this case, maladaptations are patterns of behavior that are detrimental or counterproductive, that interfere with life. As applied to personality disorders, these maladaptive patterns of behavior deviate from what is considered “normal” or expected by society. Put it all together, and what is a personality disorder? It’s a type of mental disorder marked by rigid and enduring patterns of thoughts and behaviors that deviate from the expectations of society, and cause significant impairment in many areas of a person’s life. 

According to the shrink bible, the DSM-5, personality disorders are primarily problems with self identity and interpersonal functioning. That’s a shrinky way of saying people with personality disorders have problems with how they perceive themselves and how they interact with others. This affects how they form and maintain relationships with employers, family, friends, and intimate partners. They generally have poor coping skills, and tend to repeat patterns of behavior which are often volatile, confusing, and difficult. Maladaptive behavior may have consequences, and can cause significant problems in relationships, social activities, work, school, and potentially every facet of life. Some disorders may be so problematic that people actually avoid relationships whenever possible. These problems lead to distress, not only to the person with the disorder, but to those around them. Unlike people with anxiety or mood disorders- who know they have a problem but are unable to control it- people with personality disorders are often not aware that they have a problem, and as a result, will not seek treatment on their own. If they do, it’s the distress caused by the consequences of the maladaptive behaviors that lead them to seek treatment, rather than any discomfort with their own intrinsic thoughts and feelings. In my experience, when they do seek treatment, the chief complaint is often of depression or anxiety rather than the actual manifestations of the personality disorder.

Personality disorders are among the most common of the severe mental disorders, and often occur along with other mental illnesses, such as substance abuse disorders, anxiety disorders, and mood disorders, like depression and bipolar disorder. It’s estimated that 10 percent to 13 percent of the world’s population suffer from some form of personality disorder, and it’s thought to be underdiagnosed. While signs are sometimes apparent during childhood, most personality disorders start to become evident during the teenage years, as the personality further develops and matures. As a result, almost all diagnoses occur after the age of 18. As far as prevalence, there are no clear distinctions in terms of ethnicity. Regarding gender, most differences exist in the manifestation of symptoms within each disorder, as opposed to prevalence of diagnosis among the ten disorders, with three exceptions: antisocial personality disorder is far more common in men, while borderline and histrionic personality disorders are more common in women. Though they’re considered chronic or enduring, more recent studies indicate that some types of personality disorders may become less severe over time. 

Personality Disorders: Ten Types

The DSM-5 allocates each of the ten personality disorders to one of three groups or clusters: A, B, or C. Each disorder rarely appears in its “textbook” form, they often blur into one another. Their division into clusters is intended to reflect this tendency, with any given personality disorder most likely to blur with others within its cluster. Many people diagnosed with one personality disorder also have signs and symptoms of at least one other, typically within the same cluster.

Cluster A personality disorders are characterized by odd, eccentric thinking or behavior. They include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Cluster B personality disorders are characterized by dramatic, overly emotional, erratic or unpredictable thinking or behavior. They include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.

Cluster C personality disorders are characterized by anxious, fearful thinking or behavior. They include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Please note this is not the same as obsessive-compulsive disorder, OCD.

Our understanding of personality disorders and what it means to experience them is constantly evolving. It can be a controversial diagnosis, especially in regard to terminology.  

Incidence and prevalence statistics ultimately depend on where clinicians draw the line between a “normal” personality and one that leads to significant impairment. Diagnosing personality disorders reliably is difficult. Why? How far from “normal” must personality traits deviate before they can be counted as disordered? How significant is “significant impairment”? And how is “impairment” to be defined? Next week, we’ll continue with personality disorders, though I won’t be answering those questions… those are just food for thought. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Thyroid Disease and Mental Health

Thyroid Disease and Mental Health

Hello, people! Welcome back to the blog. We’re continuing with our look at thyroid disease, and this week will be focused on its links with mental health conditions. 

Thyroid hormones regulate metabolism in every organ of the body, including of course the brain, which contains one of the highest concentrations of thyroid hormone receptors of any organ. These hormones are essential for brain development and maturation, as well as for function throughout life. Neurons are more sensitive to thyroid abnormalities than other cells, so it comes as no surprise that thyroid disease commonly results in various clinical manifestations affecting mental health/ function. In fact, the majority of people with thyroid dysfunction will develop cognitive, mood, and/ or emotional symptoms, it’s mainly a matter of degree. If that’s the case, where do thyroid symptoms end and psych symptoms begin? In recent years, we’ve learned they’re more connected than we once thought.

People with an overactive thyroid, hyperthyroidism, can suddenly feel tense and anxious. They may experience bouts of impatience or overactivity, panic attacks, and extreme sensitivity to noise. Are these symptoms of their thyroid disease? That sounds a bit like anxiety. People with an underactive thyroid, hypothyroidism, may feel overwhelmed, disinterested, and tearful. They can experience a progressive loss of memory and appetite, a dulling of personality, difficulty concentrating, and a lack of interest and mental alertness. Sounds a whole lot like depression. People with both thyroid disorders commonly suffer from mood swings, short temper, and difficulties in sleeping. And generally speaking, the more severe the thyroid disease, the more severe the mood changes. They can be the result of abnormal or rapidly changing thyroid levels, or it can even be a side effect of treatment.  For example, if you have hyperthyroidism and take beta blockers to slow down your heart rate, this can make some people feel less mentally alert, depressed, and fatigued.

A review of the literature estimates that up to 60 percent of people diagnosed with hyperthyroidism also have clinical anxiety, and up to 69 percent of people diagnosed with hypothyroidism are also clinically depressed. As you can imagine, misdiagnosis can become a problem. When thyroid conditions are misdiagnosed as mental health conditions, that can leave you with symptoms that may improve, but a disease that still needs to be treated.

There can be a lot of overlap in symptoms. Thyroid disease is often at the top of my list of differential diagnoses with many new patients, especially women of menopausal age. It can be a confounding riddle, especially in times of crisis, if patients are unaware that they may have either condition. I’ve seen patients in emergency rooms for new onset of severe psychotic symptoms- auditory and visual hallucinations- and it turns out to be severe hypothyroidism. It’s usually a woman in her 50’s who’s been suffering through various symptoms for years, but assumed it was associated with menopause. In years past, even physicians would take a wait and see approach before doing labs. Today we’re better understanding the progression of illness and the links that exist between conditions.

Common Symptoms

Hyperthyroidism and Clinical Anxiety

Hyperthyroidism and Bipolar Disorder

Insomnia, anxiety, elevated heart rate, high blood pressure, mood swings, irritability

Hyperthyroidism can produce symptoms similar to those seen in cases of clinical anxiety. It can also produce symptoms of mania that are more or less identical to the mania symptoms found in people with bipolar disorder. We also know that people with bipolar disorder have increased risk for developing hyperthyroidism. And lithium, a drug used to treat bipolar disorder, can aggravate or trigger hyperthyroidism. Good to know.

Common Symptoms

Hypothyroidism and Depression

Hypothyroidism and Cognitive Dysfunction

Bloating, weight gain, memory loss, difficulty processing information, fatigue

Hypothyroidism symptoms have a lot in common with those of clinical depression as well as cognitive dysfunction- meaning memory loss and difficulty organizing thoughts. In fact, there’s fairly recent evidence that thyroid hormone replacement medication may be helpful for treating depressed patients, even those with normal thyroid function. German researchers found that high doses of thyroxine improved the symptoms of 17 depressed patients who had not responded to multiple antidepressant drugs. Half of them recovered, and only one failed to improve. 

Autoimmune Thyroiditis (AIT) 

aka Hashimoto’s Hypothyroidism or Disease

Hashimoto’s disease is the most common cause of hypothyroidism, and affects about 10 percent of the population. It primarily affects middle aged women, but can also occur in men and women of any age, and in children as well. AIT means the person’s immune system is creating antibodies that mistakenly attack their own thyroid, leading to chronic inflammation, which interferes with hormone production. This leads to a potentially severe drop in thyroid hormone levels, and the person feels exhaustion and tension, and all the symptoms of hypothyroidism, up to psychosis- myxedema madness. 

AIT often goes undiagnosed because symptoms are attributed to menopause, as women aged 30 to 50 are the most common sufferers, or to depression and anxiety. If you have AIT and seek psych treatment, make sure your psych provider knows you have AIT, you can receive more effective treatment by being able to choose antidepressants that are less likely to cause weight gain. And you should also know how your antidepressant effects selenium levels, which can help with inflammation. Patients with depression and anxiety disorders should consider having a full thyroid panel with antibodies to test for AIT. And for patients with AIT, a screening for psych symptoms is recommended. Early administration of appropriate treatment- antidepressants and hormone replacement- provides a distinct advantage to patients. 

Recent studies have quantified links between AIT and depression, anxiety, and bipolar disorder. If you have AIT, you’re 3.5 times as likely to suffer from depression and  2.3 times as likely to suffer from anxiety. Inversely, more than 40 percent of people diagnosed with depression also suffer from AIT, and the same is true for 30 percent of people diagnosed with anxiety. And AIT is an endophenotype of bipolar disorder, meaning that both conditions have the same genetic origin.  

The main message today is that if you have thyroid disease or a mental health diagnosis, be sure to inform all of your physicians, be aware of the links between the two conditions, keep an eye on your symptoms, and consider screening for the linked condition as early as possible to initiate treatment if needed. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Treating Thyroid Disease

Hello, welcome back to the blog, people! We’re continuing our look at thyroid disease. Last week, we took a pretty deep dive into diagnosis, especially lab tests. I mentioned that the TSH (thyroid stimulating hormone) test is considered by most practitioners as the gold standard test, as it regulates the release, and therefore balance, of the thyroid hormones T4 and T3. A T4 (thyroxine) test is commonly ordered with the TSH, as together, they offer a good snapshot of overall function, as well as suggest a cause for an abnormality. A T3 (triiodothyronine) test is usually only ordered to support a diagnosis of hyperthyroidism, as it’s not very helpful in hypothyroidism, since it’s the last hormone to be affected. Thyroid antibody tests can also be run to help identify different types of autoimmune thyroid conditions, such as Hashimoto’s hypothyroidism and Graves’ Disease hyperthyroidism. 

There are different recommendations on how to screen for abnormal thyroid hormone levels, and your health insurance may “help” determine what tests are done and when. In most US states, and probably elsewhere as well, you can order your own thyroid tests on the interwebs, and this may be a more affordable way to have them done. You can find plenty of analyzers there too, so you can enter your results if you’re confused about what they mean. 

A TSH alone can be a sufficient screening test for abnormalities, and it can be followed by a T4 and/or T3 should any be found. 

Generally speaking, an elevated TSH, with or without low T4 or T3, is associated with hypothyroidism, and a low TSH with high T4 and/or high T3 is associated with hyperthyroidism. I should note that in order to receive a diagnosis of hyperthyroidism, lab tests must demonstrate that one or both thyroid hormones are elevated, so there must be a high T3 and/ or T4. 

In addition to lab tests, diagnosis of thyroid disease generally involves a review of signs and symptoms, physical examination of the neck to feel for masses or nodules, while noting the condition of hair, nails, and eyes, with imaging and ultrasound tests to further evaluate findings if needed. A primary care physician can make the diagnosis and formulate an effective treatment plan, but a physician who specializes in the thyroid, an endocrinologist, is very helpful, and may be required in some cases. 

Once diagnosed, treatment is aimed at correcting the imbalance and returning thyroid hormone levels to normal, in order to alleviate the symptoms the person is experiencing. This can be done in a variety of ways, depending on the cause, and whether the imbalance has resulted in a hyper- or hypothyroid condition. 

Hyperthyroidism Treatment

Several treatments for hyperthyroidism exist. The best approach depends on your age, personal preference, physical condition, and the underlying cause and severity of your disorder. 

Radioactive Iodine 

Taken by mouth, radioactive iodine is given to a large percentage of adults with hyperthyroidism, as it effectively destroys the cells of your thyroid, preventing it from making high levels of thyroid hormones. It also causes the gland to shrink, which may make it a good choice in cases of goiter. Symptoms usually subside within several months, and excess radioactive iodine disappears from the body in weeks to months after treatment is discontinued. This treatment may cause thyroid activity to slow enough to actually be considered underactive, meaning that it may result in secondary hypothyroidism; so you may eventually need to take medication every day to replace thyroxine. Common side effects include dry mouth, dry eyes, sore throat, and changes in taste. Precautions may need to be taken for a short time after treatment to limit or prevent radiation exposure to others.

Antithyroid Medications 

Medications like methimazole (aka Tapazole) and propylthiouracil gradually reduce symptoms of hyperthyroidism by preventing your thyroid gland from producing excess amounts of hormones. Symptoms usually begin to improve within several weeks to months, but treatment typically continues for at least one year, and often longer. For some people, this clears up the problem permanently, but other people may experience a relapse. These drugs can be pretty gnarly. If you’re allergic, you can develop skin rashes, hives, fever, or joint pain. They can make you more susceptible to infection, and can cause serious liver damage, sometimes even leading to death. Because propylthiouracil has caused far more cases of liver damage, it should really only be used when you can’t tolerate methimazole.

Beta Blockers

Beta blockers such as propranolol and Inderal are usually used to treat high blood pressure. They don’t affect thyroid levels, but they can ease some symptoms, such as tremor, sweating, rapid heart rate, and palpitations. For this reason, your physician may prescribe them to alleviate symptoms until your thyroid levels are closer to normal. For patients with temporary forms of hyperthyroidism, ie thyroiditis, inflammation of the thyroid gland, beta blockers may be the only treatment required. Once the thyroiditis resolves, they can be discontinued. These medications are generally well tolerated, but aren’t recommended for people who have asthma, and side effects may include fatigue and sexual dysfunction.

Surgical Thyroidectomy

In a thyroidectomy, most of your thyroid gland is permanently removed. If you’re pregnant, can’t tolerate antithyroid drugs, and don’t want or can’t have radioactive iodine therapy, you may be a candidate for thyroid surgery- although this is usually an option of last resort, as it is permanent. Risks of this surgery include damage to your vocal cords and parathyroid glands, those four tiny glands situated on the back of your thyroid gland that help control the level of calcium in your blood. Postoperatively, you’ll need lifelong treatment with synthetic hormone to supply your body with normal amounts of thyroid hormone. If your parathyroid glands are also removed, you’ll need medication to keep your calcium levels normal as well.

Hypothyroidism Treatment

If you have hypothyroidism, low levels of thyroid hormones, the main treatment option is to replace the hormone. Daily use of the synthetic form of thyroid hormone thyroxine, called levothyroxine, ie Levo-T and Synthroid, restores adequate hormone levels, and reverses the signs and symptoms of hypothyroidism. Determining proper dosage may take time, but you should start to feel better soon after you start treatment. To determine the proper initial dosage, your physician may check your TSH level after six to eight weeks. With a proper diet, the medication will gradually lower cholesterol levels elevated by the disease, and may also reverse any weight gain. Treatment with levothyroxine will be lifelong, but because the dosage you need may change, your physician should check your TSH levels periodically as needed. If you have coronary artery disease or severe hypothyroidism, your physician may start treatment with a smaller dose and increase it gradually. This progressive replacement allows your heart to adjust to the increase in metabolism.

Levothyroxine

Having excessive amounts of this hormone can cause side effects, such as increased appetite, insomnia, heart palpitations, and tremor or shakiness. It causes virtually no side effects when used in the appropriate dose and is relatively inexpensive, but try to stick to the same brand, as there can be some variances in dosing. Don’t skip doses or stop taking it because you’re feeling better; if you do, your symptoms will return. Food hinders absorption of levothyroxine, so it should be taken on an empty stomach at the same time every day. Ideally, you take it in the morning and wait one hour before eating or taking other medications. If you take it at bedtime, wait four hours after your last meal or snack. Certain medications, supplements, and even some foods may seriously affect your ability to absorb it. Tell your physician if you eat large amounts of soy products or a high fiber diet, or you take other medications, such as iron supplements or multivitamins that contain iron, aluminum hydroxide, which is commonly found in antacids, and calcium supplements. 

Thyroid Disease: Prognosis 

Generally speaking, even if you have a thyroid disease, you can usually live a normal life without many restrictions, as long as you have appropriate treatment. The overall prognosis varies depending on your diagnosis. With hypothyroidism, your levels and overall symptoms may improve with medication, but it’s a condition you’ll be treating for the rest of your life. You’ll take medication daily, and your physician will likely monitor you to make adjustments over time if needed. But this is not necessarily the case with hyperthyroidism. If antithyroid medications work, then your thyroid hormone levels will most likely return to normal without any further issues. That said, once you have any form of thyroid disease, your physician may need to monitor your condition with occasional blood tests to make sure your thyroid hormones are at optimal levels.

Thyroid Disease: Complications

As with any disease, early diagnosis and treatment of symptoms improves the long term outlook. The complications of undiagnosed, uncontrolled, and/or inadequately controlled thyroid disease can lead to a number of health problems that can affect your long term quality of life, and in some cases, can even be life threatening. 

Even if you are under treatment or have received treatment for thyroid disease, if you start to notice signs of any of the following issues, see your physician to check your thyroid levels, or seek emergency treatment when appropriate.

Hyperthyroidism: Complications

Heart problems

Some of the most serious complications of hyperthyroidism involve the heart. These include a rapid heart rate, a heart rhythm disorder called atrial fibrillation, which increases your risk of stroke, and congestive heart failure, a condition in which your heart can’t circulate enough blood to meet your body’s needs.

Brittle bones

Excess thyroid hormone interferes with your body’s ability to incorporate calcium into your bones, so untreated hyperthyroidism can lead to weak, brittle bones and osteoporosis. 

Eye problems

People with Graves’ Disease can develop eye problems, including bulging, red or swollen eyes, sensitivity to light, and blurry or double vision. When left untreated, severe eye problems can lead to vision loss.

Red, swollen skin

People with Graves’ disease can develop Graves’ dermopathy. This affects the skin, causing redness and swelling, often on the shins and feet.

Thyroid Storm

Thyroid storm, aka thyrotoxic crisis, is a life threatening hypermetabolic state induced by excessive release of thyroid hormones, resulting in a sudden worsening of symptoms. An individual’s heart rate, blood pressure, and body temperature can reach dangerously high levels, causing delirium. This requires urgent medical attention, as without prompt, aggressive treatment, thyroid storm is often fatal.

Hypothyroidism Complications

Goiter

Constant stimulation of your thyroid to release more hormones may cause the gland to become larger, a condition called goiter. Although it’s generally not painful, a large goiter can affect your appearance and may interfere with swallowing or breathing.

Heart problems

Hypothyroidism puts you at greater risk for heart disease and heart failure, and can raise your levels of LDL, low-density lipoprotein or “bad” cholesterol.

Mental health issues

Hypothyroidism can cause depression that becomes more severe over time. You may notice decreased interest in activities you used to enjoy. It can also cause slowed mental functioning, and memory or concentration lapses.

Peripheral neuropathy

Long term uncontrolled hypothyroidism can cause damage to your peripheral nerves that carry information from your brain and spinal cord to the rest of your body. Peripheral neuropathy causes pain, numbness, and tingling in affected areas, most often the legs and feet.

Joint pain

Uncontrolled hypothyroidism can cause you to have aches and pains in your joints and muscles, as well as tendonitis.

Infertility 

Low levels of thyroid hormone can interfere with ovulation, which greatly impairs fertility. In addition, some autoimmune causes of hypothyroidism can also impair fertility.

Myxedema

Myxedema is a life threatening condition that can result from undiagnosed hypothyroidism. The term “myxedema” can be used to mean severely advanced hypothyroidism. But it’s also used to describe skin changes in someone with severely advanced hypothyroidism. The classic skin changes include swelling of your face, including lips, eyelids, and tongue, and/ or the swelling and thickening of skin anywhere on your body, but especially on your lower legs. Signs and symptoms include intense cold intolerance and drowsiness, followed by profound lethargy and unconsciousness. In people with severe hypothyroidism, trauma, infection, exposure to the cold, and certain medications can trigger a life threatening condition called myxedema coma, which causes a loss of consciousness and hypothermia, extremely low body temperature. If you have signs or symptoms of myxedema, you need immediate emergency medical treatment.

That’s all for this week, folks. Next week will be devoted to thyroid disease and mental health issues. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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The Thyroid, Part Trois

The Thyroid, Partie Trois

Hello, people- welcome back to the thyroid blog! Last week, we took a deep dive into all of the causes and symptoms of hypothyroidism and hyperthyroidism, and today I’ll get into diagnosis and testing. Before I do, I just want to highlight some key points from last week and squeeze in a couple of other little facts, or “factlets” if you will. As I mentioned last week, hypothyroidism- underactive thyroid causing low hormone levels- is far more common than hyperthyroidism, with its overactivity and elevated hormone levels, but about 60 percent of people are unaware of their diagnosis at all. Thyroid disease can occur in anyone at any time, but it’s more common in women, and risk increases with age. In the United States, prevalence is generally highest in Caucasians, followed by Mexican Americans, then African Americans.

About 95 percent of cases of hypothyroidism are due to a problem in the thyroid gland itself, so they’re called primary hypothyroidism. However, certain medications and diseases can also decrease thyroid function, and this is called secondary hypothyroidism. An example of this may be when there’s a problem with the pituitary gland- the endocrine gland that controls the thyroid- and that results in decreased production of TSH, thyroid stimulating hormone, and as a result, the thyroid produces less hormone. Another example of secondary hypothyroidism that’s important to note actually involves hyperthyroidism- specifically after medical treatment for hyperthyroidism. When you have treatment for hyperthyroidism that includes surgical removal of the thyroid, called thyroidectomy, or even radioactive iodine treatment to destroy thyroid tissue and reduce hormone levels, you can then develop a secondary issue related to these decreased thyroid hormones, and this would be considered secondary hypothyroidism. And sometimes, a condition of tertiary hypothyroidism can occur. This happens when an underactive thyroid results from a problem with the hypothalamus. The hypothalamus is the endocrine gland responsible for stimulating the pituitary, which in turn is responsible for stimulating the thyroid. In cases of tertiary hypothyroidism, the problem with the hypothalamus stops up the works- the pituitary isn’t properly stimulated, so the thyroid isn’t properly stimulated, and as a result, it doesn’t produce enough thyroid hormone. Hence tertiary hypothyroidism.

Thyroid Regulation

The system by which the thyroid gland is regulated is what’s called a negative feedback loop. The thyroid regulation loop includes the two aforementioned endocrine glands- the hypothalamus and pituitary- in addition to the thyroid. Here’s how thyroid regulation works: the hypothalamus secretes its hormone called TRH, thyrotropin-releasing hormone. TRH stimulates the pituitary gland to produce TSH, thyroid-stimulating hormone. TSH, in turn, stimulates the thyroid gland to secrete its hormones T3 and T4. When the level of these thyroid hormones is high enough, the hormones holler back to stop the hypothalamus from secreting TRH, and that stops the pituitary from secreting TSH, which then prevents the thyroid from secreting more hormones. So when T3/ T4 get high enough, they holler back ‘No! Stop!’ – that’s the negative bit- and that stops the loop. Clearly they don’t actually holler back, they “feedback” to stop the loop, which is why it’s called a negative feedback loop. When that feedback happens, without the stimulation of TSH, the thyroid gland stops secreting its hormones T3 and T4, and the level of thyroid hormone starts to fall. 

When all three glands are functioning normally, thyroid production is regulated to maintain relatively stable levels of thyroid hormones in the blood. But if the thyroid gland is underactive- doesn’t produce sufficient T4/ T3- either due to thyroid issues or to pituitary issues/ insufficient TSH, then the affected person experiences symptoms of hypothyroidism, such as weight gain, dry skin, cold intolerance, irregular menstruation, and fatigue, etc. If the thyroid gland is overactive- produces too much T4/ T3- the affected person experiences symptoms associated with hyperthyroidism, such as rapid heart rate, anxiety, weight loss, difficulty sleeping, tremors, and eye issues, etc. I gave a much more complete list of symptoms last week so check that out if you need to refresh your memory.  

Thyroid Disease: Diagnosis and Testing 

Thyroid disease can be difficult to diagnose, because the symptoms are easily confused with those of other conditions. Fortunately, there are specific tests that can determine if your symptoms are being caused by a thyroid issue. These include lab tests, imaging, and physical exams.

Thyroid Lab Tests

One of the most definitive ways to diagnose a thyroid problem is through blood tests. These give an indication of how your thyroid gland is functioning, by measuring the amount of thyroid hormones in your blood. I imagine some of you have seen ads on the interwebs for home thyroid screening kits. You get it, lance your finger, send it in, and five days later, you get the results. I’m sure they’re pretty limited, and it’s probably better just to see your primary, but if you have symptoms and you can’t do that for some reason- say a no insurance sitch- and you don’t want to spend a small fortune on bloodwork to satisfy a hunch, then a home kit probably wouldn’t be the worst idea- definitely better than ignoring it. 

No matter how you get labs, measuring hormone levels sounds pretty straightforward, but this is the endocrine system we’re talking about here people, so it’s not that simple… There are multiple tests to measure function, but I’m going to simplify it as much as possible and only talk about three: TSH, T4 and T3. During thyroid diagnostics, there are so many tests that can be done, but these three, singly or in combination, are always among them. They offer the best snapshot of thyroid function, even post diagnosis, for monitoring treatment efficacy.

TSH Test

Arguably the most useful thyroid test, a TSH test measures the levels of thyroid stimulating hormone made by the pituitary gland. Looking at TSH is often the best way to initially test thyroid function, and changes can even serve as an early warning system, because they often occur before the actual level of thyroid hormone in the body becomes too high or too low and starts causing major symptoms.

Doctors generally consider TSH levels to be within a normal range if they are between 0.4 and 4.0 milliunits per liter (mU/l). I should note that this normal range can vary based on a person’s age, as ranges tend to increase as a person gets older. It can also vary in pregnant women. That said, research hasn’t shown a consistent difference in TSH levels between males and females. Some studies suggest higher levels in males, while others suggest the same in females, but any such difference appears quite small, and it’s unlikely to be clinically relevant.

