COUPLES AND CONFLICT

Couples and Conflict

One of my foremost jobs as a psychotherapist is to be a listener. All day, every day people come to me to talk about their problems. As you can imagine, many times patients want to talk about their spouses, specifically how they fight with them. So I want to talk a little bit about couples and fighting. Whether it’s about money, children, career, housework, all couples fight. Nobody gets along 100% of the time without some conflict. It’s all a matter of how you resolve that conflict. I had a patient named Roxanne come in for her session yesterday, and she told me that she and her husband Bill fight all the time. One yells at the other and the other yells back louder until it reaches a terrible crescendo and both storm off in opposite directions. She said she had no choice in this, he just made her so angry and they just didn’t get along. I told her that the first thing that had to happen for the relationship to move forward was to decide that it wasn’t his fault and wasn’t her fault, it was both of them. She immediately recoiled and told me I was dead wrong. That it was all Bill’s fault. He was never home, he didn’t want to be a part of the family, he this, he that, ad nauseum. I asked her about how they fight, her yelling and screaming…was it working? Was it resolving anything? She launched in again, saying it wasn’t her fault, it was his fault because he made her yell. He antagonized her. I told her that she didn’t have to go to every fight he invited her to, she had the choice. This is a point that I think a lot of couples miss. Just because your spouse may be baiting you, looking for a fight, it doesn’t mean you have to give them what they’re looking for. You don’t have to respond at all. You have a choice in how you behave.

I explained to Roxanne that the only way to start to resolve an issue is to not yell and scream, not raise a voice. Once you express anger, you’ve made the situation worse. I suggested to her that the only way to make the situation better when Bill is yelling and screaming is to fall silent. Until the yelling stops, nothing productive can be accomplished. A conflict cannot be resolved through warfare. Once people raise their voice, no interaction happens. For instance, if you raise your voice at a child, they shut down. They will hear nothing you say. The same happens in couples. If one raises their voice at the other, from that moment forward, nothing constructive happens. So, if you’re married or in a relationship and you find you are having problems or there is fighting, and yelling, you are responsible for your response, and your response should be to not yell back, fall back. All yelling does is put fuel on the fire. If you fall silent, eventually they will stop yelling, and once the yelling stops, resolution can start. You can begin a conversation by discussing what the problem is, why you keep arguing, and what you can each do to make things better. That’s the only way these things will really be resolved. But you have to be willing to change how you respond to conflict and how you fight. Learn to fall back if baited. Talk should replace screaming matches. 

I hear so often in my office “it’s not me, it’s him, it’s her, they’ll never change, we tried that” blah, blah, blah, blah. If you really want to effect change in your relationship, change your own behavior and then the reaction you get back from your spouse or partner will change. Stop yelling and start conversing. Focus on what you can each do to make the relationship better. To resolve conflict, cooler heads should always prevail over heated emotions.

Learn More

Personality Disorders

Hello people, I hope everyone had a great holiday weekend! Did everyone set off a bunch of fireworks? Did you grill some burgers or dogs, have some baked beans, and a scoop of potato salad? Top it off with some apple pie? Me neither. Can I just ask, why do people shoot off fireworks on Saturday day, like before the sun sets? Are they testing them to see if they’re loud enough? Just wondering. Maybe they can’t wait. Anyhoo, last week, we talked about Antisocial Personality Disorder, the first Cluster B personality disorder, the dramatic and erratic disorders. If you recall, ASPD is the official diagnostic term for the colloquial terms sociopathy and psychopathy. That’s the big takeaway. So this week, we’ll be continuing with the Cluster B’s with Borderline Personality Disorder. 