Most labs use the following reference values for TSH levels for what is considered normal vs low, indicating hyperthyroidism vs high, indicating hypothyroidism:

Low TSH: 0 to 0.4 = Hyperthyroidism

Normal TSH: 0.4 to 4 = Normal

Elevated (mild) TSH: 4 to 10 = Mild hypo

High TSH: >10 = Hypothyroidism

These are the commonly accepted values, but there is some debate about the ranges- some studies suggest that normal levels are more likely to fall between 0.5 and 2.5 milliunits per liter (mU/l) so I suspect far more people would qualify as hypothyroid. 

A low TSH level indicates that the thyroid is producing too much thyroid hormone, meaning hyperthyroidism. It may seem counterintuitive at first glance, how a low level of one thing could cause overactivity of another, but low TSH levels being indicative of overactive thyroid makes sense in terms of the negative feedback mechanism: when the thyroid gland is secreting high levels of hormones, the pituitary gland is told to stop producing TSH, so TSH would be expected to be low.

On the flip side, a high TSH level indicates that the thyroid is not secreting enough thyroid hormone, meaning hypothyroidism. In this case, not only won’t the pituitary gland be told to stop making TSH, it will actually produce more TSH to try to compensate, to make the thyroid secrete more hormone. 

T4

A T4 test measures the blood level of thyroxine, the main hormone that accounts for about 95% of all thyroid hormone circulating in the blood at any given time. A typical normal range is generally about 4.5 to 11.2 mcg/dL, micrograms per deciliter, though I’ve also seen 5.0 to 12, it varies among different laboratories. Just so you’re aware, T4 exists in the body in two forms- bound and free- and there are a few different types of T4 tests, but I’m applying the KISS principle, and that’s too complex for our purposes today. But check it out if you’re interested. 

High levels in any T4 test generally indicate an overactive thyroid, or hyperthyroidism, while low levels in any T4 test generally indicate an underactive thyroid, or hypothyroidism.

It’s important to note that T4 levels are affected by several medications and medical conditions. Estrogen, oral contraceptives, methadone, amiodarone, pregnancy, liver disease, and hepatitis C can cause a high T4 level. Testosterone or androgens, anabolic steroids, lithium, phenytoin, propranolol, interferon alpha, and interleukin-2 can cause a low T4 level. 

The T4 test and the TSH test are the two most common thyroid function tests, and they’re usually ordered together. When their results are looked at together, they can offer a snapshot of overall function, as well as potentially suggest a cause for an abnormality. In fact, these are the tests I mentioned last week that are routinely performed on newborn babies to identify a low-functioning thyroid gland- a condition called congenital hypothyroidism- which, if left untreated, can lead to those severe developmental disabilities.

As a practical example of how looking at T4 and TSH together can give you an idea of the cause of an abnormality, consider this hypothetical: say lab results show low T4, indicating hypothyroidism. If TSH testing shows an elevated or high TSH, this would indicate that the problem is with the thyroid gland itself, because the pituitary is doing its job properly- you’d expect TSH to be high when hormones are low. So this would be like 95% of cases, primary hypothyroidism. Contrast that same low T4 with a TSH test that shows low TSH. That would indicate that the pituitary gland is the likely cause, because TSH should be high, and it’s not, so this would be considered a case of secondary hypothyroidism. 

T3 Test

A T3 test measures the level of the thyroid hormone triiodothyronine, which normally accounts for about 5% of thyroid hormone circulating in the blood at any given time. Like T4, T3 also exists in two forms. If T4 tests and TSH tests suggest hyperthyroidism, a T3 test is usually ordered to support the diagnosis, and T3 testing is especially useful in helping determine the severity of the hyperthyroidism present. It may also be ordered if you’re showing symptoms of an overactive thyroid gland, but your T4 and TSH aren’t elevated. In hypothyroidism, T3 testing is rarely helpful, because it’s generally the last hormone to become abnormal. Many factors influence T3 levels, including age, sex, and some health conditions, such as liver disease, and of course pregnancy. As such, an abnormal T3 level doesn’t always mean that a person has a thyroid condition.

A normal T3 level might be somewhere between 100 to 200 nanograms per deciliter. A high T3 level is indicative of overactive thyroid, or hyperthyroidism, and a low T3 level is indicative of underactive thyroid, or hypothyroidism. That said, patients can be severely hypothyroid- with a low T4 and high TSH- but still have a normal T3 level. That’s why it’s not super helpful in many hypothyroid patients.

T4 vs T3

In some individuals with hyperthyroidism and low TSH, only the T3 is elevated and the T4 is normal, and vice versa. In some specific types of thyroid diseases, the levels and proportions of T3 and T4 in the blood change, and in doing so can actually provide diagnostic information. For example, a pattern of increased T3 vs T4 is characteristic of the autoimmune condition called Graves’ disease, the most common cause of hyperthyroidism in the US. On the other hand, severe illness and medications- like steroids and amiodarone- can decrease the amount of thyroid hormone the body converts from T4 to T3, resulting in a lower proportion of T3. As a result, depending on the individual and the type of disease, generally the best way to get an accurate depiction of thyroid function is to look at blood levels of all three of these hormones: TSH, T4, and T3.

In addition to these most common hormone level tests, there are several thyroid antibody tests that can be run, especially during an initial diagnostic workup, to help identify and confirm different types of autoimmune thyroid conditions, such as Hashimoto’s Thyroiditis and Graves’ Disease. There’s also antibody testing; microsomal antibodies called TPO, thyroglobulin antibodies, aka TG abs, and stimulating immunoglobulins and blocking immunoglobulins. So many other components that can be part of thyroid disease. As part of a diagnostic workup, a physician may also look at calcitonin and thyroglobulins to look for potential hyperplastic, or cancerous and/ or inflammatory processes. 

One last note on thyroid labs, triglyceride levels may also be tested, because these can be an indicator of metabolic rate, and that’s what the thyroid controls. For instance, having very low triglycerides can be a sign of an elevated metabolic rate, so could support or suggest a diagnosis of hyperthyroidism.

Imaging Tests

If your blood work suggests that your thyroid gland is overactive or underactive, your doctor may order imaging tests to assist in diagnosis. Ultrasound can be used to examine and measure the size of the entire thyroid gland- as well as any masses that may be present within it- and then determine if a mass is solid or cystic. A thyroid uptake scan can be used to see if the thyroid is overactive; specifically, it can reveal whether the entire thyroid or just a single area of the gland is causing the overactivity. Based on these findings, a physician may want to sample tissue from the thyroid to check for cancer. Other imaging tests like CT or MRI can be used to look for things like pituitary tumor that could be causing the condition.

Physical Exam

Another way to quickly check the thyroid is with a physical exam in your healthcare provider’s office. This is a very simple and painless test where your provider feels your neck for any growths or enlargement of the thyroid. There are plenty of resources on the great interwebs that claim to make you an expert in self exam to determine thyroid health, but I think that’s a pretty dubious claim. If you think you might have a thyroid issue, see your primary. Or at the very least, order a home screening kit, lance your finger, and send it in. 

Next week, I’ll start with treatment for hyper and hypothyroidism; I’ll cover meds and modalities, as well as how diet and nutrition can be used to help manage or possibly prevent thyroid dysfunction. 

hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Thyroid 2

Welcome back, people! Last week I introduced a new topic- the thyroid- and hopefully you remember that it’s a butterfly shaped endocrine gland that wraps around the windpipe in the forward aspect of the middle throat. It plays a major role in regulating the body’s metabolism, growth, and development by production and release of thyroid hormones, called T3 and T4, into the bloodstream. When it doesn’t work properly, it can have a huge impact on multiple systems throughout the entire body. We also talked about how all of the functions of the endocrine glands are interlinked, and that the thyroid works especially closely with the pituitary gland located in the brain. In order to make the right amount of T3 and T4, the thyroid gland needs the help of the pituitary, to “tell” it- through its own hormone called thyroid stimulating hormone, TSH- when to produce and release more or less hormones into the bloodstream. And we left off with an introduction on the two basic states that result from thyroid disease or dysfunction: hyperthyroidism, when you make too much thyroid hormone, and hypothyroidism, when you make too little. 

This week, we’ll get deeper into thyroid disease and talk about the various symptoms of thyroid imbalance. But I should remind that the endocrine system and the thyroid are very dynamic and can change temporarily in response to normal natural processes other than disease. If and when the body needs more energy in certain situations- if it’s during a growth spurt, time in a very cold environment, or during pregnancy for example- the thyroid gland may temporarily produce more hormones. That increase in T3 and T4 increases the basal metabolic rate, so all of the cells in the body work harder. That causes a faster pulse and stronger heartbeat, a rise in body temperature, and activation of the nervous system and then other systems needed to accomplish whatever the situation may call for. Because the cells are working harder, they need more energy, so energy stored in the liver and body is broken down and utilized faster, and food is used up more quickly as well. When the situation has ended- say the growth phase is over, or mom has the baby- the demand is lessened, the thyroid will produce less T3 and T4, the basal metabolic rate will slow, and energy requirements will reduce to previous levels.  Ultimately, the thyroid and entire endocrine system will return to their previous functional levels, ready to respond next time. 

Thyroid Disease by the Numbers

Thyroid disorders are very common, and very commonly run in families, and affect more than 12 percent of Americans, or an estimated 20 million people. They can occur in anyone- men, women, teens, children, or infants- at any time, meaning they can be present at birth or may develop later. Hypothyroidism is much more common than hyperthyroidism, though the latter is easier to diagnose. About one in 20 people has some kind of thyroid disorder, which may be temporary or permanent, and up to 60 percent of people with thyroid disease are unaware of their condition. While they can occur in anyone, thyroid disease affects 5 to 8 times more women than men, so one woman in 8 will develop some type of thyroid disease at some point in her life. 

When the thyroid is properly balanced, it produces and replaces just the right amount of hormones to keep your metabolism working at the proper rate. When the thyroid makes too much hormone, as in hyperthyroidism, that’s sometimes also called overactive thyroid. And the flip-side of this, when your thyroid makes too little hormone, in hypothyroidism, that’s sometimes called underactive thyroid. These conditions can be standalone or caused by other diseases and conditions that impact the way the thyroid gland works, including genetic and inherited disease.

Hyperthyroidism Causes and Conditions

There are several conditions that can cause overactive thyroid, or hyperthyroidism. The most common cause is an inherited autoimmune disorder that affects 1% of the general population, called Graves’ disease. This causes immune cells attack the thyroid gland, which responds by enlarging and secreting excess thyroid hormone. Immune cells may also go on to attack the muscles and connective tissue of the eyes, causing them to bulge, a state known as exophthalmos, and this eye condition is usually then referred to as thyroid eye disease or Graves’ eye disease. 

Thyroid nodules, which are small, round, usually benign masses present within the thyroid gland tissue, can also cause thyroid overactivity. There may be a single autonomously functioning nodule or a condition called toxic multinodular goiter, where there are multiple nodules within the thyroid which produce too much hormone. As the nodules increase in size and/ or number, it can cause a large, externally obvious swelling called a goiter in the neck. 

Having excess iodine in your body can also stimulate the thyroid to make more hormone than it needs, since iodine is the mineral used to make T3 and T4. Excessive iodine can be found in some cough syrups and other medications like amiodarone, a heart medication. 

An inflammatory process of the thyroid called thyroiditis may also cause hyperthyroidism. The person may or may not be aware of it, as it can be painful or not felt at all. In early stages of some types of thyroiditis, the thyroid may release or leak hormones that were stored there, and this hyperthyroid state can last for a few weeks or months. If it continues, the inflammation will eventually impair the production of thyroid hormone, and this will result in hypothyroidism.

Hypothyroidism Causes and Conditions

Some of the conditions associated with underactive thyroid, or hypothyroidism, include other types of thyroiditis, where the swelling of the thyroid gland impairs hormone production. Hashimoto’s thyroiditis is the most common cause of hypothyroidism. This is an inherited autoimmune disorder whereby the body’s own immune cells attack the thyroid, causing inflammation and damage to the tissue that inhibits or halts production of hormone. 

Postpartum thyroiditis is a usually temporary condition that occurs in 5% to 9% of women after childbirth, whereby the thyroid is temporarily inflamed and underactive as a result. 

An iodine deficiency is a common cause of underactive thyroid, or hypothyroidism, outside of the US. When the body is deficient in iodine, it simply doesn’t have enough to produce a sufficient amount of T3 and T4 hormone. Even today, iodine deficiency affects several million people around the world. 

Sometimes, the thyroid gland simply doesn’t work correctly from birth, and for obvious reasons, this can have severe implications. This condition affects about 1 in 4,000 newborns. If left untreated, the child can have both physical and mental issues in the future. Because of the potential consequences, all newborns are given a screening blood test in the hospital to check their thyroid function.

Thyroid Disease Risk Factors

The causes of thyroid dysfunction are largely unknown, but there are several factors that can place you at a higher risk of developing a thyroid disease. The first and most obvious is if you have a family history of thyroid disease, as it is commonly familial. Also, if you have had treatment for a past thyroid condition, such as a partial thyroidectomy, or cancer treatment such as radiation, you are more likely to have thyroid issues later. If you are Caucasian or Asian your risk is slightly higher. If you have prematurely graying hair, your risk for developing thyroid disease is higher. In addition, if you have certain other medical conditions like Down Syndrome, Turner syndrome, and bipolar disorder, it increases your risk. If you have autoimmune or related disorders, you are at especially increased risk: lupus, rheumatoid arthritis, pernicious anemia, celiac disease, type 1 diabetes, primary adrenal insufficiency, Sjögren’s syndrome, Addison’s disease, or vitiligo. If you take a medication that’s high in iodine, such as amiodarone, this excess iodine increases the risk for developing hyperthyroidism. And if you are over 60 years old, your risk increases. This is especially true in women, as their risk is already so much greater than men. 

Thyroid Disease Symptoms 

Because there are such a variety of symptoms associated with thyroid disease, many can be very similar to the signs and symptoms of other medical conditions, as well as general stages of life changes. This can make it difficult to know if your symptoms are related to a thyroid issue or something else entirely. 

Symptoms of Hyperthyroidism

Because the thyroid is overactive, it speeds cellular activity and generally causes the body processes to move faster. This causes the body to use energy too quickly, so people with hyperthyroidism usually have increased appetite, and may feel weak unless they consume more food to keep up with energy demands; and even if they do, they may still lose weight unintentionally. In addition, it may cause them to have trouble sleeping and sleep disturbances, confounding the fatigue they feel. Hyperthyroidism also tends to cause increased heart rate, stronger heart beat, tremors, heat sensitivity, itching, and increased sweating. It often results in feelings of anxiety, irritability, and nervousness, and causes racing thoughts, and difficulty focusing on one task. It may cause an enlarged thyroid gland to the point of goiter, where it is visible externally, as well as problems with vision or eye irritation, including protruding or bulging eyes called exophthalmos. Women with hyperthyroidism will typically have light and irregular menstrual periods. And rarely, men with hyperthyroidism can see some breast development. Be aware that if someone experiences symptoms like irregular heart rate, dizziness, shortness of breath, and/ or loss of consciousness, that requires immediate medical attention. Hyperthyroidism can cause atrial fibrillation, which is a dangerous arrhythmia that can lead to strokes as well as congestive heart failure. This is an extreme medical emergency. 

Symptoms of Hypothyroidism

When the thyroid is underactive, body processes move more slowly, and this causes people to feel extremely tired and fatigued. Because cellular processes move more slowly, less energy is required, so less stored energy is utilized. Because the metabolism is sluggish, less food is required and more is stored, so having hypothyroidism makes someone much more likely to gain weight. Mentally, people commonly experience depression, mental slowness, and forgetfulness. Physically, they commonly experience constipation, puffy face, muscle cramps, dry skin, brittle nails, dry and coarse hair, hair loss, hoarse voice, and intolerance to cold temperatures. They may experience fatigue and shortness of breath with exercise. They are likely to have joint pain, stiffness, and swelling, and even carpal tunnel syndrome. Women with hypothyroidism are likely to have frequent and heavy menstrual periods.

Kids and teens with hypothyroidism can have all of the signs above, but may also have delays in sexual maturity or puberty, growth delays and shorter stature, slow mental development, and slower development of permanent teeth. 

Infants and babies with hypothyroidism may have no symptoms at all. But if symptoms do present, they can include cold hands and feet, constipation, extreme sleepiness, weak or hoarse cry, little or no growth, poor feeding habits, puffy face, stomach bloating, swollen tongue, and umbilical hernia. In addition, you may notice low muscle tone, sometimes called floppy baby, as well as persistent jaundice, which is yellowing of the skin and whites of the eyes. These symptoms require immediate medical attention. 

I think we’ll pick up there next week, with complications and prognosis.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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The Thyroid

The Thyroid

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.

Thyroid Imbalance

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.  

I hope you enjoyed today’s blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Phenylethylamine (The Love Molecule)

Phenylethylamine

We’ll be starting a new series next week, so this week I thought we’d just keep it light this week- have some fun. Believe it or not, this week’s topic, phenylethylamine, is a good time. Before I tell you why and how, let’s go over how to say it. Phenyl is pronounced just like the green herb fennel. Ethyl is exactly like it sounds- like Lucy’s sidekick. And amine is pronounced with a long a, like Canada, ehh… plus mean, as in “what do you meanphenylethylamine is a good time, Dr. A?” Fennel-Ethyl-ehh-mean. While it’s fun to say, science nerds, myself included, call it PEA to make life easier. I’m all about that, so that’s what I’ll be using hereafter.

So, what is PEA? It’s a naturally produced alkaloid, which is basically a biologically active chemical, with similar pharmacological properties to amphetamine. In the human brain, it functions as a neuromodulator, sort of an influencer of the happy hormones, the endorphins like dopamine and serotonin. While it’s produced naturally in the body, PEA is also found in nature, most notably in a particular strain of blue green algae called Aphanizomenon flos-aquae or AFA. It’s also found in many common foods, and can be easily synthesized in the lab as well. 

There is evidence demonstrating PEA’s efficacy as an antidepressant and for ADHD, and it’s also responsible for the brain chemicals involved with “runner’s high” and even love and monogamy. In fact, PEA is commonly referred to as the “Love Molecule.”

That’s my best Barry White voice: luuuvvv mol-e-quuullle.

People who don’t make enough PEA naturally may be helped by taking it as a supplement. That’s where that blue green algae called AFA comes in- it’s loaded with PEA, and commonly taken as a supplemental source. In addition to helping stave off depression, and to improve mood and attention, some people also use PEA for athletic performance and weight loss, because it’s properties are so similar to amphetamine. But for that same reason, taking too much of it can induce side effects that are similar to amphetamine as well. 

As I said, it’s found in many foods, but most popularly, it’s found in chocolate. Yum! It’s actually believed to be the component responsible for producing chocolate’s positive effects on mood. One UK study I read looked at over 13,000 people, and found that individuals who reported eating any dark chocolate within two 24-hour periods were 70 percent less likely to report “clinically-relevant depressive symptoms,” as compared to those who ate no chocolate at all. In other words, eating dark chocolate made them feel happier. This is not only because chocolate contains PEA, which induces those happy hormone endorphins, but also because chocolate contains a higher concentration of antioxidants that reduce inflammation, which is directly linked to the onset of depression.

There have been a number of studies that show other health benefits of dark chocolate. Daily consumption of dark chocolate can reduce LDL, the “bad cholesterol” levels we’ve all heard about. By doing so, dark chocolate can help reduce the risk of heart disease by as much as 30 percent. It’s also been shown to reduce the risk of dying from a stroke by nearly 50 percent. Studies even show that eating dark chocolate at least once per week can also improve cognitive functioning.

So is dark chocolate a superfood? Maybe so- especially when you consider that on top of all of the health benefits, it also acts like an aphrodisiac, because it stimulates the production of those endorphins, and they’re the chemicals in the brain that create feelings of pleasure. After all, PEA has earned its reputation as the luuuvvv mol-e-quuullle. But before you reach for a candy bar, there is a small catch- literally. All you need to produce those happy-happy effects is half an ounce of chocolate per day. There’s also a big catch- literally. If you’re watching your weight, even a small amount of chocolate has a big calorie impact. A half-ounce of dark chocolate typically contains between 70 and 80 calories, depending on the percentage of cacao solids- that’s pronounced like Batman’s ka-pow! That’s the paste that results from fermenting, roasting, and crushing the cocoa beans that make it. This cacao then gets mixed with milk and sugar, and tah-dah: chocolate!

Dark chocolate is called dark because it contains more cacoa and less milk and sugar than milk chocolate. While dark chocolate can contain as little as 45 to 50 percent cacao solids, research shows the greatest benefits come from dark chocolates that contain at least 60 percent cacao solids. Some dark chocolates contain as much as 85 percent cacao solids, so if you venture to the darker side, will that make you even happier? Well, that’s the last catch- but this one’s a good one. The evidence suggests that the mood benefits only happen if you enjoy the chocolate you eat. Since that suggests that the experience of eating the chocolate is also an important factor, it’s vital to choose what you like. But keep in mind that white “chocolate” doesn’t count, because it doesn’t contain any cacao solids- it’s not actually chocolate… wah wah wahhh.

The chemical ingredients in the chocolate clearly make an impact, but it’s very interesting to me that the taste matters as well- definitely indicative of a stronger correlation between dark chocolate and mood, so future studies may tell more of the tale. Until then, I’ll happily gather anecdotal evidence. But remember that second catch, people- the big one. If you like dark chocolate, a half-ounce clearly won’t kill you, but it might kill your diet- or at least inflict some damage. 

Luckily, I have a simple solution. Enjoy your half-ounce, then take a fifteen or twenty minute walk, preferably with someone you like- a loved one or friend. That way, you’ll burn off the calories while strengthening your relationship, and you’ll be quadruple dipping on the benefits of eating chocolate: you’ll get the enjoyment of eating it, its mood lifting and cognitive benefits, its general health benefits, and all the benefits of exercise. Not to mention how all of those things work together synergistically, because walking positively impacts mood and cognitive ability as well, as does positive interaction with someone you care about.

It’s a win-win-win-win. And win. 

Next week, I’m starting a new series on the thyroid. I’ll tell you all about how it impacts just about every aspect of your life, and maybe especially your mental state. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like and subscribe.  

Please feel free to share the love- share my blogs and YouTube videos with family and friends!

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Xanax Withdrawl

Xanax Withdrawal

Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.

As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.

They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.

To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.

Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.  

Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary. 

Signs and Symptoms

The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.

Physical Withdrawal Symptoms

As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.

Psychological Withdrawal Symptoms

Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.

Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.

Xanax Withdrawal Timeline

Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected. 

Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.

Factors Affecting Withdrawal

Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present. 

Coping with Xanax Withdrawal

The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax. 

Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.

In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well. 

Alleviating Symptoms of Withdrawal

An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.

Xanax Withdrawal Safety

Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death. 

People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.

The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.

No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Alprazolam Use Disorder

Alprazolam Use Disorder

Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right. 

If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder. 

Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction. 

This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug. 

Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:

-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.

-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.

-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.

-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.

-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.

-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it. 

-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use. 

-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.

-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.

-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.

As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.

Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:

-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.

-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.

-Continued Xanax use despite hazardous circumstances.

-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.

-Continued Xanax use despite experiencing one or more negative personal outcomes.

-Using more Xanax or using it for longer than recommended or intended.

-An inability to stop using Xanax despite an ongoing desire to do so.

-Obsessive craving for Xanax.

-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.

-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.

-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.

These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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CounterfeitDrugs:Fake Xanax

Counterfeit Drugs: Fake Xanax

For this week’s alprazolam blog, I want to know if I can fake you out. We’re going to talk about fake Xanax. Look at the picture above. Can you tell which Xanax are fake? Are you certain? Enough to roll the dice with your life on the pass line? Because, make no mistake- if you get your Xanax from anywhere other than a licensed pharmacy, you are absolutely, positively doing so every single time you take it. By the end of this blog, you’ll definitely know the answer to the first question. As to the second, I’d hope you already know the answer, because even Captain Obvious won’t bother with that one, people. 

When you think of counterfeit drugs, you may not be too concerned if you consider them to be just weakened copycat versions of the real thing, made with a bunch of essentially harmless junk. Probably the worst that could happen is it won’t work, right? Wrong! Obviously, the main problem with counterfeit drugs in general is that they’re clearly illegal and therefore unregulated, so you don’t know what you’re getting. I mean, with counterfeit drugs, there’s no truth in advertising. And helll-ooo, they’re produced in somebody’s gnarly basement, so there sure as hell isn’t any quality control. While they can be cut with innocuous things like baking soda or baby powder, they can also be laced with extremely harmful substances, things like rat poison, bleach, and formaldehyde. Unfortunately, many drug users don’t know, or don’t care, how dangerous it is to ingest substances like these. But there are cases where counterfeit drugs are especially dangerous, and fake or counterfeit Xanax is at the top of that list. In late 2015, the entire country learned this lesson the hard way when in three months, there were nine documented cases where people in San Francisco suddenly overdosed from “Xanax.” To be clear, it wasn’t Xanax at all. That number included a baby, who had picked a tab of it up off the floor and put it in their mouth. It also included one person who didn’t even get to live to regret it. I think we got off pretty easily in that singular event, but obviously more have followed. 

By the Numbers… Without Numbers (?)

Again, since production and sale of fake Xanax is illegal, underground, and unregulated, there aren’t national or global databases to collect information or statistics as there are with other drugs. But I found some reports from various global sources that were interesting. And by that I mean frightening. Some highlight snippets include a report citing that 25% of 2018 drug overdose deaths in Northern Ireland were caused by counterfeit Xanax. Another report from U.S. Customs and Border Protection stated that in the first four months of 2020, during unspecified smuggling attempts, their CBP officers seized 27 shipments of fake Xanax, totalling over 35 pounds. I also listened to part of a podcast on the subject that featured an officer from Portland, Oregon talking about a spate of teenage overdoses on fake Xanax, and the subsequent investigation. They apparently did a round up of all the street dealers they could find, and busted down doors and did everything they could to clean up the area. The goal was to get every Xanax pill off the street, and he stated that of all the “Xanax” pills they recovered, not a single one was legit. He didn’t say exactly how many that was, but it seemed like a lot. Every pill in the area was fake. That’s huge. And very scary. 

Fake Xanax: Beyond the Obvious

“Good” counterfeit Xanax pills look exactly like the real thing. And clearly, by “good” I don’t mean that in the traditional sense. That means they have the same color, size, shape, and pharmaceutical markings, aka imprints, on the pills as the bonafide prescription versions do. While the difference isn’t obvious to the naked eye, there is one huge difference between real and fake Xanax that makes it especially scary: the latter usually contains fentanyl, an extremely potent opioid that is responsible for countless accidental overdoses in numerous counterfeit and legal preparations. In fact, it’s estimated that many thousands of U.S. citizens ingest a deadly dose of  each year without ever even realizing it. How horribly tragic and senseless is that?  

Fentanyl is a schedule II synthetic opioid that is 50 to 100 times stronger than heroin and morphine, respectively. It is typically prescribed by a specialized physician strictly for patients struggling with severe or chronic pain, and it is such a potent and dangerous drug that the DEA has advised officials to take extra protective precautions, like gloves, even just when handling it, to avoid accidental death. This is because it is easily absorbed through the skin, and takes so little to be lethal. While other opiate doses are measured in milligrams, fentanyl is dosed in micrograms, and an amount equal to two grains of salt is lethal to nearly all individuals. Clearly, a drug that is 100 times stronger than morphine is no joke, and it officially now kills more Americans annually than any drug in history.

People who take fentanyl accidentally will be unaware of what they have taken, or how much, so they face an even higher risk of an opioid overdose. In the case of fake Xanax exposure, if or when a person does overdose on it, in the unlikely event that they’re lucky enough to make it to a hospital, it presents a unique problem. As a physician, I can tell you that when a person’s symptoms present differently from what is expected, it delays treatment, and Xanax overdose and fentanyl overdose present very differently. So when it’s reported that a person took “Xanax,” or some pills are found on their person, but their symptoms don’t look like a benzodiazepine overdose, those few minutes a medic or doc takes to assess the situation may be the few that end up costing them their lives. But that can be the case fake percocet or oxycodone as well, because fentanyl is commonly used in producing counterfeit versions of all of those. Even cocaine- maybe especially so because of the cost differential- fentanyl is so much cheaper that it’s very commonly used to cut it. And talk about presenting differently: cocaine and fentanyl overdose are not even remotely similar to one another. Even if users are aware that fentanyl is in the product, and aren’t that concerned about it, there’s still no way to know how much fentanyl is in it, or exactly how potent that fentanyl is. As a result, it is extremely easy to overdose after consuming any counterfeit product. 

Since the pills look exactly like the real thing, it’s nearly impossible to tell the difference. But, if someone consumes counterfeit Xanax made with fentanyl, there will be noticeable symptoms and side effects that wouldn’t ordinarily be present with genuine Xanax. The side effects of fentanyl include excessive itching, slowed breathing, nausea and vomiting, flushed skin, and constricted pupils. These can quickly progress to overdose, and those signs and symptoms are progressively shallow breathing, usually followed by gurgling or choking sounds, or sounds like “snoring,” pale, blue, cold, or clammy skin, limp body or unresponsiveness, and finally suppressed breathing. People often report that they didn’t recognize that someone was overdosing, even though they literally sat there watching it. They usually think they’ve nodded out and are snoring, and then just stop snoring. In reality, they’re really choking, then their breathing is severely suppressed, and when they stop making noise, they’ve simply stopped breathing. Fentanyl also yields some dangerous psychological effects, such as depression, hallucinations, difficulty sleeping, and nightmares. These are all signs to be aware of if you ever take a drug from a questionable source.

Fake Xanax: How it’s Done

Counterfeit Xanax is made using a pill press, which is exactly what it sounds like: it’s a device that is used to press powders together with a binding agent, to make the substance into a solid pill form. Pill pressing devices can be smaller than the size of a person’s palm, or large enough to need a small room for storage. Pill molds are added to the pill press to press the pills into certain sizes and to make markings or indentations. Sometimes they’re called “stamps,” and manufacturers use these to customize the appearance of the pill and mimic the exact imprint used by the legit pharmaceutical company. Currently, it’s not illegal to own a pill press, and in fact, some people use them to make their own vitamins or supplements at home. But it is illegal to own a pill mold that is used in a pill press. As a result, counterfeit pill molds are usually designed in other countries and sold to the U.S. as “spare parts” or “equipment.” This allows street dealers and manufacturers to purchase their supplies without gaining attention from the police, and continue to make fake drugs in their gnarly basements.

Fake Xanax: Why it’s Done

Helll-oooo! People who sell drugs don’t do so because they enjoy it, they do it to earn a profit. It behooves them to find a way to make their drugs cheaper and more potent, because that’s the best way to generate more profit from a smaller amount of product- that’s just common business sense. Believe it or not, many street-level dealers can get their hands on fentanyl very cheaply, either through theft, or through overseas production of cheap, sketchy fentanyl look-a-likes, so they commonly use it to cut their drugs, and this actually makes their products cheaper and more potent. To be clear, these fake products may not even contain the actual primary component. But in cases of fake Xanax, if it does contain actual alprazolam, the combination makes it even more dangerous-  but the fentanyl alone can just as easily provide or mimic the effects the user is looking for. The result is a product that looks and feels pretty much like real Xanax, but is infinitely more dangerous; sold at a fraction of the price, as compared to the real thing, brought to you by your friendly neighborhood street thug. 

Fake Xanax: How to Avoid It

Clearly, the easiest way to avoid purchasing fake Xanax is to never purchase the drug on the streets in the first place. In fact, the only reason anyone should ever take Xanax in the first place is if they have a prescription for it and are instructed to by their doctor. Unfortunately, some people who are prescribed the medication seek out cheaper ways to fill their prescription, such as purchasing it from shady online pharmacies or from overseas stores. But you’d be surprised how enterprising some dealers are, and a “pharmacy” selling counterfeit drugs is certainly not unheard of. So kids, the take home lesson is that if you have a Xanax prescription, you should always get it filled at a licensed pharmacy.

Fentanyl: The Masked Killer

As a final word of caution, I just wanted to include a short synopsis of three stories I read about counterfeit drugs containing fentanyl. None of them have happy endings. 

A 28-year-old smoked “a powdery substance” at his mother’s home, where he was living at the time. His mother found him unresponsive in the living room, and having no idea of what had happened, called 911. He was pronounced dead on arrival. The death investigation determined that the substance had been given to him by a friend, who stated they both thought it was cocaine. Toxicology confirmed that while he had a non-lethal level of cocaine in his system at the time of death, the cause of death was acute fentanyl intoxication- he died of a fentanyl overdose.

A 20-year-old college student suffering from undiagnosed anxiety was panicking about a test the following day, so consumed a single oxycodone pill he had obtained illegally before going to bed. His roommates found him dead the next morning. Toxicology confirmed that he died from a fentanyl overdose.

A 19-year-old purchased two Percocet from a friend. He consumed both pills and subsequently died from an overdose. His friend confirmed the purchase, but then toxicology showed the presence of lethal levels of fentanyl. His friend swore he didn’t know they were fake and was very distraught. That friend was also later found dead of an overdose. It was confirmed that it was also due to fentanyl, but it wasn’t clear if it was suicide or accidental. 

These are cases where four individuals died of fentanyl overdose, with all of them consuming a different drug, and three of them never even realizing they were consuming fentanyl. On that note, have you decided which group of Xanax in the picture were fake? I’ll tell you now: both are fake. Guess it’s a good thing you couldn’t actually choose. Get my point?

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Alprazolam

Alprazolam

Welcome to a brand new blog, people! Last week we talked about mindfulness, so I hope everyone has been trying to practice that in at least some small ways everyday, especially when stressed. If not, the topic of the new series I’m introducing today may be a bit of foreshadowing, as you might need it. Trust me when I tell you that it’s far easier, not to mention more rewarding, just to live a more mindful life. The new topic is alprazolam, which you might better recognize as Xanax, a drug used nearly solely for anxiety, at least when used as intended, but we’ll get to that. 

Today as an introduction, I’ll give you an overview on what you should know about alprazolam if you’re thinking about taking it. But my advice? Don’t, because while it works, it can be so sneakily addictive, in a way that seems almost sinister. Insidious. It took me a second to get there, people. My point is, it will creep in and take over anyone’s life if given the smallest opportunity to do so. We’ll talk more about that later. For now, suffice it to say that it’s so abused by so many people, it’s literally become a threat to public health. I hear stories everyday about how it ruins the lives of good people with only the best of intentions. For that reason, plus more that I’ll get into, everyone should really know the basics about alprazolam. 

Alprazolam belongs to a group of medications called benzodiazepines, aka benzos. Other meds in this group include Valium, Klonopin, and Librium.  You may have seen my YouTube video on benzodiazepines, barbiturates, and alcohol. If not, I’ll put the link at the bottom so you can check it out. Alprazolam, aka Xanax, has a lot of slang names as well, mostly referring to its shape and color. Bricks, zanny bars, blue footballs, and z-bars are the ones that come to mind right now, but there are others used on the street. Speaking of, alprazolam is pretty cheap in the pharmacy. On the street, it’s pretty damn expensive when you consider it can easily cost you your life, but it usually goes for around $3 to $5 per bar or pill, depending on strength. What a bargain. 

Alprazolam, like other benzos, is most commonly prescribed for people with anxiety disorders or panic disorder. Sometimes it’s also used short term for treating severe insomnia, alcohol withdrawal, and prolonged seizures. I myself prescribe it for these indications- very short term and as low dose as possible- because it works well and it’s so fast acting. For anxiety and panic attacks, I almost universally try other meds and methods first, because of its aforementioned insidiousness, but occasionally I might use it as a bridge while the other meds and methods start to work. 

How Alprazolam Works

Like all other benzodiazepines, alprazolam works by binding to specific receptors in the CNS called GABA (gamma-aminobutyric acid) receptors. GABA is an inhibitory neurotransmitter, meaning it works to decrease nerve activity. The simplified pharmacological mechanism looks like this: when alprazolam binds to the GABA receptors, it enhances GABA’s inhibitory activity. This pumps up the GABA, which greatly reduces neural stimulation. This decreased neural activity produces general CNS depression, and elicits the anti-anxiety and sedative-hypnotic effect that’s felt by the person ingesting it. It’s important to note that alprazolam doesn’t affect everyone in the same way. There can be other factors involved, including the person’s mental state at the time the drug is taken, the dose taken, the person’s age, weight, and individual variances in the metabolism of the drug. 

How Alprazolam Feels

Captain Obvious says that this depends on the dose, which I’ll get into next, but when taken as prescribed for anxiety or panic disorders, the idea is that you should feel “normal” after your first dose. The sedative effect should help alleviate the symptoms of anxiety, and calm your body’s response to the anxiety or the stressor. If you take it recreationally, aka without a prescription, the effects you feel would still be dose dependent, and if you take a small dose, in theory you would have the same effects. I say in theory because that would depend greatly on where you get it. If you buy it on the street, you’re probably not taking actual alprazolam. Fake alprazolam is a huge, lethal problem, and I’ll be dedicating an entire blog to that topic in this series. You’ll be shocked. Hint: if you want to live, don’t buy Xanax on the streets! Unlike stimulant drugs like cocaine, which produce a euphoric “high” feeling, recreational alprazolam users describe feeling more relaxed, quiet, and tired, often to the point of passing out for several hours at a time. Some people have memory lapses or amnesia or black out periods, where they can’t remember anything that happened for several hours, even if they’re awake at the time. Equally important is what you should not feel when you take alprazolam, and I’ll cover that below, when I talk about side effects.

Alprazolam Dosing

Alprazolam is available in multiple milligram strengths, 0.25 mg, 0.5 mg, 1 mg, and 2 mg. 

The effects become more significant as the dose increases, so first-time alprazolam users should absolutely start with the lowest possible dose and let your prescribing physician know exactly how it affects you to determine if the dose needs to be adjusted. You don’t ever get to play doctor here, people. Don’t increase the dose on your own, even if you’re an experienced user. This is because higher doses can be fatal for everyone- from first-time users all the way up to people who’ve used it as prescribed for many months or years. Again… don’t take a higher dose than what’s prescribed by your doctor. 

In addition to instant death, high doses are associated with a counterintuitive complication known as the “Rambo effect.” This unusual side effect can happen out of the clear blue sky in anyone taking alprazolam, prescribed or not and experienced or not, and generally presents as the user beginning to display behaviors that are very unlike them. These might include aggression, theft, or promiscuity, but can really be any unusual legal or illegal behavior- the key is that it’s very atypical and seems to occur suddenly. It’s not clear why some people react this way, or how to predict who it will happen to, so it adds a very unwelcome guest to the alprazolam party. 

Alprazolam Metabolism

How alprazolam is broken down and affects you also depends on those aforementioned factors of age, weight, and individual variances in metabolism, but can also be impacted by the presence of other substances and/ or  medications you may be taking. When taken by mouth, alprazolam is absorbed quickly by the bloodstream, so it’s very fast acting. Some people can begin to feel its effects within 5 to 10 minutes of taking the pill, but almost everyone will feel the effects within an hour. One of the reasons why it’s so effective for treating panic attacks and anxiety is that the peak impact from the dose comes so quickly. But, fast acting meds wear off fast too, so the effects are brief. Most people will feel the strongest impacts from the drug for two to four hours, though lingering effects or “fuzzy feelings” may stretch out beyond that for several more hours. Some people even report a hangover type effect as well.

The length of time that alprazolam stays in the body before being excreted also varies person to person by those aforementioned factors. The half-life of alprazolam in a healthy adult averages about 11 hours, meaning that it takes the average healthy person 11 hours to eliminate half of the dose from the bloodstream. Typically speaking, that time would generally be a little shorter for younger people, and longer for older people. It’s important to recognize that you will stop feeling the effects of the alprazolam long before you reach half life.  

It is possible, even likely, to build up a tolerance to alprazolam, and this can happen very quickly. If that happens, you may begin to notice it takes longer to feel the sedative effects of the drug, and that feeling will wear off more quickly. As alprazolam wears off, most people will stop feeling the calm, relaxed, lethargic sensations that the drug is associated with. If you take this medication to relieve symptoms of anxiety, like a racing heart, those symptoms will begin to return long before it’s half-life. If you don’t have these symptoms, you’ll begin to return to feeling “normal.” However, some people who take alprazolam for reasons other than anxiety may find they actually begin to experience feelings of depression and/ or anxiety, even if they’ve never had an issue with these conditions, as the chemicals in their brain adjust to the lack of the drug. This rebound anxiety or depression is usually temporary, but will often happen each time it’s taken. I have a Huntington’s patient who never had any anxiety or depression until his specialist put him on alprazolam for severe muscle spasm, and now it’s a real problem. Sometimes it’s hard to tell what’s worse, the disease or the “cure.”

Alprazolam Side Effects

Captain Obvious says that being aware of potential side effects is very important when considering taking any drug. He also says that should you experience any of these, stop taking it and contact your prescribing physician immediately, or seek emergency medical attention if appropriate. Possible side effects of alprazolam include sleepiness, dizziness, headache, confusion, muscle cramps, decreased appetite, weight loss or weight gain, diarrhea, nausea or vomiting, manic symptoms, difficulty walking, dry mouth, irregular heartbeat, low blood pressure, and blurry vision.

How it Shouldn’t Feel 

When taken properly at prescribed doses, the effects of alprazolam should be mild, but detectable, and the symptoms for which it is prescribed should be decreased. If the drug appears to be having a significant negative impact, seek emergency medical attention and then contact the prescribing physician later. It should go without saying, but don’t take it again. Symptoms to watch for include extreme drowsiness, muscle weakness, confusion, fainting, loss of balance, and/ or feeling lightheaded. You should also seek emergency medical attention if you experience signs of an allergic reaction. Signs may include swelling of the face, lips, throat, and tongue, and difficulty breathing.

Alprazolam Special Considerations

Some people should avoid alprazolam entirely because they may be more sensitive to its side effects, or it could potentially harm them in some other way. This includes pregnant women, older patients, children and teenagers, people with a history of alcohol or drug abuse, and people with certain medical conditions such as respiratory illnesses.

Alprazolam Tolerance, Abuse, Dependence

I cannot overstate the potential for misuse, abuse, dependence, and addiction associated with alprazolam. And it doesn’t “just happen to junkies” people. Some folks without any reason take it recreationally just because they like the way it makes them feel. Others have undiagnosed anxiety disorder, so they start buying it or taking it. Others are prescribed it for anxiety, insomnia, seizures, or severe muscle spasm, but begin to need higher or more frequent doses of it to achieve the same effect; this is known as tolerance. 

Though the routes to get there vary widely, without any intervention, all of these situations usually lead to the same place: dependence and addiction. This happens when the body begins to rely on alprazolam to function normally. Over time, we’ve collected scientific data and anecdotal reports to determine that certain people/ groups are at greater risk for abuse, tolerance, and dependence on alprazolam. These include non-hispanic whites, young adults 18 to 35 years old, people with a current psychiatric disorder, and people with a personal or family history of substance abuse. For these people, taking alprazolam is like playing with fire. If you’re one of them, don’t risk getting burned. 

Alprazolam: Synergistic Interactions

A synergistic interaction occurs when the combined effect of two drugs or substances is greater than the sum of the individual activity of each. As a CNS depressant, alprazolam has synergistic interactions with other CNS depressants, and there are lots of those out there. The biggest example is also the most commonly overlooked one: alcohol. Good ole EtOH. Other examples include: other benzos (duh), opioid analgesics ie OxyContin, Vicodin, morphine etc, barbiturates ie Seconal and Nembutal, hypnotic drugs ie Ambien, heroin, methadone, neuroactive steroids ie estrogen and testosterone, and intravenous and inhalational anesthetics. If you take alprazolam and any of these substances, the alprazolam intensifies the effects of that substance and vice versa, so when taken together, they literally become exponentially more potent than if you used either of them on their own. 

This is because all of these substances also increase neurotransmitter GABA activity in the CNS, slowing the activity of the nervous system, causing the sedative effect. When alprazolam is mixed with any of these substances, because the effects are synergistic and exponentially more potent than just the two combined, you’re at risk of excessive sedation, extreme confusion, prolonged memory loss, seizure, loss of consciousness, respiratory depression, cardiac problems, dangerous accidents from increased clumsiness and sedation, and unintentional death. Please note that these synergistic interactions occur whenever the substances are mixed- even if it is at prescribed doses. 

However, there are some drugs that cannot be combined with alprazolam that you wouldn’t even think about. This includes some oral contraceptives, antifungals, antidepressants, antibiotics, and heartburn drugs. These drugs can affect the pathway that’s responsible for eliminating alprazolam from the body, so that the alprazolam isn’t removed as quickly as it should be. Over time, this can lead to a toxic buildup of the drug, and eventually an overdose. Always speak with your doctor to review meds and discuss potential interactions. In addition, your pharmacist is an excellent resource for any questions about med interactions. Some specific meds that may interact with alprazolam include cimetidine (Tagamet), fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), carbamazepine (Tegretol), diltiazem (Cardizem), isoniazid (Laniazid, Rimifon, Hyzyd, Stanozide, Nydrazid), and cyclosporine (Sandimmune). 

Also, not a medication, but important to remember is… grapefruit juice! Grapefruit juice can block the action of CYP3A4, which is a critical enzyme in the body. Mainly found in the liver and the intestine, it oxidizes small foreign organic molecules, like toxins and drugs, so that they can be removed from the body. When CYP3A4 is blocked, instead of being metabolized, more of the drug enters the blood, and stays in the body longer. The result is too much drug in the body. I should add that there is some controversy surrounding this. The FDA says grapefruit juice does slow alprazolam metabolism, but some studies have published results that indicate it is “unlikely to affect the pharmacokinetics or pharmacodynamics of alprazolam, due to its high bioavailability.” Translating this geek speak to plain english, they’re saying their studies found that grapefruit juice had no effect on how alprazolam was metabolized and cleared from the body, because so much alprazolam is absorbed and available for biological activity in the cells and tissues where it’s metabolized. I say err on the side of caution and avoid alprazolam, or grapefruit juice if you just can’t. I should add that CYP3A4 is involved in the metabolism of other meds as well, so if you drink grapefruit juice, keep that in mind- tell your docs and pharmacist.  

Stopping Alprazolam

I touched on the dependence issue associated with alprazolam, but I’m going to discuss that and withdrawal in more detail in next week’s blog. Regardless, even if you have only taken alprazolam exactly as prescribed, and you’re sure you’re not dependent on it- if you want to stop using it, you must do so with the guidance of your prescribing physician or another healthcare provider, because stopping alprazolam abruptly can lead to serious, medically dangerous withdrawal symptoms and rebound anxiety. Don’t stop alprazolam on your own! Depending on how long you’ve been on it and how much you take, your physician will need to taper your dose, meaning step you down on the dosage until you stop it altogether. This is the only way to go. Withdrawal is no picnic, but stepping down makes it so much easier, and it eliminates the dangers associated with cold turkey. Rebound anxiety from abrupt alprazolam withdrawal is no joke- people who experience rebound anxiety report that their anxiety symptoms are at least at the same level, but usually worse, than they were before starting alprazolam- so not only are they not better, they’re worse. You want to avoid this if at all possible, so don’t stop alprazolam abruptly. 

Speaking of stopping abruptly, that’s it for this week. Next week I’ll talk in depth about alprazolam addiction and withdrawal. And we may have a guest blogger situation. We’ll see. 

I promised you a link to my YouTube video that covers a lot of this information, so here that is. Lots of other vids to check out there too. 

Benzodiazepines, Barbiturates, and Alcohol

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Mindfulness

Mindfulness

At some point in your life, I’m sure someone’s told you, “Life is short, you should stop to smell the roses.” Somebody well intentioned, maybe your Nana, your next-door neighbor Janet, or your favorite uncle Fred, giving you the benefit of their experience, and just telling you to slow down and enjoy every moment. You probably smiled, suppressed an eye roll, noncommittally murmured something in the affirmative, and kept it moving. Nobody actually stops to think about these typically unsolicited pieces of sage advice, right? The very idea is anathema to our frenetic culture of constant multi-tasking and 24/7 connectivity. Well, turns out it might not be the worst idea to actually take it to heart. It seems that science is telling us that there might be something to it- stopping to enjoy the moment may actually be good for your health. It’s a concept called mindfulness, or sometimes mindfulness meditation. 

Last week I finished up the remote work blog, and I considered adding mindfulness as a tip for dealing with stress. It’s actually a great technique to use, because it literally takes less than two minutes, so it’s easy to incorporate into your day as you need it. Essentially, mindfulness is a meditative practice where you focus on being intensely aware of everything you’re sensing and feeling in a present moment, without any interpretation whatsoever. However you’re experiencing life, you simply notice each moment as it unfolds, without any judgment or preconceived notions. You just let it flow and let it go. In this way, you take yourself off of autopilot, which is how most people normally operate, and purposefully engage with the world around you. This actively directs your attention away from whatever kind of thinking is causing you anxiety, and that puts you in a more peaceful present place. Whenever you have a few free minutes, you can practice mindfulness throughout the day, no matter where you are, answering emails, sitting in traffic, or waiting in line. All you have to do is become more aware. That can mean focusing on your breath, your feet on the ground, your fingers typing, or the people and voices around you.

Captain Obvious says that the nervous system is always working in the body, but we’re not really aware of everything it’s doing. All of its automatic functions, such as the heartbeat, digestion, and breathing, are regulated by the parasympathetic nervous system. It’s responsible for our normal, relaxed state, where the body and mind can “rest and digest” as they say. Its counterpoint is the sympathetic nervous system, whose most recognized role comes into play during its “fight or flight” mode. During these threatening situations, the sympathetic nervous system automatically releases stress hormones that flood the system, and we experience a physiological and emotional response in a cascade like fashion. Both branches of the nervous system are clearly very important, but if the sympathetic, “fight or flight” mode is activated too often, or for too long, that’s a serious health concern with harmful consequences. In an analogous way, living in a constant high stress state can elicit similar effects and have a negative effect on physical health, emotional well-being, and longevity. 

The overall benefit of mindfulness is that it encourages you to pay attention to where you are right now, without any further interpretation. Once you begin learning how to be more mindful, you’ll realize how much your mind races, and how often you focus on the past and the future. Anxiety is often the product of thoughts about where you need to be, what you need to do, what might happen, and “if and when” type thoughts. Mindful redirection without judgement helps you experience thoughts and emotions with greater balance and acceptance, and removes that anxiety and stress from your mind and body. As a result, most people who practice mindfulness report an increased ability to relax, more enthusiasm for life, and improved self-esteem. Mindfulness and meditation have been studied in many clinical trials, and evidence supports their effectiveness in improving many chronic conditions, including stress, anxiety, chronic pain, depression, insomnia, and hypertension. Meditation also has been specifically shown to improve attention, decrease job burnout, improve sleep, increase immunity, and even improve diabetes control. 

The concept of mindfulness is simple, but it’s called a practice for a reason. As I said, most people operate on autopilot, reacting to each situation or sensation as they go. When you have too many obligations and too little time, anxiety and stress often undermine healthy habits such as eating well, getting proper sleep, and exercising. This can easily become a cyclical pattern that’s difficult to break. But mindfulness actually pays out twice, because in addition to being relaxing in the moment, it also has a positive cumulative effect over time. So practicing a pattern of mindfulness breaks unhealthy patterns, which allows you to better enjoy positive life experiences, while also minimizing adverse reactions to negative life experiences. The idea of practicing mindfulness on a regular basis isn’t to get better at it. The goal is to make it second nature, so that you are essentially mindful at all times. Ideally, you then automatically become mindful, rather than anxious or stressed out. 

In our culture, we tend to place great value on how much and how fast, but mindfulness doesn’t need to be complicated or take a long time to be effective. Just interrupting daily stress with a healthy response is essentially mindfulness for dummies, so by taking just a moment to breathe deep, you’ve become more mindful. If you’re not sure if mindfulness is your kind of thing, there are some simple mindful principles you can incorporate into your life while you look for proof of concept, to see if it’s helpful for you.- Pay attention. It’s hard to slow down and notice things in the middle of a busy day in a hectic world, but try to experience your environment with all of your senses: touch, sound, sight, smell, and taste. – Treat yourself the way you would treat a good friend; with acceptance and care, and without judgement and harsh criticism. – Eliminate the negative. When you have negative thoughts, try to sit down, close your eyes, and actively remove them from your mind to gain perspective. – Acknowledge and redirect yourself as needed to maintain awareness. Anytime you’re trying to be mindful, if you find your awareness slips, or anxiety or negativity continue to creep in, acknowledge them without judgement and redirect yourself to return your focus to the present.