Borderline Personality Disorder

BPD is also sometimes called Emotionally Unstable Personality Disorder, or EUPD, but I prefer Borderline. It always reminds me of that 80’s song. BPD is the most commonly diagnosed personality disorder, and was so called, because it was thought to lie on the “borderline” between neurotic disorders (meaning anxiety disorders) and psychotic disorders, such as schizophrenia and bipolar disorder. BPD is characterized by difficulties in regulating emotion. People with BPD experience big mood swings, and they feel a great sense of instability and insecurity. They feel emotions very intensely, often for extended periods of time, and it’s generally harder for them to return to a stable baseline after an emotionally triggering event. This difficulty can lead to impulsivity, poor self-image, and intense emotional responses to stressors. Struggling with self regulation and having a poor self-image essentially equates to a lack of a sense of self, and as a result, they often experience feelings of emptiness and extreme fears of abandonment, whether these are real or just perceived. They generally have a pattern of instability in their relationships, and there can be violence involved, especially in response to criticism. These unstable personal relationships often involve “splitting,” where the person alternates between idealization “I’m so in love!” and devaluation “I hate him!” Suicidal threats and acts of self-harm are common, and this is how and why many people with BPD frequently come to medical attention. Extreme stress responses can lead to dissociative feelings, meaning they feel disconnected from their thoughts or themselves, have “out of body” type feelings, potentially even psychotic episodes. They basically check out, and may not remember these events well afterwards. 

BPD signs and symptoms may include:

-Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, reckless driving, gambling, overuse of substances, and binge eating

-Distorted and unstable self-image affecting moods, values, opinions, goals, and relationships

-Wide mood swings, often as a reaction to interpersonal stress

-Unstable and intense relationships

-Suicidal behavior or threats of self-injury

-Intense fear of being alone or abandoned, may be real or imagined

-Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days

-Ongoing feelings of emptiness

-Frequent, intense displays of anger, often followed by shame and guilt

-Stress-related paranoia that comes and goes; when stress is severe, it can lead to brief psychotic episodes

It has been suggested that BPD often results from childhood sexual abuse, and that it is more common in women, in part because women are more likely to suffer sexual abuse. However, some argue that BPD is more common in women simply because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behaviors tend instead to be labeled with ASPD, Antisocial PD. More recent research seems to back this up. Women are more likely to receive the diagnosis, because it is commonly thought of as a “female” disorder, even though there’s no such thing. In fact, of the estimated 1.4 percent of the adult U.S. population with BPD, nearly 75 percent of them are women.

Histrionic Personality Disorder

HPD is characterized by a pattern of excessive emotion and attention seeking. People with HPD generally like to be the center of attention at all times, and may actually be uncomfortable when they’re not. They often use physical appearance to draw attention to themselves, are often flirtatious, and can employ exaggerated or rapidly shifting emotions as a means to reach this goal. The surprise is that they usually lack a sense of self-worth, and they depend on attracting this attention to seek the approval of others in order to boost their wellbeing. They often seem to be dramatizing or playing a part in a bid to be seen and heard. The word “histrionic” is derived from the Latin histrionicus, meaning “pertaining to the actor.” People with HPD may take great care of their appearance, and behave in a manner that is overly charming or inappropriately seductive. Because they crave excitement, they tend to act on impulse and are easily suggestible, and they may place themselves at risk of an accident, or fall prey to exploitation. Their dealings with others often seem insincere or superficial, and in the long term, this can adversely impact their social and romantic relationships. They find this to be especially distressing, as they are very sensitive to criticism and rejection, and they react very poorly to loss or failure. It can result in a vicious cycle in which the more rejected they feel, the more histrionic they become, and the more histrionic they become, the more rejected they feel. Achieving any emotional or sexual intimacy may be difficult, and they may play a victim role, potentially without being aware of it. They may also try to control their partner using seduction or emotional manipulation, while becoming very dependent on them. They tend to be too trusting, especially of authority figures who they think may be able to solve all their problems. They often think relationships are closer and more intimate than they really are. They crave novelty and tend to bore easily, so they may change jobs and friends frequently. Delayed gratification is very frustrating to them, so their actions are often motivated by obtaining immediate satisfaction. 