Below are a few quick mindfulness activities you can easily incorporate into your daily life, including at work. Since you don’t need any specific tools, you can try them out on your commute or even at your desk when you feel stressed out.

Meditation Moment

Close your eyes and slowly breathe in and out. Concentrate on the rising and falling of your chest, and try to empty your mind. If other thoughts pop into your head, acknowledge and dismiss them, then bring your focus back to present.

Mindful Listening

It’s easy for your mind to wander during conversations. Instead of formulating your response while a colleague is still talking, clear your mind and really listen to what they’re saying. Try not to think about all the stuff on your to-do list, your plans for the evening, or your previous conversations- just be in the moment. This will help you pick up on more information, and can also improve your workplace relationships.

Observation Game

Choose any object nearby- a pen, your computer mouse, or even your tie- and really focus on it for one minute. Pretend it’s brand new to you and try to see it for the first time. Pay close attention to its shape, texture, and how it’s constructed. Try to connect with something positive about it you may have never considered before. This helps you not only clear your mind, but also helps to foster appreciation for the everyday objects that surround you.

Nature Break

This one requires you to get up and leave your desk, but so much the better. When you go on a coffee or lunch break, take a stroll by yourself through a nearby park or green area. If possible, leave your phone and other electronic devices back in the office, and use these few minutes to focus on and listen to the natural world around you. This is a healthy exercise for both your mind and your body, as you also benefit from the physical movement and the chance to get a breath of fresh air.

Those simple mindfulness exercises can be practiced nearly anywhere and anytime. Some of the more structured mindfulness exercises may require you to set aside time when you can be in a quiet place, without distractions or interruptions. You might choose to practice the following types of exercises early in the morning before you begin your daily routine. Here are some examples of more structured exercises you can use to practice mindfulness.

Mindful Breathing

Unlike when breathing is an automatic function, this mindful technique encourages taking a moment to be present, and focusing on completely inhaling and exhaling air in and out of the lungs. Breathe in through your nose to a count of four, hold for one second, and then exhale through the mouth to a count of five. Repeat often, as needed. Over time, this exercise usually leads to a pattern of slower, deeper breathing as a healthy default.

Visualization

Mental imagery exercises allow you to picture a calming place for relaxation. This technique focuses on a positive mental image to replace negative thoughts and feelings you may be experiencing at any given time. This is the classic “happy place” you can go to in your mind to reduce stress and anxiety.

Progressive Muscle Relaxation 

When you have anxiety or stress in your life, one of the ways your body responds is with muscle tension. Progressive muscle relaxation is a method that helps relieve that tension. During this technique, you tense a group of muscles as you breathe in, and you relax them as you breathe out. You work on your muscle groups in a certain order, head to toe or toe to head. The action of tensing followed by relaxation releases physical tension and relaxes you. When your body is physically relaxed, you cannot feel anxious, so this is an effective method to relieve stress.

Mindful Eating

I imagine you’ve heard of “mindless eating,” where you’re watching television with a bag of cheesy poofs in one hand, and the remote control in the other, and the next thing you know, the giant family size bag is empty. When you eat mindlessly, you shovel food into your mouth without noticing how much you’re actually consuming. Mindful eating is the exact counterpoint to this, and for this reason, mindfulness is a universally recognized tool to help people achieve and maintain a healthy weight. With mindful eating, you only eat when you’re hungry, you make sure to focus on each bite to fully appreciate what you’re eating, and stop eating when you’re full.

Walking Meditation

Walking is such an established, habituated action that this is yet another thing we tend to do on autopilot. The moment we step out the door, our minds wander and get caught up in planning, worrying, and analyzing. But it’s pretty amazing how different you feel when you pay attention to your movement and what’s going on all around you, rather than all the stuff swirling in your brain. A walking meditation is a great way to take your mind for a walk with you, and the idea is to focus on your gait and the physical experience of walking. Pay attention to the specific components of each step, being aware of the sensations of standing, and the subtle movements that help you keep your balance as you move. Research indicates that engaging your senses outdoors is most beneficial, so try to find a big green space outside and take a mindful walk. 

Ideally, you should aim to practice mindfulness in multiple ways each day. By that, I don’t mean you have to do a progressive muscle relaxation technique each day. I’m saying you can just incorporate the basic principles into your life each day. Eat mindfully instead of mindlessly. When your mind swims with everything you have to get done in a day, slow down and breathe. When you start to criticize yourself, stop the negativity and gain some acceptance. When you walk to work, try to do it mindfully. Remember that it’s far better to make small changes you can sustain than it is to make grand changes that don’t stick, so apply little mindful touches throughout your day. That way, you’re providing a break from stressful thoughts multiple times each day, allowing you to gain more perspective, and you’re also reinforcing this as a response to daily stressors so that it becomes more automatic. Over time, mindfulness becomes more second nature, and this effectively reduces stress and anxiety in the future. 

Please note, it takes time and practice to learn to slow down and live in the moment. So if it seems to take longer than you “think it should,” you’re kind of missing the point, and you should drop the judgement and continue the effort. With regular practice, you’ll find that rather than operating on autopilot, reacting as you go, with your emotions influenced by negative past experiences as well as fears of future occurrences, mindfulness will allow you to root your mind in the present moment and deal with life’s challenges in a calm, clear, assertive way. As a result, you’ll develop a fully conscious mindset that frees you from the bonds of unhelpful, self-limiting thought patterns, and this will allow you to focus on the positive emotions that increase understanding in yourself and others. And that’s never a bad thing. So the next time someone tells you to stop and smell the roses, before you roll your eyes, take a mindful moment to be present, and then say thank you. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Working Remotely,Part Trois

Working Remotely, Part Trois

Hello, people! The last couple of weeks we’ve been discussing working remotely. I was prompted to do this series after noting the ways some of my patients evolved, or devolved, after working remotely in a ‘rona world. When I did some research, I read studies and reports from years BR, before ‘rona, and saw that remote workers regularly reported higher stress levels than their office worker counterparts. According to a 2017 United Nations study involving 15 countries, 41 percent of “highly mobile” employees (defined as those who “most often,” or “more often…worked from home” as opposed to “in office” or “onsite”) rated themselves “highly stressed,” as compared to only 25 percent of the office and onsite cohort. This was of obvious interest to me, given what I’d been seeing in my patients, so I thought it warranted further investigation and discussion. And a baby blog was born. Awww…

Captain Obvious says that mental health and work are intertwined, because work is such an integral part of our lives. Remote work has a somewhat unique ability to get to people, even the mentally healthiest of individuals, because when you work from home, you may feel like you live at work. The work-home and work-life lines can blur, especially if the switch is abrupt and unavoidable. Thank you, ‘rona. Last week I talked about some of the issues that can come along with this type of remote arrangement, and the fact that they generally present as some level of SADness, so you may find you feel stressed, anxious, and even depressed as a result. You may feel these impacts within a widely variable range as well as pattern; acutely, chronically, or as more of a cumulative or building phenomenon. Just to make it more complicated, you can also have a pink cloud situation as well. After making a switch, the novelty of the setting can alter how you value certain associated factors. You may find that any negative impacts you feel from one issue are offset by the positive impacts of another. But this can be a little insidious if you’re not careful, because it’s a transient phenomenon. Once the novelty wears off, that pink cloud goes **poof-bye bye** and suddenly, the equation is altered again! It’s not really worth it anymore, and that can make you SAD. 

Sometimes the effects can be so low level, you might just generally feel blah, or ‘some kind of way,’ as the kids say, but you can’t seem to put your finger on why. There are nearly innumerable ways that stress can manifest, regardless of where you work, and it usually doesn’t just affect your work. It often seeps over into your private life as well, but this is especially true when you’re working from home, because of those annoying blurred lines. 

So if you’re a remote worker and feeling some kind of way, how would you know that it might be your remote work at the heart of it? Clearly it’s difficult to pinpoint it exactly in a generalized blog setting, because each person is different; but there are some ways stress can manifest in both your personal and professional life, some things you may start to notice. The most common things can include: insomnia and poor sleep patterns, an inability to ‘switch off’ from work, headache, feeling disconnected from other people, an increase or decrease in appetite, having difficulty concentrating, having difficulty becoming and/ or staying motivated, having difficulty prioritizing workload and daily tasks, and feeling insecure or unsure of standing or spread too thin/ pulled in too many directions in your work and/ or personal life. 

Last week I likened work, and life, to an equation. Everything has a value, and you decide what’s worth what, give and take, in order to decide what works for you. Last week I focused on the negative side of said equation, so this week will focus on the more positive side. Today will be about addressing issues I brought up last week, presenting some additional factors, and suggesting some steps you can take if you think that working remotely is having a negative impact on your life. Clearly, you don’t have to wait for that to happen, and everyone knows what they say about an ounce of prevention, people. When we’re talking about stress, it all comes down to minimization and mitigatation. I’ll try to address each issue in the same order I did last week, and make some strategic suggestions for solutions. Some of these may have been mentioned in the first blog of this series, so people that might’ve missed it can still follow along. If you didn’t miss it, please bear with me. 

Awesome Office

I’ve joked about how many patients I’ve seen in bed during facetime appointments, but I think far too many people are both working and sleeping there. Seems like a lot of people’s morning routine is just rolling over to grab the laptop. But there are good reasons why this is concerning to me. Humans need sleep, and studies show that working from home, just in and of itself, can already interfere with sleep. But this is especially true for people who find it difficult to switch off from work. Working from your bed, or even bedroom, makes it very difficult to do just that. Not only does it encourage the late night blue light exposure that has been shown to interfere with sleep, but it also makes your brain associate that place with being alert, awake, and switched on. And that’s not the association you want- your bedroom should be the place you rest and recharge. 

If you find yourself working remotely full time, you want the best possible experience. You’ll certainly be more comfortable and productive, not to mention a lot happier, if you create a dedicated space to work. Preferably, a separate room with a door you can close for privacy, and to minimize distractions and physically separate your work from your home life. If you just don’t have a separate room, find a corner or nook in your house that you can commandeer, and transform it into your home office. The goal is to make it feel detached from the rest of your house, so if it’s a small space, consider a room divider, or think about using just an area rug as a means of creating a division. Once you have “the office” location, be it a separate room or just a corner, set yourself up for success. Buy new- or check out used shops or thrift- for a desk that’s wide enough to support your wrists, arms, and elbows to keep carpal tunnel at bay while you’re tapping away at your keyboard. Better yet, go tetherless and get a wireless mouse and keyboard. Also look for a comfortable, ergonomic chair that supports your lumbar back, neck, and spine. Few paychecks are worth an orthopedic problem. Big bonus points if you can kit out your space with a sound system and other creature comforts. Try to also get some life into the space. Consider some plants and maybe even a little fish tank if you have room- they’re very soothing. If you’re only working remotely temporarily, and you just don’t have the space at home for an office, even going to a local library or cafe to work may be better than just converting your bed to one. When you have a clearly defined working space and time, it’s far easier to finish your tasks for the day, and leave work at “the office.” That way home remains home, and you avoid being “on” all the time. 

Tech No!

Once you’ve done what you can to create a dedicated work space, make sure to do what you can in the way of technological assistance. If you need a new laptop, smartphone, wi-fi, or cell booster, communicate that with your employer, if appropriate. If they provide the equipment, or some sort of assistance in purchasing it, then score! If not, investing in tech that will save you time and aggravation is always a good move, so do that as soon as is feasible. If you’re all set up and ready to roll and find you’re still having technical difficulties, most definitely communicate that with your company’s IT department, if that’s not you, to fix the issue. If that is you, take the time to deal with it as efficiently as possible, call a “geek” to come out for a diagnosis. The sooner your systems are running smoothly, the fewer the tech migraines you’ll have later. 

Coming at this from a different direction, once you’re properly setup, working from home can give you an opportunity to be proactive, learn something useful, and make friends with technology. There are apps out there that do all sorts of cool things that can be helpful in a remote work environment. You can set timers and reminders for break activities, track your social media usage, like if you need some help to use it less, remind yourself to get back to work when you become distracted for too long, and you can create to-do lists and schedules galore to help stay on top of things, simplify tasks, avoid frustrations, and be more productive. There’s nothing more encouraging than getting your mundane tasks done as quickly and efficiently as possible, so check out all the options available and learn to use tools like these to your advantage. 

And just as the expansion of the internet has made remote work possible from nearly all corners of the globe, novel programs and platforms have also been developed specifically for remote workers. If you work for an organization, they may offer access to automated online courses that will allow you to keep honing your skills, so contact human resources and make some inquiries. If those opportunities don’t exist, you can always look for other free or paid online courses for virtual and remote workers. When I searched it, the number of them available was impressive. There are courses designed to give you the skills necessary to start a new career, or to grow an existing one. Remember that any time you work to broaden your horizons, you further your personal identity and make yourself more valuable in every professional application. 

Management

A significant issue revolving around working remotely involves its management. How do you adequately supervise- and support- multiple employees, when they’re potentially thousands of miles away? Both managers and employees face a different set of challenges when working remotely. From what I hear from remote worker patients, the decreased feedback from managers and supervisors boils down to making some employees feel insecure. As I mentioned last week, it makes them feel mistrusted, and as though they have to prove that they’re actually working from home and not goofing off. I think the remoteness gives them no benchmark to judge their own progress, and that leads to increased anxiety and concerns about being up to standards. In short, they may not be getting the attaboys they did in the office, and that makes them wonder if they’re doing a good enough job. Obviously, employees need to adequately document the hours they work, and maintain regular communication with supervisors to keep them up to date on what they’re working on. More on communication later. 

On the supervisory side, I think the solutions to these issues requires an open mind. Remote companies need to start thinking about how they can ensure that employees aren’t overworked, and also utilize management courses for remote team leaders to help train them for this new working environment. They should set aside more traditional ideas that no longer work, in favor of developing more flexible policies that better correspond with a more modern arrangement. Maybe implement the concept of management by objectives accomplished instead of by time. I can tell you from years of listening to people that helicopter monitoring- actually helicopter anything- and micromanagement won’t work. Management should consider allowing some employee input into the creation of novel management methods as well. Employee happiness and engagement increases productivity by 31 percent, so getting them involved in making suggestions benefits everyone. 

Some other simple steps that management can take include encouraging employees to communicate amongst themselves, to take PTO days, to stay out of their “office” after hours, and to enjoy a hobby that does not involve a computer screen or technology of any kind. Also, performing technology and work station audits to confirm reasonable working conditions, and giving regular updates regarding organization standards and plans for future work performance will help alleviate a great deal of employee insecurity. Management also needs to be proactive in helping remote employees avoid undue stress, and allow them to feel comfortable reporting stress without worrying about repercussions. Two psychologists created the Yerkes-Dodson Law, which points out that stress can be productive up to a point, and then it results in reduced productivity. Being overly stressed without the ability to report it is detrimental, as pressure will eventually outweigh an individual’s ability to cope over time. Contrast that with the findings of one recent study, which reported that colleagues who spend just 15 minutes socializing and sharing their feelings of stress had a 20 percent increase in performance. Clearly, this demonstrates how it behooves management to implement measures for employee stress sharing and reporting. 

Given the negative impact of stress in a remote work environment, management should also avail themselves of training to learn the warning signs that signal that remote employees are feeling workplace stress. Opening up a line of communication is a good first step, so that when they are starting to experience burnout, they’ll be comfortable discussing how they feel. Management should learn to ask questions about how they’re feeling and listen closely to the answers. Do they mention having a difficult time concentrating? How about their interests in things they used to like? Are they experiencing any feelings of frustration, irritability, or hopelessness? These would all be indicators of stress that management needs to catch before employees reach a breaking point. An increase in negative language is another indicator. The use of phrases such as: “there are no options,” “I can’t do anything,” or “this is impossible” are examples of catastrophizing, and should be red flag indicators of employees having more workplace stress than they know how to deal with. There are other signs as well. Make sure to speak with employees that are starting to make mistakes, missing deadlines, or getting sloppy, as they are often the first signs of struggle. And instead of cracking down on staff that’s having a hard time, organizations must offer support through stress management initiatives in the workplace. In my opinion, management and employees making all of these efforts would result in big strides on the road toward improving the remote work experience for everyone.

Isolation and Loneliness

The solitude of working remotely can be a double-edged sword. It can be easier to focus when you’re in your own home, with no annoying coworkers randomly stopping by your desk, or your boss breathing down your neck. Aah…sweet freedom! But when there’s no social interaction during a full workday, that also means there’s no one there to ask a work related question to, or bounce an idea off of, or un-stick you at a crucial point. Social isolation was another factor associated with increased stress levels mentioned in the UN study. In addition, without personal communication, more emphasis is placed on deadlines and routine information, so remote workers can feel like a cog in a machine, rather than an essential part of a team. This just adds to the sense of isolation that naturally comes with working remotely, and the two together can make it difficult to have as much energy to be productive. In addition, it can be very unpleasant, if not impossible, to sustain this for the life of a career. A top priority should be to maintain relationships with coworkers and managers, especially if you are one who is energized by these relationships. It is critical not only to work performance, but to emotional and mental wellness. 

Technology can serve as an assist, and there are plenty of platforms like Slack, Zoom, and even good ole facetime to facilitate this. Lots of companies have established ‘virtual coffee breaks’ and even ‘watercooler’ channels to encourage break-time chatter during work hours, to foster collaboration and create a more comfortable work environment. If your company has outlets like these, take advantage of them. If they don’t, then maintaining connections is essentially up to each individual. Because everyday encounters with colleagues don’t spontaneously happen when working from home, you need to be proactive to maintain positive relationships. Think about scheduling a few minutes for informal banter at the start and end of video calls to emulate the normal casual talks you would have with coworkers when walking by their desks, or in the kitchen at the office. It may not seem productive, but it helps build internal relationships and boost morale. These connections will help you feel less isolated, reduce stress levels, and stay productive. 

You can always facetime, Zoom, message, and email people, but that’s not the same as having face-to-face interactions with them. So make it a point to meet with coworkers or friends for lunch, coffee, or drinks a couple of times a week. If you find you’re still feeling isolated and lonely while working remotely, consider meeting other digital nomads at a coworking space, or work together from one of your home offices twice a week, or more often if it’s helpful. But remember what all work and no play did to little Johnny. Make social commitments with friends and get outside of the house at least once a week. Ultimately, if you work from home and feel isolated or lonely, it’s important that you take responsibility for your own social interactions. The key is to make an effort and be proactive to do things to decrease the isolation that can come from the remote work setting. 

Burnout

One of the biggest challenges in working remotely is finding a healthy work-life balance to avoid blurring those lines I mentioned earlier. Surveys show that 51 percent of employees report stress and burnout as a result of working at home. Just as an interesting aside, the most often cited reasons for burnout are, surprisingly, the very things that made remote work seem attractive to most people. The dressing! Or not. The surveys indicated that when people dress in sweats because they are not seeing anyone, they then find that comfort makes it difficult to fully engage. Their clothing signals fun chill time, while their tasks are anything but. And while remote work seemed liberating, many employees relied on supervision and structure to manage their workday. Without it, many people fing it hard to be as productive, and are stressed about not completing tasks in a timely manner, and these cause them to overwork and risk burnout. 

Not all people can achieve proper work-life balance when they work from home, and in fact, the UN study also noted that this is one of the many negative impacts of the remote work arrangement. For some, working from home feels like a special privilege that’s been granted to them, so they feel like they should work harder, and that’s how stress and burnout are escalated. I’ve noted that some patients, who definitely seemed to have a solid, healthy work-life balance when they worked in an office, suddenly started to become work obsessed after going remote. They work ridiculous hours at home, unable to even define the end of a day, much less switch off at it. I’ve seen it happen- watched it happen- to people who had a previously healthy balance, so imagine what happens to someone with workaholic tendencies when they go remote. From what I’ve observed, working remotely is to workaholism what bar hopping is to alcoholism. If you’re in a place that facilitates a bad habit, that’s a bad place to be. In other words, workaholics probably need not- or should not- apply for a remote position.

When working in an office environment, there are often clear signs and symptoms if somebody is burning out. These commonly manifest as increased emotional reactions to situations, a general lack of motivation, and the appearance of small, seemingly minor mistakes. There are also some visible physical signs, such as bags under the eyes and even weight loss, that can be seen. When working from home, there isn’t anybody to notice these telltale signs, apart from family members or friends. But if that person lives alone or is isolating themselves, then they’re not even there to see them. So remote workers have to be able to police themselves to avoid burnout.

Flexibility is a double edged sword. It can be liberating to set your own times as to when you need to get up, when you go to bed, when you need to start work, and when you need to stop. But this feeling of freedom can gradually morph into a feeling of being out of control, especially if you don’t expect it. It sounds great to eliminate a structured office setting, but once that structure is gone, where it might have felt stifling before, it can start to feel like the scaffolding on which your whole life was built. When there’s no one there to monitor or guide you, and structure has to be self-imposed, it can be difficult to create. It can also be more challenging to function as efficiently without it.

The solution is to set a schedule and put it on a calendar. Look at it as an opportunity to exercise the flexibility that is a prime benefit of working remotely. It can be vital to not only save you from burnout, but also from distractions that will swallow up your time. More on that in a bit. There are several useful tricks for creating a schedule, and you can always use an app to help you to make one in a format that suits you. If you are free to set your own hours, meaning it doesn’t matter when you work, then decide when you work best. Many people find that working in the morning when they feel rested can provide a more productive experience than beginning work halfway through the day after cleaning the house and doing other non-work-related activities. This isn’t true in all cases, so feel free to experiment if this advice doesn’t seem to ring true for you. If it were me, I would not only start work first thing in the morning, but I would also prioritize the most challenging tasks first. Rather than letting unpleasant or difficult tasks hang over your head and create stress when you think about them, pushing yourself to get the most difficult jobs done first will give you a sense of accomplishment and increased energy to get you through the day.

To be productive and avoid burnout, you not only have to set a schedule for balance, but you have to stick to it. Make sure to maintain reasonable office hours. As I mentioned last week, your home is now your office, so you’re not technically ‘leaving’ work unless you turn off all communication platforms. Sign out of your email, close the laptop, put the phone down at the end of the day, then leave “the office.” Make sure to include time to step away from your desk to take a lunch break, and eat something sensible to avoid being distracted by hunger later. If you have children or family at home, this is a good opportunity to spend some time with them. Since you probably spend a lot of time indoors, try to have lunch outside. 

In addition to a lunch break, schedule short breaks during the day. Scheduled breaks are better than just working until you lose focus, then randomly giving in to distractions. Everyone is different, so the length and number of breaks can vary slightly, but within reason. Some people would do better taking 15 minutes mid-morning, and then again mid-afternoon, while others would rather two shorter breaks in place of one longer one. During these breaks, try to step away from your desk to disconnect for a few minutes; this is a very effective method for avoiding/ managing stress. Go outside to get some fresh air, maybe take the dog out to get the mail. The idea is to use these times to clear your head to help you focus on work when you come back. 

When you take time off, take it completely off. If you’re guilty of working on PTO days or of bringing your laptop on vacation, you’re missing the point and need to disconnect more fully. It might seem like bringing work with you means you’ll have less to catch up on, and therefore less stress, when you get back, but in reality, you aren’t allowing yourself to recharge. This goes for weekends too. Keep the laptop closed, resist the urge to check emails, and concentrate on the life part of the work-life balance during your time off.

Focus, Motivation, Distraction

Creating structure and setting boundaries are critical in a remote work setting, not only to avoid blurring the lines between work life and home life, but also those between productivity and leisure time, and socializing time and working time, in order to avoid distractions. But this can be more challenging than many people expect. If you live with family, setting boundaries with others can be difficult when people expect that you should have time to talk when they do. You may feel pulled between competing loyalties and overwhelmed by the responsibilities of your various roles. Not only is it difficult to set and communicate boundaries, but in some situations, such as when there are children in the home, those boundaries may also be constantly challenged. If you live with other people, especially children, make sure to have set office hours and communicate them to everyone. You can even show small children your schedule, and explain that you have break times and lunch time scheduled, and you’ll see them during those times. Also clearly communicate what circumstances warrant an interruption of work time in order to avoid random needless interruptions. Apparently some companies actually provide employees with do not disturb signs to hang on their office doors in order to remind others you’re actually working. It’s not the worst idea ever. I say if you have kids, and your company doesn’t provide you with one, get out the markers, glue, and glitter and them involved- ask them to create a sign for you. If they make it, they’ll be more lilely to respect it when they see it hanging on the door. 

Setting and sticking to boundaries with yourself may be even more difficult than with others, especially when you are feeling a lack of motivation. Without other coworkers around to hold you accountable, you may have a little tougher time motivating yourself, but resist random distractions in favor of taking your scheduled breaks. In addition to sticking to your schedule, you can avoid distractions by not taking personal calls during the middle of the day and avoiding the endless rabbit hole of social media. Turn off notifications and/ or mute your devices while you’re working. Just don’t go on social media if you don’t want to be Alice. It’s easy to lose sight of tasks and deadlines, especially when your superiors can’t physically see you, but you can monitor your own productivity by planning ahead of time and using time management techniques. At the end of each day, make a list of tasks to be done for the following day. On the next day, review your priorities and tackle high-value tasks first. By following this, you’ll stay organized by keeping your schedule and calendar straight, and learn how to prioritize to get your work done. It should also help you learn one of the golden rules to working remotely: don’t procrastinate! If you need more help with time management techniques, google it. There are methodologies available on the interwebs to help maintain your focus throughout the day, and I’m sure there are apps for that, as well. Aren’t there for everything?

To keep your motivation up, it’s a good idea to break big tasks down into smaller, workable goals. You can also setup project milestones, working with a manager to establish objectives when needed. Sometimes communicating those goals out loud to others can help to motivate you, so consider sharing those goals with coworkers or family members, because sometimes making public commitments to others about what you will accomplish that day helps hold you accountable. If you need to really pump up the motivation factor, you can always reward yourself for accomplishing goals as well. But this doesn’t mean a food reward, people. Maybe schedule a massage, a special lunch with a friend, or an ice cream with the kids. Okay, I guess that’s technically a food reward… so make it a yogurt if you’re trying to be healthy. At any rate, put planned rewards on the calendar so you can see it as a motivator. It doesn’t even have to be a real reward that costs anything. Sometimes it’s rewarding enough to imagine something you’re working toward, and reward yourself by taking whatever the next step is in attaining it. Maybe you want a new kitchen; you can go to the tile store and get different samples to bring home and mull over. The point is that it’s up to you to be productive, while also making your work experience pleasant. Try to keep yourself feeling appreciated, even if you yourself are the only one who appreciates you. 

Freelancing

If you’re freelancer, your monthly workload and income can be unreliable and constantly changing. This is an obvious source of anxiety and stress, as sometimes you may be swamped with too much work, while at others, not have enough; it can be very difficult to find that middle ground. And because jobs aren’t usually long-term, you need to spend much of your time searching for new opportunities, while simultaneously completing the work you have. Not only are these conditions stressful, but freelancers are independent contractors that usually have to handle everything, so switching hats from sales to service to invoicing and bookkeeping adds to the stress. Not every personality is well suited for this variability. While researching this blog, I found a lot of resources available- job boards, apps, communities, and blogs for freelancers that look like they would make their lives quite a bit easier. One blog I came across had a list of various applications with descriptions of exactly what they do, along with links to everything. If anyone is interested, the blog was called skillcrush, and can be found here: https://skillcrush.com/blog/useful-resources-for-freelancers/

Communication

Communication can be very sensitive territory, and learning how to navigate it is an essential skill to avoid misunderstandings and misinterpretations in every work situation, but especially in a remote work setting. With electronic communication methods that don’t allow for visible body language, it’s difficult to convey the true meanings of messages, leaving them open to individual interpretation. Misunderstandings can lead to hurt feelings, decreased productivity, and issues with your corporate culture. For these reasons, it’s best to have an assortment of communication and collaboration tools at your disposal for use in different circumstances. Email and instant messaging are convenient, but more complicated communications should always take place using some sort of video interface, such as Zoom or Skype, as it allows people to interact with each other in a format that provides body language and non-verbal cues that other forms of correspondence don’t express. 

When communicating with a group, make sure that any messages you share are very easy to understand. On that note, if you receive a message that isn’t understood, don’t be shy about asking for clarification. For collaboration to work properly, the right information needs to be passed along efficiently and comprehensively, so this makes proofreading especially important. 

Keep in mind that etiquette matters in all communication. Jokes and sarcasm have their place, but that is not in professional group applications. Also, remember to check your tone. Without that face-to-face connection, tone is important, so take the time to double check your phrasing before hitting send. Spending a few extra seconds to go over what you’ve written to make sure that there aren’t mistakes, omissions, or other factors to get in the way of what you’re trying to say helps keep you from having to backtrack and explain things again later. This can also keep incorrect presumptions from influencing the results of your efforts. Given that your coworkers could be located anywhere around the world these days, try to be extra aware of time zones, and remember that waking up to 20 Slack notifications/ instant messages is stressful! Try to be respectful of the different time zones that your team are working from, and keep communication to those hours whenever possible.

Conduct regularly scheduled video chat meetings to maintain good communication with your colleagues and managers. This is the best way to keep lines open and make sure everyone is on the same page about whatever projects you’re currently working on. Make sure the video chat platform includes features such as file sharing, screen share, and multiple user interfaces in one chat. Be sure to always “show up” to your organization’s online meetings and be heard. If you need to communicate with your manager about sensitive topics, such as evaluations, progress reports, or even workplace stress levels, always do it over a video conferencing platform. It’s much easier to connect and fully emote how you’re feeling when your manager can see you. 

Stressbuster Tip: Mobile Devices

Probably the biggest overall culprit common to all remote workers in causing stress is device use, especially smartphones. I’ve been yelling about this forever. While all of the sources of stress I’ve mentioned are significant, the UN study that prompted this blog found that frequent use of mobile devices appeared to be a “significant source” of added stress. Part of the reason has to do with blue light exposure from device use late at night, which remote workers are more prone to, and the serious impact it has on sleep schedule. In fact, this study found that it was linked with frequent waking at night: 42 percent of those who work from home report frequent night waking, while only 29 percent of office workers reported the same. This is especially important because poor sleep can add a significant amount of stress throughout the day. 

Research has also connected higher levels of stress to the habit of constantly checking one’s phone. Remote workers certainly check their phones often, but what else might make people constantly check their phones? Hello, social media. Not only that, but surprise, social media use itself can also lead to stress, because of increased social comparison. I’m sure I’ve mentioned that before. Ultimately, the increased use of devices, and the constant checking of devices- whether for work or social media silliness- is absolutely associated with higher stress levels, insomnia, and ironically, social isolation. Okay, rant over. The solution for this one is pretty simple: limit the number of times you check your phone for non-work reasons, ie social media, each day, make it a point to put the devices down at the end of the work day, and declare a minimum 90 minute moratorium on all device and screen use, for any reason, before bed.

Stressbuster Tip: Make it Routine

Just as you create a schedule to keep you on track at work, design a morning and evening routine unrelated to your work, to tell your brain when it’s time to work, and when work is over for the day. This will help your brain create a distinction between work and home, which helps you switch off and decompress. Yet another good reason to get dressed for work, even though no one will see you- it helps you create that division. If you have young children at home, seeing you “dressed for work” will also help them to understand the distinction. Be sure to use time spent away from work for yourself, for family time, exercise, and self care.

Stressbuster Tip: Get Comfortable Saying No

Working from home, you’ll be faced with many requests, many of which you may need to refuse if you want to have enough time to get everything done. It can be surprisingly difficult to say no to people you don’t really owe your time to, simply because most of us can find reasons why a “yes” is a perfectly reasonable answer. We may think of their needs and see ourselves as a great answer for them, and not realize that saying yes to them means saying no to ourselves. We may also have our egos involved in having a solution for them. Whatever the challenge, realize that saying no to the time drains you didn’t plan for often means saying yes to the healthy life you truly want and need. For freelancers, learning to say no is an especially important skill. You may want to take on as much work as you can, but there’s only so much you can complete in a day. Know your limitations, set boundaries based on your schedule and workload, and don’t extend yourself beyond them. Be assertive, yet courteous, and your clients will still respect you. 

Stressbuster Tip: Protect Your Sleep

A good night’s sleep rejuvenates the body so you can tackle the day ahead and can help lower the effects of stress during your workday. Because healthy sleep is vital for your productivity, do what you need to do to get it. It may sound like kindergarten time, but this includes setting a bedtime for yourself and sticking to it. Believe it or not, keeping a sleep schedule is one of the hardest things for most of my patients, even the ones I lecture to about it. In any case, when you do it for a while and feel the effects of getting adequate sleep, you’ll see that it’s well worth the effort. You already know that this is a no-no, but it bears repeating, as so many people blow it off: using screens and devices late at night alters your sleep patterns; it makes it very difficult to not only get to sleep, but to stay asleep at night, because it elicits brain patterns of wakefulness. So skip the screens before bed for a minimum of 90 minutes.

Stressbuster Tip: Accentuate the Positive

Another cause of work-related stress is focusing on the negative, and all of the things going on that are beyond our control. The best cure for stress is to concentrate on what is going right and the progress that is being made. I’m sure I’ve mentioned in various blogs that laughing and smiling lowers stress hormones like cortisol, epinephrine, and adrenaline, and can act sort of like a natural antidepressant that releases healthy hormones. When you’re working remotely, learn to take a few minutes to concentrate on positive things, and do what makes you feel calm and happy, even if these things may not be so productive and useful all the time, you’ll find you’re less stressed.

Stressbuster Tip: Slow Down

Life can come at us way too fast at times, and while you can’t just stop, you have to learn to pace yourself if you want to be a great remote worker. Slow down and remember that the best decisions are never made in a rush, and rushing is never the best decision. When you’re stressed, take a few minutes to breathe and clear your head. Try inhaling for five seconds, holding five seconds, and exhaling with another five. Do this a few times in succession if necessary. This will help you stay calm and focus, like a 90-minute yoga class, but in three minutes or less. 

Stressbuster Tip: Eat Right

Diet does matter. Eating poorly will stress your body out, while eating right will restore balance and reduce pressure. Sometimes working remotely can be a recipe for a snack attack when you get distracted or don’t eat properly, so that’s double trouble. When you work remotely, make sure to eat three decent, well balanced meals each day. 

Stressbuster Tip: Share Stress

Remember the two kinds of stress, good and bad, how they work for and against you, and the Yerkes-Dodson Law. Share your stress with coworkers to lighten everyone’s load. I’m not saying concentrate on it, just spend a few minutes each day releasing it, and then keep it moving. 

Stressbuster: Keep it Moving

Speaking of which, you should absolutely be doing something to move your body everyday, so incorporate exercise into your non-work routine. I personally exercise every morning, first thing, to get my blood pumping; and I also use that time to think about what I have coming up in my day. You don’t have to spend two hours at the gym, even just 30 minutes of walking per day can help boost your mood and reduce stress levels, and you can do that on a treadmill if you have one, or just in your neighborhood if you don’t. That way you also get some fresh air and kill two birds with one stone. In addition, a pre- or post-work workout will help enforce those divisions in your brain to keep your work life separate from your home life, and prevent those lines from blurring. 

Mental Health Benefits of Flexible Work

Yes, remote work can cause and exacerbate mental health issues, but it can also act as a support mechanism. I read a survey of over 3,000 professionals conducted in 2018 on flexible work options, which includes remote work, flexible hours, and reduced schedules; and the results were interesting. It demonstrated that flexible work options have a lot to offer in supporting mental health at work, and in life in general. In fact, the impact that work flexibility can have is so great that 97 percent of people surveyed said that having a more flexible job would have a “great,” “positive” impact on their quality of life. That same survey also found that work-life balance and commute-related stress are two of the top factors that make people want a job with flexible options. For people with mental health concerns, caregivers, and professionals at large, flexible work options appear to support efforts to improve the mental health of everyone. It should be noted that this study included people who self-identified as living with a chronic physical or mental illness, making up 16 percent of those surveyed; and also included people who were caregivers of someone with a physical or mental health issue, making up 10 percent of those surveyed. 

There other notable way flexible work can positively affect mental health is directly related to commute-related stress. Even if a person loves their job, sometimes what they have to go through to get there is so stressful that it can negate that positive impact and result in added stress. The average commute time in the U.S. is approximately 26 minutes each way. But according to this survey, people who are most interested in flexible work options have even longer commutes, with 73 percent of respondents reporting commutes exceeding one hour. And 71 percent said they’d like to work from home just to eliminate commute-related stress, so this is clearly a huge factor in the appeal of remote work.

Other interesting findings from the survey on specifically how remote work could help respondents “reduce stress and improve productivity” included: 75 percent indicated by generally reducing distractions during the work day; 74 percent indicated by eliminating interruptions from colleagues, 65 percent indicated by keeping them out of office politics, 60 percent indicated by allowing for a quieter work environment, 52 percent indicated by giving them a more comfortable work environment, and 46 percent indicated by a giving them a more personalized work environment.

Remote work also provides more job opportunities in economically disadvantaged areas. Living through the decline of an industry or long-term high unemployment can negatively affect mental health. High rates of depression and anxiety are found in rural areas, especially among older adults who have often had their lives greatly affected by their community’s economic decline. Those living in rural or economically struggling areas may miss a key piece of the human experience: engaging in the workforce in a meaningful, long-term way. Remote work may be an solution to all of these issues by providing options to people in economically disadvantaged areas that may have mental health issues. It shows huge promise in bringing people in these situations back into the workforce, and there are partnering programs established to help spread the awareness of these opportunities.  

Another population that would reap great benefit from flexible work options are neurodivergent individuals. For example, employees on the autism spectrum and people with mental disorders like OCD can benefit from more time working from home, as loud noises, distractions, and pressure to appear “neurotypical” in front of colleagues and coworkers takes an emotional toll and impacts performance. By working remotely, they can benefit greatly, both professionally and personally. 

All professionals put a huge amount of time, energy, and focus toward work each day. By offering flexible work options, companies are signaling to their employees that they can, and should, devote more time to health and wellness. And that’s never a bad thing.

The other top factors that make people want a flexible job, in addition to better work-life balance and eliminating commute related stress, were family time savings. The constant pull that people feel between time spent with family versus time spent at work can negatively affect mental health, and flexible work options allow those priorities to coexist more peacefully. But this isn’t just a benefit for employees, because companies also benefit when their workers are healthier. Multiple studies have demonstrated that employees in unhealthy workplaces are likely to experience higher stress levels and lower engagement, and that these feelings actually spread throughout the workplace, negatively affecting productivity and corporate culture. Companies that give employees more control over when, where, and how they work by offering flexible work options, are supporting the health and wellness of their workers and enhancing the company’s culture and productivity, all at the same time.

The only demonstrable good thing ‘rona did was to reveal the opportunities that working from home poses for many companies that may not have considered it an option otherwise. Maybe it helped them realize how important health, both physical and mental, is as well. Nothing like a pandemic to set your priorities straight. Ultimately, mental health at work must remain a priority for employers, regardless of whether that takes place at the office, or at the employee’s home. 

The news that remote work can actually be as stressful as working from an office, if not more so, may have come as a shock to many people who considered a work-from-home lifestyle to be one that’s less stressful just because it offers more personal freedom and eliminates a commute. Part of the stress experienced by remote workers may be due to the fact that those who work from home face a host of challenges that are unique to this particular setup. While there are certainly pitfalls, there are also a number of benefits. As remote working becomes more popular, it’s very important that companies adapt and put the right policies in place to ensure their employees don’t experience any undue stress or burnout, and still feel like a valued part of a team. The right kind of communication is key to overcoming the challenges, as is being proactive about using it. Everyone involved in the remote work equation, top to bottom, needs to think about what makes them productive, happy, and successful in everyday life, and try to replicate those things in a remote setting. When you implement ways to mitigate and manage the stress associated with working remotely, then you’re free to enjoy all of the many benes.  

Hopefully now that you know how common some of these stressors are, you may feel less isolated in what you face, and more energized in tackling these challenges in the remote work environment. While employers should make the mental health of their employees an important priority, remember that ultimately, we’re all responsible for monitoring our own mental health, so if the simple exercises and routine changes I’ve suggested here are not enough, and workplace stress becomes too much for you to handle, it’s important to talk to somebody about it, so please seek professional help if that’s the case. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

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And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Working Remotely,Part Deux

Working Remotely, Part Deux

Last week I discussed some of the more personal issues I’ve noticed in remote workers, aka digital nomads, and made some suggestions (lectured?) on some things they should be doing for themselves in order to help ensure a better, more fulfilling life. As a global workforce, ‘rona allowed us, or forced us, depending on your point of view, to embrace the remote work concept. So much so, that many companies are progressively implementing it into their current strategies, and/ or incorporating it into their expansion plans. But given my profession, I have to ask, how psychologically healthy is it? It seems to me that as it stands in some companies now, not very. But certain personality types are somewhat uniquely suited to remote work, and thrive in the independence associated with it. Even if you aren’t necessarily one of them, humans are supremely adaptable beings. The questions then become, are you a person that could be happy working remotely, or could you make it work for you? 

Many of my patients say remote work has been an answer to their most ardent prayers. But a disturbing proportion of them say it through a mouth of unbrushed teeth, from a face covered with scraggly unshaven beard, and topped with a head of tangled unkempt hair, so I’m just not buying what they’re selling. So what’s up with that? Why are some digital nomads, who are usually neat and tidy, suddenly messy and… messy?! The answer is deceptively simple: they’re SAD. Stressed, Anxious, and Depressed. But why, when most people’s greatest wish, to 🙌👼🏼work from home👼🏼🙌 has suddenly been granted? Can you hear the angels sing? Visual sound effects! I’m absolutely positive that it might become a thing. 

Well, as with so many things in life, the remote work format is like an equation, with positives and negatives to take into account. In order to know if it works for you or not, you have to know the factors involved in order to effectively evaluate them. Today will basically focus on the more negative side of that equation, and some of the reasons why some people might feel SAD, even though they 🙌👼🏼work from home👼🏼🙌 Just wanted to test them to make sure they still worked. 

I know I make a lot of jokes, maybe as the result of a coping mechanism that morphed into a habit, but there can be real and unanticipated mental health consequences as a result of the stresses associated with working remotely, and it is important to be aware of this fact. I should also note that it’s equally important to remain aware of it, as sometimes it can seemingly sneak up on you, or can even be a building phenomenon. While they can have a serious impact on mental health, these effects can also be very subtle, or happen within a dynamic and fluctuating range. The best idea if you start to notice that working from home is bumming you out, is to make some changes to improve your situation right away, because you don’t get extra points for spending more time miserable. Toward that end, next week’s blog will discuss some solutions to the issues I’ll be posing here today, along with the positive side of the remote work equation.

The Work Experience

Clearly, the actual experience of working from home is very different from doing so in a public office. But it also differs amongst each person who works remotely as well. On a basic level, the work experience is vastly different, because the quality of the home working experience largely depends on the home. Captain Obvious says it’s a much better experience for people that have dedicated rooms within their homes than it is for people in small apartments, or those who share homes, and therefore have to work in their bedrooms. Please note the five extra letters denoting the compound word- bedrooms– not beds, people. At any rate, companies must consider what they can do to help even that playing field a bit, if they want to improve productivity in a remote work situation for all of their employees. 

Tech No!

Another huge difference in the remote work experience comes into play when we talk about technology. When it doesn’t work at home, it’s a bigger problem than when that happens at the office.  One specific concern focuses on the speed of technology- or lack thereof- when working remotely. Most organizations demonstrated great agility in switching to remote working nearly overnight, but it’s common knowledge that technology never works as well remotely as it does in an office, where it’s laced together with high-tech cabling and hardware. Here in the good ole US of A, if our wi-fi drops out, we feel pretty indignant, but in some places on the planet, just getting a good enough signal to even access the internet can be challenging enough. It may not sound like a big deal, but internet connectivity is important, because it’s how technology talks. As a human, if you’re speaking with someone, and they choose not to respond for ten or fifteen minutes, or not at all, that would be frustrating, no? Especially if it happened all. the. time! All. day. everyday! That’s why connectivity is a big deal when working remotely; because the lack of it is very frustrating to humans, especially when we’re working. 

If you’re working from home and faced with problems with wi-fi or getting a decent signal, it’s usually a persistent and pervasive issue. Because it can extend timelines and destroy deadlines, it affects your everyday business, and sometimes can even affect your employment. All of that of course impacts your stress levels, so you can’t really afford to underestimate it. The short answer solution is that you have to do whatever you can to mitigate the issue. Communicate with your supervisor, if you have one, and call whomever you need to call to have the issue resolved. Captain Obvious says your supervisor has a vested interest in making sure you’re adequately equipped, because they want you to get your projects done too. Or build an office entirely out of wi-fi hotspots and boosters, and maybe wear a tin foil hat. You decide. 

No Ball

No matter where you are, if your computer decides it doesn’t want to play ball, forget feeling indignant, we feel screwed. If you’re from a conventional office environment, and now working from home, any tech problems you may have probably won’t get resolved as quickly off site as they would in the office, and unfortunately, that can make it difficult- even impossible at times- to work remotely. The time it takes the IT software and people to diagnose and fix any issues further disrupts processes and extends timelines, adding to everyone’s frustrations. That’s if you even have IT people, people. If you’re the IT department, president, and janitor, that makes it a little more frustrating, and time consuming, to solve tech issues. Because bringing the office home depends so much on remote technology, when you multiply networking issues by slow running apps and software, working from home can equal big tech stress. 

MicroManagement

But it’s not just IT that has a long road to hoe in the remote work equation. Management also has to make big changes if the remote work equation is going to balance, because you can’t manage people the same way if you’re not with them. If nothing else, ‘rona proved to management that most employees do have the capability to adapt to remote work, and fairly productively and effectively, to boot. But in reality, management and supervisors themselves have to adapt as well. For it to work effectively, they have to learn to trust and enable their staff, rather than interrogate and demand. One of the biggest complaints I hear from employees is that while working remotely, they sense an implied, or sometimes more direct, mistrust from supervisors and management. They feel like every minute must be accounted for, like they have to prove they were working during the day, not just watching television or doing their nails. That said, one of the biggest complaints I hear from supervisors and management types about working remotely, is that they suspect that their employees are taking advantage of a remote work arrangement. I wonder if maybe they suspect they’re watching television or doing their nails instead of working?

This dichotomy would be funny, if it didn’t have the capacity to be so inherently stressful and anxiety producing in all parties involved in the equation. I think the concept of how to manage a person you’re not watching poses interesting psychological questions. When you feel like you’re “losing control” over something, or someone, a natural human response is to grip it tighter; evolution has built that into our brains. In a remote work environment, when a supervisor can’t see what an employee is doing for eight plus hours every day, that equates to the dreaded micromanagement. And in the minds of the employees or people being supervised, that often comes across as suspicion, and can feel accusatory. Taken together, this tends to breed mistrust; and so the problem begins. If the problem sounds complicated, imagine the solution. Personally, I can easily see both sides of this issue, but I know that traditional management methods aren’t the answer to a modern remote work problem, and that for the equation to balance long term, we have to take big strides on the road toward improving the remote work experience for everyone.

Isolation and Loneliness

As I mentioned briefly last week, isolation and feelings of loneliness are among the most commonly reported issues that remote workers face. While working remotely has some benefits, like allowing you to effectively bypass distracting and/ or annoying coworkers, it also prevents you from sharing pleasantries with your boss, clients, and the coworkers you doenjoy camaraderie with. You miss out on the more social aspects of traditional work life, like water cooler venting, office gossip, and bouncing ideas off of one another. These interactions simply don’t translate to tech like Zoom very well, and this lack of interaction between coworkers can be a detriment to team building and corporate culture. In a prolonged state, such as occurs in a remote work environment, this disconnectivity contributes to isolation and loneliness in individuals, and is associated with higher rates of anxiety and depression, as well as somatic symptoms, such as headache and generalized body pain.

If you’re a person who is already accustomed to, and appreciative of, conventional office life, and the steady rate of social interactions at work, the effects of switching to remote work might have a surprising effect, because our daily interactions help us reinforce our sense of well-being and belonging in a community. Researchers have demonstrated that loneliness as a result of isolation is actually twice as harmful to physical and mental health as obesity. One study I read found that 19 percent of people who work remotely report loneliness; and as with many such conditions or feelings, this poses a bigger risk when it becomes chronic. As you can imagine, people who not only work remotely, but also live alone, are especially at risk for feeling lonely, though I certainly see a fair amount of it in digital nomads who live with others. 

Burnout

Working from home can also feel like never leaving work, and another commonly reported cause for concern is burnout. I read a 2019 US study that polled remote tech workers. It found that 82 percent reported feeling burned out, 52 percent reported that they believed they work longer hours than their in-office counterparts, and 40 percent reported feeling as though they were required to contribute more than their in-office counterparts. These points are very common themes that people considering remote work, and new to remote work, should definitely keep in mind. In my experience with patients, this near compulsion to work longer hours is almost universal. I assume it’s the result of attempts to prove their ability to be productive from home, despite the presence of distractions and the availability of “extracurricular” activities that can accompany working from home. 

For many people, it’s already difficult to maintain a healthy work-life balance when working from an office, and it seems that this is also the first thing to go when work goes remote. The lines start to blur, and every hour in a day becomes a work hour. If you’re behind on a project, you figure you can afford to spend the “extra” hours in your day on completing it. But not for long. After a much shorter period of time than you’d think, that becomes a dangerous practice. Five minutes for one more email becomes hours, and when you stop to look up, you’ve spent far too long working, and you haven’t moved for 13 hours. My response to burned out, remote workers is to remember that home is also your office now, so you’re not really leaving work unless you turn off all communication platforms. You have to make a concerted effort to leave work, just as you would if you worked in an office. So just as you would walk out the office door about nine hours after you walked in, when you’re working from home, you turn off the devices after about the same amount of time…or else risk the ravages of burnout. Besides, when you’re mentally and physically exhausted, you’re not at your sharpest, not doing your best work, and you’re bound to make mistakes. 

Focus, Motivation, Distraction

Any number of factors in a remote work situation can make you lose focus and motivation, and chief among them are distractions. These are the things, intended or not, that distance you from your work. But the reverse is also true. When you’re not focused and motivated, it’s easy to fall prey to the siren’s call of distraction. Remember last week, I said that just because the refrigerator is a short distance away, that doesn’t mean you should constantly make the trip? Eating can be a distraction you act on when you’re bored. If snack o’clock happens every hour, or you’re having multiple versions of lunch, you’re distracted, or maybe looking for something- anything- to do, other than work. When you’re working remotely, you have a lot of freedom, which is generally a good thing in life. But understand that distraction is really the blacksheep cousin to burnout, and it’s all too easy to get sidetracked by it. 

Some other favorite classic distractions include wanting to sleep in, kids, myriad chores, online surfing and social media, calling friends or vice versa, pets thinking playtime is whenever you’re breathing, and good weather tempting you to ditch work and go to the beach, mall, spa, movies, etc. It’s easier to become distracted because you may be the only one managing your time, and this is one of the big reasons why people may not be as productive at home as they would be in a traditional work setting. It’s also the biggest reason why employers and management don’t generally like the idea of working remotely. While it might seem that the only way to be a successful remote worker is to be a self starter with superhuman focus who is impervious to distraction, there are ways to manage distraction, focus, and motivation. I’ll get into all of that next week, but here’s a hint until then: having a door to shut is an incredibly helpful head start. 

Inconsistent Pay

Working remotely can also be stressful because of the inconsistent wages that may be associated with it. The term freelancing is the one most commonly used for positions of this type, though you may better recognize the alternative terminology of independent contractors. It essentially means that they are self-employed, rather than being directly supervised or employed by someone else; as a result, they typically follow a remote arrangement. No matter what you call it, when you compare freelance work to a regular full-time job, there are some important distinctions. In a regular job, you know that no matter what happens, you’ll be paid (at least) the same amount each month; and since you took the job, I can only assume it’s sufficient to cover whatever bills it’s supposed to. But with freelance positions, because getting paid is typically based on contracts and invoices, payments can be pretty variable, and you don’t have any guarantees that your invoices will be paid on time. If the payor is unreliable, or decides to dispute, you have to expend time, and sometimes even money, to collect. Understandably, these variables and unforeseen complexities can result in cash flow concerns, and we all know that can lead straight to stressville. Not only is income variable, but workload is too. The temporary, variable, too much or too little nature of freelance assignments is intensely anxiety producing, and can wreak havoc with your sense of well-being.  

Communication

Communication with coworkers, supervisors, and clients can be a minefield, as things can easily be misconstrued under the best of circumstances. In a remote work arrangement, when you often keep in touch through non-visual methods like email and instant messaging, communication is further complicated, and this can have some very unwanted effects. Fortunately or unfortunately, depending on how you look at it, the amount of damage that can result from ineffective communication falls along a spectrum, from “uh oh” to “oh no!” One big problem in general, not just in a work setting, that may serve you well to remember, is that you can’t really get a sense of a person’s tone via typed electronic communication, because they can’t read facial expressions or hear your tone of voice. To the recipient, words read the same way regardless of whether you were smiling or yelling when you typed them. I can’t tell you how many times I’ve heard a complaint from a patient start with, ‘And then he texted…’ because instant messaging, while convenient, can also be a recipe for instant miscommunication.  

In a work setting, most tone concerns have to do with accuracy; that the words you’re using are literally sending the right message. Do you have a tendency to be very lighthearted and positive, and therefore potentially at risk for sounding like perhaps you’re not serious enough about a certain topic with a client? Or maybe you have a tendency to be sarcastic and risk that same issue? You might be most vulnerable to this when the person doesn’t really know you, or in circumstances where you may be sending an instant message you don’t give as much thought to as you would a more formal email. As you might imagine, these are situations where the smiley face in cool shades emoji doesn’t really cut it. 😎

Probably the most common communication issue I hear about is the lack of communication. Just as with the tech issue I mentioned previously, when a coworker is unresponsive, humans get frustrated. And understandably so. When you need an answer, but the person you need it from is uncommunicative via whatever digital channels you try, it can pose a problem. In the office, you could simply visit that individual’s desk and see them in person, but in a remote setting, that’s not an option. Since it’s work, you may have a deadline to complete a project, so not having that answer might make it late, and that may have a negative impact on your reputation. It can be a gnarly domino effect, I get it. But I can tell you that the answer is not to sendthem a message you may regret later, because chances are very good that’ll have an even bigger impact on your reputation, than the original lack of communication on their part would’ve had. 

Another thing to keep in mind when communicating electronically is not to set yourself- or anyone else for that matter- up for disappointment, by asking questions that really can’t be answered satisfactorily via these methods. If you’re seeking appreciation or other “feelings” on job performance in a text, you’re nearly bound to read disappointment in the reply, whether it was intended or not. Save the sticky wickets for more personal communication methods, even if they’re not necessarily the easiest choice. While some sarcasm or jokes may be funny, some people may not think so, and that can lead to all sorts of misunderstandings that can have a serious effect on company culture, productivity, team dynamics, and relationships with coworkers, supervisors, and/ or clients. Remember that nothing dies on the net, and everything leaves a digital trail, especially in a remote work setting, so things can come back to bite you later. Lastly, I would suggest that you always think twice whenever you instant message someone in order to avoid instant embarrassment and instant regret, proofread messages to make sure nothing’s getting in the way of what you’re trying to say, and save the complicated stuff for face to face when possible, or at least for video chat when it’s not.

Next week, the working remotely blog continues- I’ll address some solutions to all of the issues I mentioned today, and then I’ll tell you about the positive side of the remote work equation.

I hope you enjoyed today’s blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love and send blogs and YouTube videos to 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, and share them.

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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When Home Becomes Work:Challenges of Working Remotely

When Home Becomes Work: Challenges of Working Remotely

Captain Obvious says that while coronavirus is responsible for thrusting us (with IT people kicking and screaming) into working remotely as a necessity, it was already a fairly common practice BR (before ‘rona). In fact, a statistic I read indicated an overall global trend toward remote work long BR, with a global increase of 159% between 2005 and 2017. As far as US stats on remote work go, 17% of US employees report that they worked from home five days or more per week BR, but that jumped to 44% DR (during ‘rona). As for the future, polls indicate that totally AR (after ‘rona) a minimum of 16% of American people who had previously worked outside the home BR will switch to working remotely from home at least two days per week AR. In addition, more than one-third of US firms that had employees switch to remote work DR believe that it will remain more common at their company AR. Globally, polls now predict that 25% to 30% of the earth’s workforce will work remotely multiple days per week by the end of 2021. In short, the genie is out of the bottle, and it’s not likely to go back in.

Many employers and business leaders think that going remote is as simple as sending an employee away from the office with a laptop and a to-do list, but unfortunately, it’s not that simple. In truth, there are real life consequences associated with working remotely. It may sound like a dream come true, but from where I’m sitting, it’s become more like a nightmare. A lot of people have gone back to their outside offices now, but many are still working from home. This is either because they- or their employers- are still too reluctant to make the switch and return, or have found it beneficial enough that it behooves them to continue remote operations. Regardless of why you may find yourself doing so, working remotely does present its own set of challenges, not the least of which is that companies were essentially forced into it overnight, without benefit of true preparedness and system checks. 

But in any event, if you are still working remotely at this point, you may find yourself continuing to do so indefinitely. I find that most of my patients enjoy lounging in their pajamas all day as they work from home, never leaving their house because it’s such an effort to get dressed; though they fail to understand why they’re so anxious, irritable, and depressed. The good news is that there is a way to do this work from home deal effectivelyand happily, and even excel at it, while still having a personal life and functioning appropriately. The bad news is there are some not-so-nice ramifications and consequences associated with the routine, and a lot of people are starting to recognize this after far too long being “trapped” at home. Spoiler alert: most people actually are not. The bottom line is that your whole world doesn’t have to change just because you’ve eliminated a commute. Out of necessity DR, it did change for a time, but at this point, it’s time to get out and reclaim some normalcy. Some of the issues that come up with working remotely are more rooted in the personal realm, and deal with basic self care and psychological health, while others center more on professional matters. But don’t kid yourself, there’s a lot of overlap and cross reactivity betwixt and between them. So this blog marks the beginning of a series dedicated to identifying the issues surrounding working remotely, and discussion on how to address them appropriately, with some tips and tricks and coping methods thrown in for good measure.  

Today’s blog will deal with some problems that I’ve noted in video calls and appointments with my patients. I sometimes call them “duh!!” issues, because a lot of you are going to be like, “Duh, Dr. Agresti, we all know that!” Well, what some people know and what they do are two very different things. If you’re depressed, and you haven’t brushed your hair or gotten dressed for a week straight, then you might hear me say, “Duh, go brush your hair and get dressed, you’ll feel better.” I suppose you could also call them “helll-ooo!!” issues, as in, “Helll-ooo… you really need to take a shower!!” That’s a real thing, people. Not all of the things I’ll discuss are quite that extreme, but my list of remote work must-do’s includes some personal care requirements that must become- and remain- second nature to you; they must be part of a regular routine, regardless of the fact that you may be all alone, with nobody even there to see (or smell) you. So that’s where we’re starting; with just some very basic, very simple recommendations for a better life and more success in a remote work situation. Most of these you probably already know, but you may not be doing them. Allow this to be your kick in the can if that’s the case.

-Sleep in your bed, but then get out of said bed when you get up in the morning. Don’t just wake up and roll over to reach for your laptop to start your day. I cannot tell you how many patients I talk to while they’re working in bed; they’re literally in bed 24/7. Get out of bed!

-Create a dedicated office, preferably with a door you can close to keep things quiet and help you avoid distractions. If you don’t have a spare room, then at least create a dedicated work space. Even a corner of a room will do if that’s all you can spare. You really just need room for a table or desk large enough to hold a computer and whatever supplies you need, and a chair. Try to make it as comfortable- and functional- as possible.

-Make a schedule and stick to it. And be sure to keep an accurate account of the hours you work. I’ll be discussing supervisory micromanaging in the next blog, but if you keep a regular schedule and good records of your hours, you’ll have all the info you need if you are questioned by a micromanaging supervisor.

-Now that you aren’t commuting to and from the office, you’re going to be physically moving a lot less. So you must make time each day for exercise. So many of my patients that have switched to working remotely have gained a fair bit of weight and almost all of them have lost serious muscle tone. When you’re working from home, it’s easy to get comfortable and complacent, and turn into a flabby flaccid couch potato. Do something to move your muscles every day. 

-Eat three square meals each day, and no more 24/7 snack attacks. Just because your refrigerator is mere steps away doesn’t mean you should make the trip every 30 minutes. A small midmorning, midafternoon, or late night snack is okay, but that’s it. Note my word choice: or not and. Three decent meals and one small snack each day is acceptable- just try not to go too crazy- and try to make it reasonably healthy, maybe a yogurt, cottage cheese, or piece of fruit. Like, a box of girl scout cookies is not a snack, people. 

-Because you aren’t commuting to and from the office, you’re also rarely going to be required to go outside. So you must make a special point to go outside every day, even if it’s just for 15 minutes after lunch. Human bodies require vitamin D, and nothing’s a better source than sunlight. Try taking a walk around your neighborhood after you have lunch, just something where you’re exposed to the sun. 

-A lot of my patients are complaining of decreased intimacy and a lack of sexual energy since they started working remotely. So my next suggestion is to do whatever you can to be close to your partner. Emotional and physical intimacy are important, so have sex, but maybe don’t combine this suggestion with the one above it, unless you have an excellent privacy fence. 

-When work is over, stop working. It can be tempting to work more hours when you’re at home. This may sound counterintuitive, but it’s true. To avoid this trap, work the same schedule and number of hours each day at home as you would if you were commuting to an office. Don’t try to cram jam in four16 hour days days a week in order to take a 3 day weekend, unless it’s an unavoidable situation, and/ or you receive permission or clearance from a supervisor if applicable.

-Make sure to get adequate sleep. Go to bed at a reasonable time, get up at a reasonable time, and try to stick to a sleep schedule. And remember to avoid blue light exposure for at least two to three hours before you go to bed, otherwise you’ll have a hard time falling asleep. 

-Keep your regular grooming routine- you’ll feel better about yourself. If you didn’t get the hint, shower every day. Brush your hair, and your teeth. Shave and put on makeup if you’re about that life. Work is not a pajama party, so get dressed in appropriate clothing. You don’t have to wear a suit or heels, but make an effort to be presentable, even if there’s no one to present yourself to. 

This isn’t rocket science, people. Basically, you should follow the same routine you always have, and do everything you would do if you were going to an actual outside office or workplace: go to bed at a reasonable and regular time on work nights, get up at a reasonable and regular time each morning, and resist the urge to hit snooze 97 times. Shower, shave, get dressed in decent clothing, and eat breakfast. Then go to work in your in-house office space, just as you would if you were going to commute to an office. Avoid distractions and get your work done. Take a one hour lunch break maximum, and make sure to actually eat something reasonable, but avoid eating at your desk. Think about taking lunch outside for some fresh air, vitamin D, and a change of scenery, and you can kill multiple birds with a single stone. After lunch time is not nap time- and it hasn’t been since kindergarten- so after lunch, go back to work until it’s time to stop at the end of the day. Make sure to put in a full day’s work, while also being careful not to overwork. Behave as if you owned the company and were paying employee salaries. Supervisors will be less likely to micromanage you to death if you give them no reason to mistrust you or doubt your motivations.  

No Nearly Naked Zooming

Captain Obvious says that videoconferencing has become a big part of our lives DR, and will continue to be long AR. Here’s a fun fact for you, Zoom saw phenomenal growth in 2020, and ended the third quarter of 2020 with an astounding report of 367% year-over-year revenue growth. If you had stock in Zoom Video Communications BR, which I did not, that’s a very fun fact for you. And get this… Zoom hosted an average of 300 million meeting participants per day throughout 2020. That’s 300 million people that don’t need to see you in your underwear, people. Same goes for gnarly, used-to-be-white, ripped t-shirts with yellow pit stains. Get it? If you didn’t, here’s the simple concept: put on a shirt. One with at least two buttons at the top. 

Drinks, not Zinks

Even if you dress appropriately for video conferencing calls, there’s really no replacement for real deal interaction, because shockingly, humans are hardwired for human connection. Even Captain Obvious wouldn’t bother with that one. It’s just not possible to simply erase our evolutionary zeitgeist and replace millions of years of in-the-flesh interactions with technologically mediated virtual communications. While Zoom and its brethren have helped us in our attempts to recreate a certain degree of face-to-face experiences, that’s really as much thanks to the power of human imagination as it is to technology; and nothing stifles human creativity and imagination like isolation and loneliness. As a society, we spend a lot of time creating tech to replicate real-life experiences, but it’s a cheap substitute. In most situations, we’re better off spending a larger portion of that time experiencing real-life personal experiences. If you live alone and work from home, you could literally spend days without any human contact. You should make an effort to socialize, but remember to do so responsibly and wear your mask, people. Call a friend and suggest you meet for dinner, coffee, or lunch, or go on a date night. Drinks are hands down better than Zinks, so arrange to meet a friend IRL. 

Loneliness or isolation is one of the most commonly reported issues that remote workers and digital nomads face, along with anxiety, stress, and depression. Next week, in part deux of this remote work blog, I’ll talk more about those, as well as some professional issues that can come into play when working remotely, and I’ll make some suggestions on how to deal with them. Then in part three, I’ll talk about some specific anxiety and stress busting techniques you can incorporate into your routine during the day, as you need them, and they won’t complicate or derail your work schedule, or negatively affect your productivity. In fact, they’ll do just the opposite.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too.

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well, people!

MGA

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How you “Catch” Feelings

How You “Catch” Feelings

You’ve probably heard the expression “Smile and the world smiles with you,” or at least heard Louis Armstrong’s rendition of the song that refers to it, When you’re smiling, in the movie Analyze This with Robert De Niro and Billy Crystal- which, being a shrink, I of course found very amusing. Expressions don’t become embedded in the public’s consciousness for no reason, so where does this one come from? 

Maybe you’ve experienced a situation where “contagious laughter” has swept through a room, or even been the catalyst for it yourself, because of your “infectious laugh.” If you watch the news, you’ll eventually hear a reporter describe how “panic ensued” while covering certain events involving “mob mentality.” But what do these things really mean? How can feelings be shared or transmitted between people, even when they’re all strangers to one another? 

The answer is a phenomenon called emotional contagion, or EC, the subliminal process by which emotions are transferred from one person to another, such that the receiving individual experiences the emotions as their own. Living in a covid-19 world, we’re all too aware that it takes just a cough or a handshake to spread germs from one person to another, but you can “catch” feelings far more easily than you can catch covid, and far faster. The process takes just milliseconds, faster than the blink of an eye. EC is an important and primitive instinctual process that forms the basis of interpersonal communication, but don’t let that confuse you, that doesn’t mean it can’t or doesn’t occur amongst groups, because it absolutely does. I should note that EC can also be induced in people via some inanimate objects and cultural artifacts, such as photographs, movies, cartoons, and music. Think about crying at sappy movies or dancing in the car when your favorite song comes on. Not only that, but EC isn’t a “humans only” phenomenon; studies have demonstrated that it also occurs in all other primates, some birds, and it’s even been demonstrated in rats. 

To further the covid analogy, the “virulence” of EC and the susceptibility to EC vary by individual. That is to say, some people can be more effective at transmitting it, and some can be more prone to feeling its effects, i.e. susceptible, but everyone is essentially both to varying degrees. EC isn’t type specific, meaning that research has found that both positive and negative emotions- enthusiasm, joy, sadness, fear, and anger- are easily passed from person to person, typically without either party being aware of it. You can be going about your business, feeling whatever you’re feeling, and have an encounter with someone doing the same thing; then afterwards, you feel differently, for reasons that you can’t specify. That can be a bad thing or a good thing, depending on a number of factors that I’ll get into. So apparently Forrest Gump’s mama was right… life is like a box of chocolates- you never know what you’re gonna get. Covid and chocolates- it’s a mixed metaphor day, people. 

How Emotional Contagion Happens

At the most basic level, it works like this: if someone is happy and smiles at you, it tends to cause you to smile back, and that act of smiling back actually improves your mood and causes you to feel happier. But how and why? You might’ve noticed I’ve said that EC is a process; in fact, it involves three stages: mimicry, facial feedback, then contagion. 

As people communicate, they express themselves not only through language, but also through gestures and facial expressions. Throughout a communication exchange, individuals constantly read each other’s faces and body language, then instinctively and unconsciously tend to reflect it i.e. copy it; that is called mimicry. When a person then displays the emotion on their face through mimicry, those muscle movements trigger the actual feeling associated with the emotion, and they then get a subjective experience of that emotion i.e. they start to feel the emotion as their own, which is sometimes referred to as adoption. This is because the area of the brain that is activated through the unconscious act of mimicry is the same area that normally would’ve been activated if the person had initiated and performed the action themselves. Same area of brain activated equals same response, regardless of the catalyst for the activation. Handily, this phenomenon is explained by “mirror neurons” in the brain. These neurons fire whether an individual initiates the act themselves, or observes the act being performed by another individual. So the act of mimicry causes the observer’s neurons to fire, and thus “mirror” the activity of the first person’s neurons. It’s sort of like monkey-see, monkey-do for neurons. 

When you put all of the stages of the EC process together, it works like this: when someone is happy and smiles at you, you will typically smile back (mimicry) and that act of smiling back actually improves your mood (facial feedback) and ultimately causes you to experience that happiness as your own feeling (contagion). 

Role of Emotional Contagion

Humans are social beings. We are born equipped with the evolutionary capacity of EC to help synchronize our emotions and express our wants and needs. A simple example would be a newborn baby crying to be fed because it’s the only way they know how to get food from their caregiver. When they cry and are then fed in response, it reinforces the mechanism. In this way, EC acts as a primitive tactic that continues to develop, and later assists in the recognition and processing of feelings, and a cumulative understanding of how to deal with them in an appropriate manner.

Emotional contagion contributes to empathy, and there is a direct correlation between the two. In other words, decreased sensitivity to the EC results in a decrease in empathy. They are also linked by the fact that both involve the monkey-see, monkey-do mirror neurons, but they are not technically the same thing. Empathy is the capability to share and understand another’s emotion and feelings that is often characterized as the ability to “put yourself into another person’s shoes,” in an effort to experience what the other person is feeling. But it is a conscious choice, so you know the source of the emotions you feel. In contrast, EC is an automatic, subconscious and subliminal process, generally mediated through mimicry of facial and/ or vocal expressions, whereby your feelings or emotional states are influenced by those of another person, such that you experience, or adopt, those feelings as your own. This is also termed emotional convergence or synchronization, and the source of the feelings is typically unknown, and often unexamined.

Scientists agree that there is an emotional climate and culture that tells us which emotions we should or should not display and when. Our understanding develops over time, and guides us in making behavioral decisions according to what is and is not socially acceptable. Imagine that you somewhat reluctantly made plans with an acquaintance, but then they see you and tell you they need to cancel them. Inside, you may actually feel some sense of relief, but instead, you noncommittally say, “Well, that’s too bad, but okay.” On the other hand, if you are insensitive to EC, and therefore are lacking empathy, you might say, “Phew, because I didn’t want to go anyway.” But because you realize that saying that would probably hurt the person’s feelings, and/ or would make you look like a cad, you respond appropriately. This is an example, albeit an extreme one, of how EC allows you to instinctively know what is appropriate, and alter your response and exhibit the correct emotional behavior to maintain success in relationships. In fact, because the automatic processes of EC happen so quickly, you have the ability to change your reply on the fly, even mid-sentence, based solely on the other person’s emotional response as communicated by their facial expression, in order to avoid a social faux pas. All brought to you, in a matter of milliseconds, courtesy of emotional contagion. Which gives you an idea of how important it is in avoiding problems and. 

Factors Influencing Emotional Contagion

As I mentioned in the beginning, some people can be more effective at transmitting emotional contagion, and some can be more susceptible to its effects, but nearly everyone is affected, albeit at varying levels and times. There are many factors that influence susceptibility to EC; most of them essentially boil down to the common bases of individual differences, such as age, genetic predisposition, personality traits, gender, and early emotional experience. But it has also been found to vary between interactions, based on the type of interaction, intensity of the expressed emotion, mood at the time of the interaction, and the level of empathy and power dynamics between the individuals involved. All of these influence the intensity of the contagion and have an impact on how likely a person is to “catch” an emotion. 

But in fact, you don’t really have to guess how susceptible you may be to EC, because there is an accepted way to accurately measure it, called The Emotional Contagion Scale. Designed in 1997, it takes the form of 15 questions that measure individual differences across five basic, cross-cultural emotions: love, happiness, fear, anger, and sadness, by determining how likely a person is to mimic those emotions. I’ve included the scale and scoring instructions at the end of this blog if you’re interested in taking it. In the meantime, I’ll continue with the factors that tend to influence EC. 

Some personality types generally have greater awareness of emotional states, their own as well as those of others, and are therefore more open to the process of emotional contagion in general, in both transmitting emotions to, and receiving emotions from, others. They are also generally more sensitive, attentive, and skilled at reading non-verbal cues. 

Other people who are more expressive, meaning that they wear their hearts on their sleeves- and their faces- may be more likely to transmit or share their emotions because they telegraph their feelings more powerfully. Not only that, but the more expressive someone is, the more likely another person is to notice that expression and mimic it. And remember those mirror neurons? They come into play here bigtime, because when that emotion is reflected through mimicry of the associated facial expression, those muscle movements trigger the actual feeling in the brain, brought to you by mirror neurons. On the other hand, people who have a stronger internal response to emotional events- whose hearts may race when they’re nervous, even if they seem calm on the outside- may be more susceptible to catching other people’s moods. 

EC is also influenced by the level of intimacy, and therefore empathy, between the individuals involved. People who know one another well and are in frequent contact are typically more affected by EC; this is generally true whether they are the transmitter or receiver. Have you ever found yourself tearing up when you see someone else crying? It’s perfectly fine if you have, and can even be considered a very good sign in relationships where it serves as an indicator of the level of emotional investment. It is more likely to happen when the person crying is someone close to you, such as a spouse, child, parent, or close friend. In fact, studies have shown that emotional convergence occurs more often in relationships that are more cohesive and less likely to dissolve. Not surprisingly, people living under the same roof are especially likely to catch each other’s emotions and moods, as they are the types of relationships where individuals tend to become more similar in their emotional responses.

That said, studies have shown that mere acquaintances, or even strangers, can catch each other’s moods, though the degree to which it happens does depend more on their individual susceptibility. But if you bump into someone in your neighborhood while getting the mail or taking out the trash, and they smile and just say hello you, they can make you feel a mood boost. Or if you’re in the elevator in the morning on your way to work, and someone is impatient and grumpy because the door opens to let someone new on board, they can easily influence your mood, even if no words are exchanged. Normally that’s not amusing, but loyal blog readers may be chuckling if they recognize that as a little DISC humor from last week. If you don’t know what on earth I’m thinking right now, read last week’s blog on the DISC model, because even this instruction is laced with it! 

Researchers have also found that language and word choice drives some part of the contagion process, as negatively charged words, i.e. strong language, like “hate,” “worthless,” “anger,” and “sad” are more likely to increase susceptibility to the emotion being conveyed. So strong language generally induces a stronger EC response, which isn’t always great news. There’s enough of that in the world, no need to propagate it. 

We’ve learned that age plays a role in influencing EC. Scientists very recently published research describing how the moods of teenagers were affected by those of other teenagers around them. If you’ve ever raised a teenager, this definitely resonates; but more not-so-great news, bad moods were more potent. They also found that when a teenager “catches” a bad mood from a friend, the friend’s outlook becomes more cheerful. That’s a very interesting finding with very mixed news- good for the friend that’s transmitting, but bad for the person that catches it. So much for sharing means caring… more like take this away and don’t stay! Remember that I’m a shrink, not a poet, people. 

EC is influenced by gender as well. I should preface this by saying that the relationship of gender to emotional contagion can be a pretty thorny one, as it’s a complicated issue. You’ve probably noticed that I used the word “appropriate” to describe the ideal effects EC has on the expression of emotion, i.e. behavior. The issue is that behavior is often governed by cultural rules which actually vary according to gender; that makes it difficult to make hard and fast “rules” about which gender “should be” expressing which emotion(s), and how and to what level it “should be” expressed. Using a purely theoretical example, women “should be” nurturing caregivers, so they are more susceptible to EC. In other words, it’s super biased, sexist, and constrictive.

Probably as a result of this issue, the research into gender differences in EC has had mixed results. An early study hypothesised that because women were more emotionally expressive than men, they would be more susceptible to catching emotions; and indeed, the results from the EC scales of the participants confirmed this. In contrast, another study found that there were only minor differences between men and women in their experience of “caught” emotions. However, it also found that both men and women had a stronger emotional response when the emotional model used was female rather than male. Still another study found that gender differences came into play when the expressive model was displaying a threatening emotion, such as anger. They found that women responded to the angry faces with more expression, whereas men suppressed their emotional expression, and some even displayed a tendency to smile in response. The scientists hypothesised that this was due to the effect of socialization in the expression of emotion, with women being more likely to attempt to communicate their distress and men more likely to mask or suppress it. This is consistent with the concept of hegemonic masculinity, which is shrink speak for having stereotypically male dominant traits. Yet another study examined moods, before and after pairs of friends talked about multiple predetermined topics. It found that, after talking with a troubled friend, women’s moods were more likely to deteriorate in general, on both sides of the contagion equation (hey, maybe I am a poet) but men’s moods were far less changed, regardless of whether the troubled friend’s mood improved or not. 

Regardless, all of the differences in these studies can only be interpreted as confirmation of the fact that cultural and behavioral “rules” are actually responsible for the mixed results and ensuing confusion when it comes to attempting to define how gender affects the expression of EC. And that’s pretty much what we figured, right? So now you know for sure.

Emotional Contagion: Practical Applications

Captain Obvious says that if you’re unhappy, being able to adopt the emotions of a happy person may allow you to feel better and more motivated. And clearly, a positive mindset helps you feel less stressed, which has a positive impact on emotional and physical health. By now you know that this phenomenon helps people connect on a basic emotional level, but EC also has some less obvious practical applications and implications as well, and some of these are an argument for how it can be developed as an intentional tool. In fact, some people subscribe to a broader definition of the phenomenon of EC as “a process in which a person or group influences the emotions or behavior of another person or group through the conscious or unconscious induction of emotional states.” I can appreciate the value of applying EC as a tool to motivate others, but I don’t appreciate it when it’s used as a tool to manipulate others into serving personal interests. First I’ll talk about the positive applications and implications of EC, then I’ll address the less than positive. 

Humans generally want to be accepted and understood. To that end, it’s beneficial to know what other people are thinking, if they agree or disagree with you, if they’re understanding what you’re attempting to convey, and whether or not you’re connecting with them on a very basic emotional level. In a way, EC is sort of like a very primitive form of mind reading, as it gives you an idea of what another person is thinking, and therefore feeling.

EC is important to personal relationships because it fosters emotional synchronization. If you want to connect with a person on a deeper level, you want to be “in sync” with them, the euphemism derived from the term, and awareness of the phenomenon can give you an idea of whether your attitudes and beliefs are sympatico with another person’s.  

EC can be developed as a skill for use as a tool for effective communication, and therefore one that would be especially important for public speakers and trial attorneys, and people in motivational type positions like sports coaches, among others. Think about listening to a lecture where the presenter is dynamic and expressive, and clearly believes what they’re saying; then contrast that with a presenter who is monotone, slumped over the podium, not moving, and clearly disinterested. Same idea goes for the coach or captain of any team. If one is animated and motivated and obviously believes and expresses that you’re a valuable and capable player, and that your team will win, will that be more effective than one that is totally unmotivated and seems unconvinced that the team is up to the task? Who would you be more inclined to listen to and believe in either of these situations? Even Captain Obvious says that the answers are so clear that they don’t even require responses. 

EC has survival value as well. It has been conserved, developed, and reinforced throughout human evolution, which doesn’t tend to keep unnecessary processes. In fact, evolutionarily speaking, EC has evolved, in part, to ensure survival. The brain is hard-wired to keep you safe, and that’s one of the reasons it’s especially attuned to pay more attention to negative emotions like fear and pain. Speaking of which, let’s talk about a real world example of EC’s survival value. Imagine that you were on a plane, and (heaven forbid, but just go with it people) there was some emergency; you may not know how serious the situation is or how concerned and prepared you should be, but by paying attention to the emotions expressed on the faces and in the voices of flight attendants and the pilot(s), you can infer signals that may be critical to your survival. Like when to assume the crash position. I say early… very, very early. Like maybe immediately after boarding. Jk, people.

EC can also be useful in work settings, but only when the moods swing the right way. Numerous researchers have found that when business leaders are in a good mood, members of their work group not only experienced more positive moods, they also experienced fewer negative moods. Studies have also demonstrated that groups with leaders in an upbeat mood were more coordinated and actually expended less effort on tasks than groups with more downbeat leaders, which made them more efficient. But keep in mind that this is a double-edged sword, and a co-worker’s or boss’ bad attitude can spread quickly through a company and create a toxic environment for everyone.

Emotional Contagion: Conscious Strategy

We’ve just discussed how EC can be used as a positive tool, but as I mentioned, EC can also be used as a strategy for… let’s say, potentially less altruistic means. 

Emotional Contagion in Marketing

Because it influences thoughts and feelings, EC results in changes to mood, emotions, and behaviors; and studies confirm that this includes consumer behaviors. This was verified by setting up experiments that videotaped participants’ facial expressions before and after exposure to specific photographs. After analyzing the changes in the expressions, these studies concluded the following:

-Participants who saw a smiling model in an advertisement mimicked the picture, smiling back, therefore confirming the process of CE.

-The positive emotion conveyed by the facial expression was also associated with a positive evaluation of the product displayed in the advertisement. 

Therefore, as expected, the advertisement with a positive expression of a smiling model elicited a more positive attitude, sympathy, and increased perceptions of reliability and intentions to purchase, as compared to the neutral condition before the photograph was shown. In other words, if an advertisement can make you smile, laugh, or stimulate EC through any positive means, you will feel more positive about the product that the advertisement features. It will make you believe that you need that product, it is the best, better in every way when compared to similar products; and it will do that as if you thought these points yourself, thanks to the monkey-see, monkey-do mirror neurons. 

Advertising and marketing execs know this and use it. I’m not saying that this is good, bad, right, or wrong; I’m just saying that EC is purposely used as a tool by employing advertisements that feature cute and cuddly babies, beautiful women in bikinis, hunky men in uniforms, and whatever imagery execs think will elicit a positive response, to sell you a product that you may or may not need, and that may or may not actually be as awesome as you might (literally) be led to believe. So be aware. 

Emotional Contagion in Dating

Remember how I used the words “less altruistic” to describe some of the ways EC can be used as a strategy? Well, for this particular application, I’m going to replace those words with “morally reprehensible.” And I suspect many of you will agree. There’s a guy that developed what he calls a “method,” (I use quotation marks because it isn’t actually a method) for men to study and apply EC in an effort to manipulate women into “dating” them (which is actually just a euphemism for having sex with them), and all for the “low, low price of” (my best announcer’s voice) of whatever over-inflated amount he charges for it. 

There are so many faults in this that I almost don’t know where to start. First, given my profession, I find it especially deplorable that a person would intentionally manipulate someone else’s feelings just because they can’t manage to get a date, i.e. have sex, with someone any other way. That said, my views on this would remain the same if I were a garbage man. And, it does bother me that this guy is so sexist that he clearly can’t even envision, much less appreciate, the fact that he developed a program “for men to get women,” and clearly doesn’t recognize that men can love men and women can love women; not that any program like this should exist, regardless. Also, not for nothing, but the light that this casts the users of this “method” in isn’t flattering at all. Helll-ooo, desperation. And that has to be considered, because I can almost guarantee you that eventually, your target will find out that you’re using psychology to manipulate them- which won’t make them very happy- because this program is fake. 

Speaking of fake, who wants to be fake enough, in order to manipulate people long enough, to get them to sleep with you? And people with even an average amount of awareness can usually sniff out fake like two week old fish, because that’s what fake- and this program- smell like. And if your potential target didn’t have enough awareness before reading this blog, they certainly will after. So the solution to this problem is to share this blog and spread the awareness, people. 

Unfortunately, I’m sure that this may cause some of you to want to try to look it up, even though I haven’t given you the name of this program. I say unfortunately, because I don’t want this guy to get any more credit than he already has; and because regardless, you’d be wasting your money. I can save you that, plus a lot of time and fake energy, and tell you that it won’t work, for any number of reasons. I can even make an alternate suggestion if you’re lonely enough to consider paying for something like this “method” which isn’t a method. Why don’t you use that money and make an investment in yourself, see a psychiatrist or psychologist and try to find out why you might not be attracting whatever person you want to be with, because I can say with some authority that attraction really starts with you, so you have to know yourself to attract other people.

I’ll even help you out here and now and tell you that, of the six factors that influence attraction, the most important psychological factor is reciprocity, which basically means that you are more likely to like someone who likes you. Some of the other factors that influence attraction are things like familiarity and similarity, which- guess what- also depend on you knowing yourself. So I suggest you get to know more about you. The very worst that could come of it is that you gain some perspective and some self esteem, and that’s half the battle won. 

I apologize if my opinion is too clear, or offends anyone, but everyone has people they care about- friends and family- and most people wouldn’t want them to be manipulated and conned in this way, just to serve someone else’s purposes. That perspective is empathy at work, by the way, and hopefully it’s contagious. Maybe this guy and his “method” upset me so much because I expend such a huge amount of time and energy undoing the damage caused by manipulation. Just a theory. Anyway, moving on to slightly less manipulative applications of EC as a strategy.

Emotional Contagion in Digital Interactions

Emotions can even spread through all of our digital interactions, because EC doesn’t rely solely on visualizing facial expressions; it can also be influenced by emotions that are implied via language and word choice. All digital interactions are subject to EC, including text messages, emails, instant messages, and most importantly, social networks. It’s the most important because the moods are propagated i.e. spread to, and influenced by, the mood of your friends, that of your friends’ friends, and their friends’ friends, and so on. This has been demonstrated by one study that looked at online social justice movements, and which found a demonstrable “amplification effect,” wherein people more frequently liked replies that were actually more emotional than the original message posted. This would be a very effective method for propagation, because again, language and word choice play a role in the contagiousness of EC. But that’s another double-edged sword.

And speaking of social network studies, one dominant social media site, whose name rhymes with placelook, conducted a particularly controversial study that came to light in 2014, when scientists published a paper revealing that, in 2012, researchers (who were also employed by the same social media site by the way) conducted a study into EC. In the study, they surreptitiously altered the news feeds- the main page that users land on for a stream of updates from friends- of nearly 700,000 users. Feeds were changed to reflect more “positive” or “negative” content, in order to determine if seeing more sad messages makes a person sadder. My response: duh. 

After analyzing more than 3 million posts, the team found that people exposed to fewer positive words made fewer positive posts themselves, whereas those exposed to fewer negative words made fewer negative posts. In other words, you are what you feed, not what you eat, on placelook. The experiment also demonstrated that personal interaction and verbal clues weren’t necessary for emotional contagion. It’s worth noting that both of those things had already been discovered from separate studies, designed and conducted by different researchers, one of which found that the very existence of feeds was making some users sadder. So basically, now we are absolutely sure, as if we didn’t know before, that placelook can manipulate your mood, which does affect your perspective, what you buy, why you buy it, whether you vote, how you vote, and pretty much everything else in your life. It certainly has the biggest effects on how you interact with your social media friends, especially after your news feeds are altered… helll-ooo!!  

If you’re wondering about permission, here’s the scoop on how news feeds were surreptitiously tweaked without warning: placelook users agree to the social giant’s general terms of data use when they create a profile, and researchers tracked emotional responses of test subjects by judging any subsequent changes in their use of language, which is covered in those terms. It’s unclear if you, or I, were tested, and it will remain that way. Ultimately, as users, the check-box agreement gave permission for this kind of psychological experimentation.

I should add something. One reporter that had been aggressively following this story for Forbes got a response from placelook, which stipulated that, “…the research was conducted for a single week and none of the data used were associated with any specific user.” They further explained that they do research to make the content “…as relevant and engaging as possible” and that, “a big part of this is understanding how people respond to different types of content, whether it’s positive or negative in tone, news from friends, or information from pages they follow. We carefully consider what research we do and have a strong internal review process. There is no unnecessary collection of people’s data in connection with these research initiatives and all data is stored securely.”

One last note on this topic: another reporter had apparently spoken with the editor of the placelook study, who is also employed by them, and she reported that even they thought the mood study was creepy. I agree, and I also think that, when it comes to studies, placelook may not know exactly what they’re doing, but they definitely know what they have the power to do, and what a platform with access to the personal interactions of more than a billion users can do. And now I’ve said all I’ll say about the placelook study controversy.

When it comes to the ways emotional contagion can be used as an external tool, potentially on- or against- you, the take home message is be aware and beware.

Emotional Contagion: Final Thoughts

With any luck, people catch all the positive emotions, a colleague’s enthusiasm for a promotion at work, or a friend’s excitement over an engagement, and miss the negative ones. But what goes up must come down. Research suggests that just being around someone who’s stressed can increase your own stress levels. Other studies have found the same to be true for depression. Negative emotions, like sadness, fear, pain, and anger, are more contagious; and on top of that, they can be damaging to your overall health, as they can lead to sadness, depression, fatigue, decreased energy, and stress. Ultimately, negative states of mind may increase the risk for heart disease and other serious health issues over time. You’d think that with such negative impacts, people would always stay away from those who emit negativity. But it’s not that simple. 

While the idea of making yourself impervious to other people’s emotions may be appealing, putting up an emotional barrier isn’t the answer. This is because the cost of it is the loss of empathy. You have to consider that shutting out other people’s dark moods precludes you from catching their good ones as well. So how should you respond to negativity? 

First, consider this: research indicates that people can catch something that isn’t actually there to begin with, for the same reasons why EC confers survival value. Because we are wired to pick up on threats in the environment, we are susceptible to interpreting situations negatively. In addition, humans tend to create our realities in accordance with our beliefs, so if we go into an ambiguous interaction believing the worst of someone, we tend to act in a way that makes the other person more defensive, or worse, antagonistic; and this confirms our original view. The lesson is that reality is what you make it, so try to make it positive, even if it seems negative.

Since you can’t- and shouldn’t- shut out all negativity, what can you do to regulate it, while still ensuring that the positivity comes through loud and clear? There is some strategy involved in managing this, and like EC, it’s a skill you can work on. Take some time and reflect on your own emotional state. 

Now we know how easily so many things can affect our mood, and then affect the moods of others, without us even realizing it. Below are some tips to manage EC if you think your moods “infect” others negatively, or vice versa, and some ways to do yourself a favor when they do.

Awareness is Key

When you become aware of the emotions you exude toward others, it helps you recognize when you’re picking up on the negative or positive emotions of others; this will allow you to create change if needed and protect your own emotional well-being, as well as that of the people around you. Take care of yourself when you need to. If you feel exceptionally stressed, first remember the possibility that you may be feeling something that’s not actually there. If you find it is actually there, then proceed with management. 

Seek Professional Guidance

If you find that you’re more aware or sensitive to the moods of others, you can always evaluate those relationships and those triggers. Talking with a trained professional can help you in thought pattern recognition and guide you into healthy coping skills to ward off EC.

Create Your Happy Place

Surround yourself with things that make you happy. You’re less likely to succumb to someone else’s bad mood if you keep your surrounding environment full of things that bring you joy. So create your own personal happy place, at home and at work, that can help you if you start feeling like you’re coming down with a bad case of negativity. Bring in plants, put up photos of your pet, partner, children, and friends, and listen to your favorite music. 

Accentuate the Positive

Incite radical acts of positive contagion: play upbeat songs on your way home if you’re stressed, like on the way home from work. Find proactive ways to boost your moods, and those of loved ones will increase as well. If you don’t want another person’s negativity to affect you, try turning the tables by smiling and trying to keep your voice cheerful. This not only helps you feel more positive, but the other person might also mimic your body language and catch your mood, making it a win-win situation. 

Laugh

When you feel negativity creeping in, share a funny video, tell a good joke, or enjoy your favorite sitcom or movie for a boost of positivity. Just like offering positivity, laughing can help improve your mood and relieve stress, and it can also spread to people around you.

Engage

One of the best ways of avoiding contagion with people who are down is actually to engage with them. Do things with them that will lift both their mood and yours, like taking a walk, sharing a meal, working out together, or just being generally supportive and talking through things. 

It’s Not Personal

People have their own issues and they have nothing to do with you. Don’t encourage or even engage with bad behavior, or anything else that doesn’t feel right, and that includes online. Bad behavior breeds bad behavior. If you send out calm, positive signals, you are more likely to attract the same, and less likely to attract the opposite.  

Not Changing

Remember that changing the behavior of an adult who thrives on negativity is typically very unlikely to happen, and the attempt can wear you out, especially because you’ll find you’re doing it over and over. If you’re dealing with an angry boss or an anxious father, always remember to take time for yourself to think the situation through before engaging and trying to convince people to change their bad behavior.

Control Yourself

When you’re in a bad mood, there are also ways to avoid infecting other people with your negative emotions. They all boil down to one central theme: control. Realize that you have the power to “infect” a room via contagion, especially in your own home, and use that as an incentive to keep emotions in check and safeguard your colleagues, neighbors, and loved ones from your negativity.

Inoculate

We know what inoculation means, so try to do that first to make yourself less susceptible to bad moods that you can easily pass on to others. This includes the basics, like getting adequate sleep, eating well, exercising, and cultivating a sense of purpose.

Cope

Compartmentalizing can be useful in managing the effects of EC. You might think you have every right to be cranky, but if you consider how it can infringe on other people’s rights to exist in a content state, you might find it easier to set aside your negative thoughts and emotions. So shelve the bad mood when you know you’ll be interacting with other people. You can always choose to wallow in your negativity later, in private.

Feedback

Show some emotional awareness by asking a long-term partner, or someone else you trust implicitly, for input on whether you’re giving off negative vibes too often. If so, work to regulate your sadness, anger, and anxiety through therapy or mindfulness, or by modifying your expectations or looking at the situation from a different perspective.

Quarantine

If you’re particularly irritable, consider isolating yourself. We’re all familiar with this one. You might be better served by watching happy movies or going to bed early.

Ask yourself some questions:

-What types of emotion do I give off and how does that affect the people I interact with, my family, roommates, spouse, colleagues, etc?

-How easily do I let others affect my emotions? Am I even aware when it’s happening? 

-Are the people in my social networks the type of people I really want to surround myself with?

-Whom do I feel my best around? 

-Who reinforces my strengths and best qualities? 

-With whom am I the best version of myself?

-Are there actions or changes I need to make?

Keep in Mind:

-You aren’t responsible for the feelings of others, only your own.

-You may not be able to help other people, but you’ll never be of much help if you’re not feeling well, either. You can always take the time to help yourself, and you’re absolutely worth it.

-People usually share their experiences in the only way they know, and this is especially important to remember when they’re depressed. 

-Check out the Emotional Contagion Scale to see how vulnerable you are to catching and adopting the feelings of others.

The Emotional Contagion Scale 

This examines a person’s tendency to mimic five basic emotions: sadness, fear, anger, happiness, and love. 

If you want to take it, forget everything you’ve just read- temporarily, mind you- and remember that there are no right or wrong answers. Read each question and choose the answer that best applies to you using the key below. Scoring interpretation instructions are at the end.

4 = Always; 3 = Often; 2 = Rarely; 1 = Never

1. If someone I’m talking with begins to cry, I get teary-eyed.

2. Being with a happy person picks me up when I’m feeling down.

3. When someone smiles warmly at me, I smile back and feel warm inside.

4. I get filled with sorrow when people talk about the death of their loved ones.

5. I clench my jaws and my shoulders get tight when I see the angry faces on the news.

6. When I look into the eyes of the one I love, my mind is filled with thoughts of romance.

7. It irritates me to be around angry people.

8. Watching the fearful faces of victims on the news makes me try to imagine how they might be feeling.

9. I melt when the one I love holds me close.

10. I tense up when I overhear an angry quarrel.

11. Being around happy people fills my mind with happy thoughts.

12. I sense my body responding when the one I love touches me.

13. I notice myself getting tense when I’m around people who are stressed out.

14. I cry at sad movies.

15. Listening to the shrill screams of a terrified child in a dentist’s waiting room makes me feel nervous.

The highest possible score is 60, and the higher the score, the more susceptible you are to emotional contagion. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Personality and Behavior: DISC Model

Personality and Behavior: DISC Model

Wikipedia defines personality as the “characteristic set of behaviors, cognitions, and emotional patterns that evolve from biological and environmental factors.” I’m sure they probably go on to list those factors in the third through fifth paragraphs, so this short definition seems neat and tidy without really committing to much. But as we all know, when you’re dealing with humans, things aren’t ever simple. In reality, there’s no formal or universal definition, but that’s okay, because it gives psych nerds something to argue about. Because there’s no universally accepted meaning, all definitions are essentially theories, most of which center somewhere around an individual’s psychological motivations and resulting interactions with their environment. Alternatively, people can refer to it as character, temperament, or disposition, but in my opinion, no matter what you call it, the bottom line is that each person has a unique combination of characteristics or qualities that form a distinctive set, and these govern their perspectives, motivations, and behaviors. 

Now, before I really get into this week’s topic, this is a good place for me to add a disclaimer: When addressing concepts like personalities and behaviors with a large group of people, I have to simplify and generalize, because these are nuanced subjects with far too many influential and individual factors than I could ever address in a blog. So if there are any psych police out there on patrol, please don’t write me a ticket for simplifications and generalizations. 

Now that that’s out of the way, I’ll start with a question: have you ever noticed at times how different the judgement and behaviors of your family and friends can be from your own? My profession means that I literally spend the majority of my life examining what someone does, their behavior(s), and why they do it, their motivation(s). I’m sure you’ve been in many situations where you’ve asked yourself, “Why did he/ she dothat?” or “What were they thinking?” While sometimes it can be frustrating to have a difference of opinion with people, the truth is that life would be boring if we all thought and acted the same way. 

So how do you understand and reconcile these differences? Believe it or not, the starting point of understanding people is actually pretty simple; accept just one fact: that while I’m sure you’re fabulous, everyone is not like you. In point of fact, everyone is not like everyone else, either. If you search for a definition of the word personality, you’ll invariably find the words “characteristic” and “unique” included, along with other synonyms. These are all evidence of, and pretty words to convey, one fact: that we’re all different. We all carry our life experiences and opinions with us, and we filter everything we see, hear, and experience through them, so they color our perceptions and motivations; and these in turn influence our behaviors. I believe the saying goes something like “different isn’t bad, it’s just different,” and I can roll with that. Each of us is unique; we think differently, and therefore behave differently. It’s really a good thing; far, far better than the alternative.

But behavior and personality can be easily misunderstood, and if that becomes chronic, these repeated misunderstandings tend to become areas of stress that affect a person’s happiness, which in turn affects motivation and productivity in every aspect of life. If you’ve ever been in a situation where you felt like you couldn’t “get along” with someone, on some fundamental level, you probably just don’t understand them. A lack of understanding and acceptance of differences can lead to tension, disappointment, and miscommunication. When issues like these go unresolved, they tend to build, and ultimately, can lead to resentment. Resentments can be notoriously difficult to untangle, so in the end, it’s far better to avoid the original problem if you can. Admittedly, that’s often easier said than done, especially if you don’t have a clue what on earth is going on inside the mind of another person. I’ll shed some light on that, so that hopefully by the end of this blog, you’ll have more insight on what that may be.  

If the problem is associated with misunderstanding(s), then it only follows that the solution to that problem probably has a lot to do with understanding. When I say that, I’m not talking about holding hands and singing kumbaya with everybody… I’m saying that accepting that people have different opinions from yours, and then making reasonable attempts at understanding where they’re coming from, will serve you better than being obstinate and absolutely refusing to do so. That said, the success of nearly every solution is in its application, so how exactly do we better understand people? There is a relatively simple visual model that can serve as a key to understanding the basics on how people behave. It’s called The DISC Model of Human Behavior, aka DISC model. It can be applied to loosely categorize a person’s personality traits and extrapolate their motivating factors and behavioral styles. More on that later.

Before I get into the DISC model, time for another disclaimer: Because personality and behavior are such diverse and nuanced human attributes, and since the DISC model is a theoretical one, it isn’t used for diagnostic or clinical applications. In other words, when you come into my office and tell me your life story, I’m not running through it in my head looking to categorize you as one of four types. People are complex and DISC is by nature more simple and general; and rarely, if ever, does anyone fall perfectly into any one type. That said, I’m covering this model today in blog form because I think it’s an interesting and practical way for everyday non-clinical people to better understand themselves and others, and to apply that in an effort to communicate more effectively with people who have differing perspectives… which is basically everyone! 

Why Personality Traits and Behavior Matter

Why should you care to learn about behavior and personality or the DISC model? Believe it or not, personality and people skills are important aspects of life: personal, social, and workplace. If you can’t work in cooperation with other people, it can be really tough to make it in this world. It can affect your ability to keep a job or advance your position, to make friends, and to keep peace with partners, family, and friends. We’re all familiar with IQ, our intelligence quotient, and we spend years in school developing and learning how to effectively use our minds. But developing your personality to effectively use behavior is also vital to successful living. Studies have shown that technical skill, beginning with intelligence and developed through education and experience, accounts for only 15% of success in the workplace; the other 85% has been shown to actually come from people skills. These skills are developed through learning better ways to behave, communicate, and interact with others. The DISC model is commonly applied as a tool to increase your ability to understand yourself and others, and communicate more effectively with everyone.  

History of the DISC Model

Even if it sounds like one, this isn’t a new age, hippy-dippy-trippy idea. Au contraire. Let’s get in the waaay-back-machineand go to Greece, around about 300 B.C.-ish. Why? To see Hippocrates. Whenever I hear his name I can’t help but smile despite myself, because it always makes me think of Bill & Ted’s Excellent Adventure. When they met Hippocrates, they mispronounced his name like the murderous mammal + crates, pronounced like it rhymed with plates, and in their characteristic burner dude affectations. And now the memory of that movie quote is inextricably linked to his name in my mind.. I hear them say it every time. Anyway, back to the topic at hand. Hippocrates was a physician, but also a rebel! And thankfully so. At a time when most of his fellow Greeks were attributing sickness to The Fates, superstition, and the wrath of the gods, Hippocrates espoused the firm belief that all forms of illness had a natural cause. Which, believe me, is a far better alternative than worrying about appeasing The Fates, the witches, and the gods. At any rate, perhaps in pondering the natural basis of illness, or maybe ways to prove his theory to his colleagues, Hippocrates began to recognize that the behaviors of individuals seemed to follow distinct patterns, and he began to loosely categorize the differences in these behaviors. 

While Hippocrates had the original notions on behavioral patterns, many psychologists and scientists continued to explore and expand on his theory. In 1928, Dr. William Marston wrote The Emotions of Normal People, in which he theorized that people are motivated by four intrinsic characteristics or factors that direct predictable behavioral patterns, and described these four factors as personality types. He then created a visual model that utilized a circle divided into quadrants to represent these four personality types. In his original work, he labelled them as D, I, S, C: Dominance, Inducement, Submission, and Compliance. And poof… the DISC model was born.

From what I’ve read, Marston was kind of a freaky guy, and the slightly(?) deviant undertones of his word choices “dominance, inducement, submission, and compliance” seem to confirm this. Even though he was a well respected psychologist by day, he was also a surprisingly successful comic book author by night, and is in fact credited for creating the comic book character “Wonder Woman.” She’s an Amazonian, a race of female warriors from an island where men were not allowed. This actually isn’t too much of a stretch, because Marston was also a champion of women’s rights. Despite this, he seemed to have had more than his fair share of female-centric scandal in his life. I found several references that said that he invented the first lie detector test, but also found some that credit someone else with this feat. Regardless, apparently he wasn’t exactly always on a first name basis with the truth, because he lied to the public about being a bigamist. Evidently, after he married his second wife (who was also a former student) and she moved in with him and his first wife, he told the public she was just a relative staying with them… and they fell for it. So during his bigamist marriage, they all lived together in a ménage à trois, and he actually fathered children with both women. But in spite of the scandal he caused with his colorful private life, Marston’s theories of human behavior are still widely accepted today. 

What is DISC Used For?

The DISC model is applied as a personal assessment tool designed to ascertain a person’s personality traits and behavioral styles. It’s essentially a series of questions that evaluate human behavior in various situations. For example, it looks at how you respond to challenges, rules, and procedures, how you influence others, and what your preferred pace is. 

While Marston’s theories and DISC model were generally well received, some organizations later modified it and created a negative tool used by organizations and employers to weed out undesirables. But in later years, to reflect a change in attitudes, it has since seen several iterations. Now all existing forms of it are used exclusively as positive tools of inclusion rather than being negative and judgemental. DISC assessments are used to foster understanding and respect, improve people skills, build better teams, increase productivity, reduce conflict, and relate and communicate with others more effectively; all of this is meant to translate to increased cooperation and the creation of better working relationships. In fact, the DISC model is widely accepted in the business community; so much so that many organizations and employers incorporate it into all associate training programs, but it is especially used in fields and positions related to sales, marketing, customer service, and management.

I was surprised to learn that DISC assessments have confirmed use in 70% of the Fortune 500 companies, including Exxon/Mobile, General Electric, Chevron, and Walmart. Pretty impressive, as these are strong companies with good management; and according to what I read, that’s where most of them focus their DISC utilization. 

But you can also apply the model to your personal life, to learn more about yourself and grow as a person, increase people skills, illuminate your own motivations, and uncover your strengths and blind spots, some of which you may not even be aware of. As a bonus, you’ll then be better prepared to answer certain questions that may come up in life; for example, when a prospective employer asks “What would you say your strengths are?” or even better, when your spouse or partner looks at you exasperatedly and asks, “Why the *bleep* do you do that?” Wouldn’t it be nice to have a handy answer to that one?! 

In the end, despite its generalizations, the model is sort of like “personalities for dummies”- not that I’m saying you’re dummies- I’m just saying it’s a simple and useful way for non-clinical people to better understand themselves and their own motivations, and apply that knowledge to relationships and everyday interactions, both in and out of the workplace. 

DISC Terminology: Four Behavioral Patterns

Since Marston’s time, while the general concept surrounding the DISC model has remained the same, some of the terminology has changed several times. Some publishers and reference models use a lowercase i in DISC as a way of distinguishing between different models and for trademarking assessments and reports (read: as a way of making money). DISC with a capital I can’t be trademarked, so I’ve used that form for our purposes. The terms used to convey the DISC personality/ behavioral types have also changed for several reasons: to reflect a change in attitudes and more positivity, as a way of distinguishing between different models, and for trademarking purposes; so now there are a few different versions that vary slightly. Different companies and publishers determine and apply their various terms, and I’ve listed the most popular ones, in an order with the ones that I find most applicable first and Marston’s being last.

D: Dominant / Dominance 

I: Inspiring / Interactive / Inducement

S: Supportive / Steadiness / Submission

C: Cautious/ Conscientious / Compliance

No matter what term is used, the basic traits and behavioral styles are essentially the same; I’ll cover those later.

I should note that now some publishers have apparently modified assessments to further extrapolate personality traits and behavioral styles; I’ve seen some that will describe up to twelve types, and even an article that referenced exactly 41 personality types. I didn’t fact-check or verify that, but just wanted to mention it as kind of an outlier. 

DISC Basics

This model is based on two fundamental observations about what drives people to behave the way they do, which are essentially their motivators. I want to emphasize something to keep in mind: as you look at fundamental behaviors, you’re looking at tendencies, not absolutes. Most people will tend to behave more one way than the other, but will behave both ways, to greater and lesser degrees, depending on the situation they find themselves in. Also, behaviors are fluid; they can and do change over time and vary by situation.

DISC: Two Fundamental Observations

(Internal) Motor and (External) Focus

-Some people are more outgoing, while others are more reserved. This is each person’s “pace,” or “internal motor.” It is sometimes simply referred to as the “motor” drive. Some people engage quickly and always seem ready to go, and these are considered outgoing types. Others engage more slowly or more cautiously, and these are considered reserved types.

-Some people are more task-oriented, while others are more people-oriented. This is each person’s “external focus” or “priority” that guides them; sometimes simply referred to as “focus.” Some people are more focused on getting things done, and these are considered task-oriented types. Others are more attuned to the people around them and their feelings, and these are considered to be people-oriented types.

Visualizing the DISC Model

As I mentioned, DISC is a visual model, and it utilizes a circle to represent the range of “normal” human behaviors. You can imagine it as a clock face.

To illustrate the application of the first fundamental observation, aka motor drive, imagine you divide a circle in half horizontally, as from 9 o’clock to 3 o’clock on a clock face. The upper half then represents Outgoing (or fast-paced) people, while the lower half represents Reserved (or slower-paced) people.

To illustrate the application of the second fundamental observation, aka focus drive, imagine you divide a circle in half vertically, as from 12 o’clock to 6 o’clock on a clock face. The left half then represents Task-Oriented people, while the right half represents those who are more People-Oriented.

When the two motor and focus circles are superimposed to combine them, you end up with four behavioral tendencies to help characterize people: Outgoing, Reserved, Task-Oriented, and People-Oriented. The balance of these four tendencies shapes the way each person sees life and those around them. 

To illustrate the incorporation of the two drives (motor and focus) you can imagine one clock face with two divisions (horizontal and vertical) and therefore in four quadrants. Starting at 12 o’ clock and moving clockwise, you would then see Outgoing at 12 o’clock, People-Oriented at 3 o’clock, Reserved at 6 o’clock, and Task-Oriented at 9 o’clock. 

By combining the two drives, you now have four total behavioral tendencies: from the upper left quadrant, moving clockwise, those tendencies are then: 

Outgoing and Task-Oriented (upper left quadrant)

Outgoing and People-Oriented (upper right quadrant) 

Reserved and People-Oriented (lower right quadrant)

Reserved and Task-Oriented (lower left quadrant).

Then to further define and describe these four behavioral tendencies, the DISC terms are added, one letter per quadrant: Dominant, Inspiring, Supportive, and Cautious. 

Illustratively, these are added to each of the four corners of the diagram, again starting with the upper left quadrant and moving in a clockwise direction: Dominant in upper left quadrant, Inspiring in upper right quadrant, Supportive in lower right quadrant, and Cautious in lower left quadrant.

Once added, starting with the upper left quadrant and moving in a clockwise direction, each DISC term correlates with the four behavioral tendencies such that:

Dominant types are Outgoing and Task-Oriented (upper left quadrant)

Inspiring types are Outgoing and People-Oriented (upper right quadrant) 

Supportive types are Reserved and People-Oriented (lower right quadrant)

Cautious types are Reserved and Task-Oriented (lower left quadrant).

What emerges is the full graphical description of the complete DISC model. 

Interpreting DISC

To make the quadrants easier to discuss, we typically call each quadrant a behavioral style or type, though some people use the phrase personality type. I’ll spare you the specifics as to why, but technically speaking, it’s not really accurate to use the word “personality” type or style with the DISC model, because it’s actually a behavioral model. While I tend to refer to it as a behavioral style, either term- personality or behavior- is generally acceptable for a colloquial discussion or a blog. 

DISCussion: Four Primary Behavioral Styles

While DISC refers to placement within four primary behavioral styles, always keep in mind that each individual person can, and usually will, display some of all four behavioral styles depending on the situation. The resultant blending of behavioral tendencies is often called a style blend, and each individual’s style blend will have more of some traits and less of others. 

The Dominant “D” Style

An outgoing, task-oriented individual will be focused on getting things done, solving problems, making things happen, and getting to the bottom line, usually as quickly as possible. They can sometimes be blunt, outspoken, and somewhat demanding. The key insights in understanding and developing a relationship with this type of person are respect and results.  

The Inspiring “I” Style

An outgoing, people-oriented individual is generally enthusiastic, optimistic, open, and trusting. They thrive on interaction and love to socialize and have fun. This person places emphasis on persuading others and is usually focused more on what others may think of them. The key insights in understanding and developing a relationship with this type of person are admiration and recognition.

The Supportive “S” Style

A reserved, people-oriented individual will place an emphasis on cooperation, sincerity, loyalty, and dependability. They enjoy working together as a team and thrive on helping or supporting others. They usually focus on creating and/ or preserving relationships and on maintaining peace and harmony. The key insights in understanding and developing a relationship with this type of person are friendliness and sincere appreciation.

The Cautious “C” Style

A reserved, task-oriented individual enjoys independence, and often fears being wrong. They will seek value, consistency, and quality information, and will usually focus on details, facts, rules, accuracy, and being correct. The key insights in understanding and developing a relationship with this type of person are trust and integrity.

I should also note that some organizations use a shortcut in discussing the different behavioral types, where the dominant type is also known as High D, the inspiring type is also known as High I, the supportive type is also known as High S, and the cautious type is also known as High C.

Behavioral Styles: Elevator Test

As you’ll see, this is a pun meant to give you an idea of your own behavioral style and to help you identify others. Captain Obvious says it’s not meant to be scientifically or clinically valid, people, it’s just to illustrate the four behavioral styles in a relatable, “everyday situation” kind of way.

The doors are about to close on a person who is eager to get on an elevator, which already has four people inside. One of the four people already inside glances at their watch, because they’re in a hurry and would prefer not to wait. But also inside is the bubbly, smiling, energetic second passenger who actually holds the door open while encouraging the newcomer to climb aboard. The third rider doesn’t mind if the new person gets on, and they simply step back to make room while patiently waiting for them to do so. The fourth passenger barely looks at the new guy, as they’re busily calculating the sum of everyone’s weight in their head while also looking around to estimate the age of the elevator. 

Did you see yourself in this scenario? Did you recognize the behavioral styles of the other elevator passengers? Read on to find out if you’ve got it.

This scenario demonstrates behavior of the Dominant (outgoing / task-oriented) person who wouldn’t really mind if the elevator door closes before the new guy can get on, because they’re just focused on getting where they need to be as quickly as possible. But that possibility is dashed by the Inspiring (outgoing / people-oriented) person who feels energized by the addition of yet another positive interaction to their day. The Supportive (reserved / people-oriented) person just calmly steps back to make room for the new guy because they empathize with him and are willing to be accommodating. All of this while the Cautious (reserved / task-oriented) person almost can’t help but make sure the added person doesn’t exceed the weight limit of the old elevator and potentially cause them all to get stuck… or worse. 

Notice that there were four different people who responded to the same exact event in very different ways? People are motivated differently, and therefore think differently, so they behave differently. 

Takeaways

Every individual person has a unique combination of characteristics and qualities that form a distinctive set, and these govern their perspectives, motivations, and behaviors. 

The DISC model developed by Marston is used as the basis for varying assessments of personality traits and behavioral styles.

While it is simplified and generalized, it can be an effective and empowering tool to examine motivating factors, to uncover and address blind spots, and to identify, highlight, and articulate strengths.

It can be used by people to better understand themselves and others, and to apply that understanding in an effort to improve people skills and to communicate more effectively with people who have differing perspectives.

It is commonly used in the professional arena, especially in Fortune 500 companies. Employers often use it for determining placement of new employees, to build better teams, increase productivity and communication, reduce and resolve conflict, and foster acceptance and understanding. 

Each person has a unique blend of all of the major personality traits and behavioral styles to a greater or lesser extent.

Behavioral patterns are fluid and dynamic, and can change over time or as a person adapts to his or her environment.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos 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, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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The Skinny on Psychostimulants, Part 3:Modafinil

The Skinny on Psychostimulants, Part 3: Modafinil

Over the past two weeks, we’ve been discussing the psychostimulants amphetamines and methylphenidate, which stimulate the central nervous system by increasing synaptic concentrations of the neurotransmitters dopamine and norepinephrine to varying degrees, and are used in pharmaceutical preparations primarily for treating ADHD, narcolepsy, obesity, and binge eating disorders. They are also used off label to treat cognitive dysfunction and depression in cancer patients and as part of a regimen in chronic pain patients, as well as being used recreationally to get high, study, take tests, improve focus, and/ or stay awake for extended periods of time. In this last installment on psychostimulants today, I’ll discuss a popular drug called modafinil.

While modafinil isn’t technically a psychostimulant, it acts “stimulant-ish,” and ultimately elicits similar effects as its stimulant brethren. It actually belongs to a class of drugs called eugeroics, which are wakefulness-promoting agents, and is also considered a nootropic. Nootropics are “smart drugs,” substances that can enhance brain performance or focus. Strictly speaking, the term nootropic is generally reserved for prescription and over the counter (OTC) pharmaceuticals and supplements that are not taken therapeutically to treat a particular illness, but rather to enhance cognitive function in healthy individuals beyond what is usually considered “normal” in humans. Nootropics or smart drugs can alternatively be referred to as performance enhancers or pharmacological cognitive enhancers (PCE’s). To cover all the bases and avoid ticking off the biohackers, I suppose you could call modafinil a nootropic eugeroic. Whatever! 

Originally synthesized in France in the 1970’s, modafinil was approved by the FDA in 1998 and is used primarily to treat sleep disorders, including narcolepsy, shift-work sleep disorder, and residual/ excessive sleepiness in obstructive sleep apnea despite continuous positive airway pressure (CPAP). 

It is used recreationally to increase focus and learning, for cognitive and physical performance enhancement, and to stay awake for extended periods of time. Modafinil is taken by mouth, usually once a day. Most people who work during the day take it in the morning on either a full or empty stomach, but shift workers who take it to promote wakefulness do so before their shifts begin. Modafinil is marketed under the trade name Provigil, while its R-enantiomer armodafinil is marketed under the name Nuvigil. If you recall, enantiomers are mirror image molecules, like left and right hands, that generally induce similar pharmacological effects. Indeed, the two are used to treat the same disorders, but armodafinil is a newer compound and has a slightly different side effect profile than its older sibling modafinil. More on that in a moment.

Both forms are Schedule IV drugs, which defines them as having a low potential for abuse and low risk of dependence. Some other examples of Schedule IV drugs are benzodiazepines like diazepam and alprazolam. That said, while I concur that (ar)modafinil has a low risk of abuse and dependence, I beg to differ on the risk of abuse and dependence being comparable to benzos. In my experience, benzos are far more commonly abused, and the incidence of dependence on benzos far exceeds that of modafinil. However, while studies have not shown any significant withdrawal effects from discontinuation of modafinil, any drug that provides stimulant effects to the brain can enforce drug taking to some extent, and thus carry the potential for dependency, which could lead to withdrawal symptoms upon cessation. Anecdotally, people have reported reduced energy, lack of motivation, and depression following discontinuation of modafinil; therefore, modafinil should always be tapered when discontinued if it has been used for a long period of time. 

I’ve found that modafinil carries a very low risk of side effects, and a very mild profile when present, one that may be comparable to having an extra cup of coffee. The most common side effects are potentially occasional minor headaches, possibly some jitters, and sometimes trouble sleeping, which is usually related to the time of dosing being too late. But the official list of side effects also includes: dizziness, upper respiratory tract infection, nausea, diarrhea, nervousness, anxiety, agitation, and dry mouth. For armodafinil, you can add upset stomach to the list and take away upper respiratory tract infection. Something you have to be aware of when taking modafinil are the synergistic effects of other stimulants. If you consume coffee, energy drinks, or anything with caffeine, you’re likely to have much stronger stimulating effects, and these may include jitters or anxiety. It is wise to avoid anything else meant to make you or keep you awake when taking modafinil, at least until you are aware of its effects on your system, and even then you should still use great caution. As with any medication, if you take other prescription or OTC medications, be sure to disclose them with your prescribing physician to discuss potential interactions. Modafinil has a half-life of 12 hours, meaning that after 12 hours, the effects will start to wear off, but half of the drug will still remain in your system.

Modafinil’s off label and “lifestyle” use in healthy individuals to stay awake for extended periods of time and increase cognitive alertness and physical performance is well documented and likely exceeds its therapeutic utility as far as numbers go. In some professional groups such as pilots, academics, and scientists, modafinil use is reported in the ballpark of 20 to 30 percent; but I’d like to note that that is the reported use, not actual use, which I think is significantly higher, given how available it is on the internet. Modafinil’s popularity among college students, athletes, and the Silicon Valley techie set isn’t exactly a state secret, but its use among the military literally was until confirmed relatively recently. The US Armed Forces tested modafinil in improving performance despite sleep deprivation and in combating pilot fatigue; in fact, at one point, we led the world in military research on modafinil. I happened to catch part of a television show over the holidays that mentioned modafinil studies in Air Force fighter pilots. The show stated that it induced vigilance (aka kept them awake) for 40 hours, which, the show mentioned, is apparently a desired effect during times that necessitate flying to Iraq quickly. Now, I’ve never flown to Iraq, much less in a fighter jet, but I can’t imagine that it takes 40 hours to get there… but you get the point. If you were exhausted, but needed to get to Iraq all quick like, modafinil may be the compound of choice. 

Of course, I had to look into these studies. Captain Obvious says that Uncle Sam has been “officially” dosing our Armed Forces for years, so modafinil is just another in a long line of compounds. I’ve had many patients that were/ are members of the US military, and I’ve been told of the sanctioned use of various drug combinations in all branches of it: hypnotics to induce them to sleep before a mission, followed by stimulants (in the form of dextroamphetamine) “go pills” to switch them back on just before, at “go time.” As far as modafinil is concerned, the experiments relating to sleep deprivation seem pretty ambitious, testing for 40, 60, or even 90 hours without sleep. In some journal articles, scientists speculated that with modafinil, troops might function for weeks(!) on as little as four hours of sleep a night. 

Back to fighter pilots: in the study I looked at, Air Force scientists looked at the effects of being awake for 37 hours on pilot alertness and flight performance; this was evaluated through simulator tests repeated every five hours to track the pilots’ level of fatigue. The same experiment was conducted with and without modafinil, and also in a rested state without modafinil for comparison. What did they find? While on modafinil, the pilots’ performance significantly improved, especially at time points after 25 hours without sleep, and the pilots sustained brain activity at almost normal levels despite their sleep deprivation. Further, while under the influence of modafinil, flight performance degraded by 15 to 30 percent. Now that doesn’t sound great, until you consider that performance by pilots without modafinil (and without sleep) degraded by 60 to 100 percent (hell-ooo!!) as compared to rested levels. All of the findings led researchers to conclude that modafinil “significantly” reduced the effects and impacts of fatigue during flight maneuvers, even though sleep deprived pilots on modafinil were unable to maintain the same performance as they exhibited during a rested state off of modafinil. I’ll say… Degraded by 60 to 100 percent?! Bottom line: clearly, if a pilot can’t get sleep, they should get modafinil. Ultimately, they stated that until more research is done, a 100 mg dose of modafinil is viewed as an option to, but not a replacement for, a 10 mg dose of dextroamphetamine.   

All of that said, most of us are not fighter pilots, much less operating a complicated machine at mach speed and 50,000 feet, under stress, and sleep deprived… and thankfully so. Most of the people that ask me about modafinil are everyday people looking to focus better at work, get excellent scores on SAT’s to get into a great school, win a medal or a pro poker tournament (pro poker players love modafinil) or maybe beat out somebody at work for a promotion. In my experience, for all of those things and more, modafinil is a safe and effective tool, and lots of folks want it in their tool box. It’s been around long enough to have some significant studies done; all findings echo my experience, and one another: it works well and nobody’s dropping dead at their desks. 

The University of Oxford and Harvard Medical School conducted a formal review of all research papers on cognitive enhancement with modafinil in non-sleep-deprived individuals, dated from January 1990 to December 2014. They found and evaluated 24 studies, which included more than 700 participants total, dealing with different benefits associated with taking modafinil, including planning and decision making, flexibility, creativity, and learning and memory. They also surveyed overall performance enhancing capabilities and side effect reporting. Findings were as follows:

Modafinil made no apparent difference to working memory or flexibility of thought, but did improve executive function, the ability to sift through new information and make plans based on it. 

As to side effects: (70 percent the of 24 studies looked at the effects of modafinil on mood and the side effects of modafinil) In those where side effects were studied, there were very few side effects overall, although a very small number reported insomnia, headache, stomach ache, or nausea, but these were also reported in the placebo group, meaning those who were unwittingly given a “sugar pill” with no biological action. 

As to overall performance enhancing capacity of modafinil: this was found to vary according to the task; the longer and more complex the task tested, the more consistently modafinil conferred cognitive benefits.

Modafinil clearly and reliably enhanced cognition, especially in higher brain functions that rely on contribution from multiple simple cognitive processes. 

Some snippets of findings from other studies:

“It has been shown to increase resistance to fatigue and improve mood.”

In healthy adults, modafinil improves “fatigue levels, motivation, reaction time and vigilance.”

Modafinil is effective at reducing “impulse response,” meaning it reduced the incidence of poor decision making.

Modafinil “…improved brain function in sleep deprived doctors.”

Modafinil “enhanced the ability to pay attention, learn, and remember.”

There is some evidence that modafinil only helps people with lower IQ, but I read validated accounts of years of use associated with validated corresponding increases in IQ, though this could theoretically be due to other unrelated factors. 

How Does Modafinil Work?

Scientists haven’t gotten it all figured out quite yet, but like the psychostimulants we’ve already discussed, modafinil increases the production of norepinephrine and dopamine in the CNS, the neurotransmitters linked to emotional well being, motivation, memory, and focus. At the same time, modafinil may also reduce the production of neurotransmitters that are known for blocking communication between neurons. It also increases the production of histamine, which increases the oxygen concentrations travelling to the brain, making you more awake, or so it’s theorized. Just as the anti-histamine Benadryl dampens histamine and puts some people to sleep, modafinil boosts histamine levels, which has a tendency to wake you up and increase alertness. If you’ve ever had an acute allergy, especially an anaphylactic reaction, and experienced the typical increase in heart rate and blood pressure associated with it (which is also associated with wakefulness and alertness) then you’ve felt the acute effects of excess histamine production. Obviously, modafinil doesn’t cause this level of histamine release, that’s just an explanation of how the release of histamines from taking modafinil are thought to cause a feeling of wakefulness or alertness: from the increase in heart rate and blood pressure associated with their release. Though scientists aren’t exactly sure how it works, they have elucidated that modafinil also enhances several other CNS neurotransmitters, including serotonin, glutamate, and GABA.

The Ethics of Modafinil Use

Pharmacological cognitive enhancers (PCE’s) like modafinil may be used to treat cognitive impairments in patients, but they are more commonly used by healthy individuals in an effort to improve focus, stay awake and alert for extended periods of time, and boost mental and physical performance. This lifestyle use of modafinil by healthy people is increasing, and in fact, it appears that it far exceeds the therapeutic use of modafinil for cognitive impairment and sleep abnormalities. As it enhances cognition and has effects on attention, learning, memory, planning, and problem solving, this lifestyle use raises a number of ethical issues. 

In societies and populations that foster or encourage academic and professional competition, access to knowledge about how to gain a competitive edge and how to perform better in the workplace is a valuable commodity, but not one that tends to be equally distributed across all social groups. As modafinil rises in popularity, will we soon be locked in a productivity arms race, pounding out after-hours spreadsheets with one hand while Googling “latest nootropic advancements” with the other? Some sports organizations already ban the use of prescription psychostimulant drugs- including methylphenidate- without an official ADHD diagnosis, for the same reasons they ban steroids and other performance enhancing drugs. Will employer drug screens soon test for off label modafinil use in an effort to avoid its presence in the workplace? Or will the opposite be the case; will CEOs welcome super sharp workers who never need sleep? Think about the Bezos’ and the Musk’s of the world… will they be adding modafinil to the water coolers? 

Considering modafinil’s popularity, you can be sure that more cognitive enhancing drugs are right around the corner. Will everyone be able to compete? What if you can’t get access to a cognitive enhancer, can’t afford it, or can’t take it due to negative interactions or side effects… are you destined to be stuck in a dead end job or hit an impenetrable corporate ceiling while you watch your friends and co-workers climb the corporate ladder? How about your kids? If you think things are competitive now… just wait ten years. Will they be able to get into a good pre-school without putting modafinil or some other enhancer in their kool-aid, or juice, or whatever you’ll put in their sippy cups? Seriously, will they be able to compete… to get into a good school without cognitive enhancement? In a cognitively enhanced society, what happens to the benefits and self-satisfaction of earning something by the sweat of the brow… especially when that’s just. not. good. enough? Could this lead to a devaluation of hard work and generate less engagement with the world? And if so, what happens to a society where few people see the value of civic work or doing something for the greater good rather than getting ahead? These won’t be hypothetical questions for very long. How about things less under our direct control? Will the FDA save us by prioritizing drugs that preserve lives, or will they bow to pressures from big pharma to prioritize drugs that will undoubtedly be more popular among healthy individuals, have a far larger market, and make more money? 

Hey people… these are things to think about. Don’t shoot the messenger. 

In situations where there is a deficit in performance due to sleep deprivation or fatigue, a medical diagnosis, or learning disorder, there’s no doubt that modafinil can even the playing field. But what about in “normal” healthy individuals? Proponents of modafinil use in healthy individuals argue that it reduces fatigue-related and work-related accidents and improves learning outcomes; in other words, it’s a good thing, so use it. But when it comes to “enhancement” or “optimization” of performance, do the ends always justify the means? To use a sports analogy, does enhancement corrupt the “rules of the game”? If so, does it make the game pointless? Or is enhancement or optimization a slippery slope that leads to the desire to “perfect” human beings? The increase in medical options available to affect human characteristics and abilities over recent decades certainly offers more options to do so, but the desire to want to do so is hardly novel. The difference is that now we’re getting much closer to being able to actually do it. The door is open, and people are walking through it. Some people are running through it. But can we ever turn around to get back to where we were if/ when we find we don’t like what’s on the other side? What happens when average abilities become less the norm, and more of a negative exception… would average people feel fundamentally inadequate?

The ethical implications of the use of modafinil in particular, and smart drugs in general, has become one of the biggest issues in neuroethics and bioethics; it’s got ethics nerds everywhere red faced and arguing, and it’s certainly a favorite topic in the popular media as well, with tons of hype. What about the ethics of biohacking, using any and all, drug and non-drug technologies to improve cognition; ie training and nutrition to boost brainpower, and/ or the application of transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), or brain-computer interfaces (BCI)? There are plenty of biohackers out there- do they have an unfair competitive advantage, or is it mostly acceptable, because a lot of it requires at least more effort and dedication than just swallowing a pill? If most people biohack themselves in order to become cognitively superior, when is superior… superior enough? There could be serious ramifications concerning attitudes towards conventional human abilities in the long term. 

I certainly don’t suppose that I have the answers to these questions, but I know that I’m not the only one asking them. The last question I’ll pose that is still unanswered is: when will we be forced to confront all of the above questions… and then some? Because that day is coming. Of that, I have no doubt.

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Thank you and be well people!

MGA

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