HPD signs and symptoms may include:

-Constantly seeking attention

-Into instant gratification

-Excessively emotional, dramatic, or sexually provocative to gain attention

-Excessive concern with physical appearance

-Speaks dramatically with strong opinions, but few facts or details to back them up

-Makes rash decisions

-Easily influenced by others

-Shallow, rapidly changing emotions

-Believes relationships with others are closer than they really are

-Gullible and easily influenced by others

-Excessively sensitive to criticism or disapproval

-Low tolerance for frustration, easily bored by routine, often beginning projects without finishing them or skipping from one event to another

-Self-centered, rarely showing concern for others

-Good social skills, but use them to manipulate others, to be the center of attention

The estimated prevalence of HPD is less than 2 percent of the general population. It is usually evident by early adulthood, and is diagnosed more often in women than in men, but this may simply reflect the higher prevalence of women in clinical settings. There is a clear tendency for HPD to run in families, which suggests a genetic susceptibility, but the child of a parent with the disorder might simply be repeating learned behavior. Other environmental factors that might be involved include a lack of criticism or punishment as a child, and unpredictable attention given to a child by his or her parent(s), which tends to lead to confusion about what types of behavior earn parental approval.

Narcissistic Personality Disorder

NPD is characterized by an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. The person is envious of others, and expects them to be the same of him. They typically lack empathy, and readily lie, exploit, or take advantage of others to achieve aims. To others, they may seem self-absorbed, controlling, intolerant, selfish, and/ or insensitive. If they feel ridiculed or obstructed, they can become very angry and even vengeful. Fueled by a belief that they’re special, and more important than others, they can have a reaction called “narcissistic rage,” which can have disastrous consequences for all involved. It’s human nature to be aware of and express our own needs, as well as want others to be aware of our abilities and achievements. These aren’t bad things, but people with NPD take this to the extreme. At the heart of it, they have fragile self-esteem, so they rely on others to recognize their worth and their needs. They are generally unhappy and disappointed when they’re not given the praise or special favors they believe they deserve. This can cause problems in all areas of life, work

school, and relationships. People with NPD usually put themselves on a pedestal, where they can look down on others and direct them, as they believe they are better than. They exaggerate their own talents and accomplishments, while downplaying those of others. They are usually preoccupied by power, success, and beauty, and may engage in impulsive behaviors, such as risky sex and gambling, in their pursuits of these goals.

NPD signs and symptoms may include:

-Fantasies about power, success, and attractiveness

-Entitled, conceited, snobby

-Exaggeration of achievements or talents

-Expectation of constant praise and admiration

-Exaggeration of intimacy with others, especially those with wealth or VIP status

-React negatively to criticism

-Show great charm but quickly become irritated or angry

-Talking at length about their own concerns but lacking interest in those of others

-Show aggression when faced with a threat to their ego

-Resent the successes of other people

-Arrogant, dismissive, or unaware of other people’s needs

-Perceived superiority that covers a deep seated insecurity

-Unreasonable expectations of favors and advantages

-Envy of others accompanies belief that others envy them

-Unfulfilling relationships; become unhappy, angry, and confused when things don’t go their way

-Typically have ongoing issues with work, school, relationships, finances, alcohol, substances

Research indicates that NPD affects 6.2 percent of the U.S. population, and is much more common in men than women, affecting 7.7 percent of men and 4.7 percent of women. There may be cultural influences associated with NPD, but this may be a stereotype. Diagnosing NPD specifically can be challenging, as the features tend to have so much overlap with other disorders. In addition, a person with NPD may not recognize that problems in their life stem from their own behavior, and they may blame others instead. Narcissists can be especially difficult to deal with. I’ve done a lot of family counseling for it, but the person with the diagnosis must accept it to make headway. Some NPD traits may appear similar to confidence, but healthy confidence and NPD aren’t the same thing. People who have healthy self-esteem are usually humble, while people with NPD, by definition, never are. It takes a lot of work on the patient’s part to modify behavior, but it can be done with sufficient motivation.

That’s the end of Cluster B Personality Disorders. Next week, we’ll tackle Cluster C disorders. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

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

Learn More

The Dark Side Of OCD

The Dark Side of OCD

Hello, people… hope everyone had an awesome weekend! Was it perfect? Because last week, we talked about POCD, perfectionism OCD. This subtype is pretty self explanatory; it’s the obsession with being perfect. Perfectionism is a little unusual, as it can exist outside of OCD, underlie many OCD subtypes, and be a subtype all on its own. In people with stereotypical OCD, perfectionism contributes to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, perfectionism can really be thought of as its own OCD subtype. Perfectionists rigidly adhere to the belief that things must be done in a certain way- perfectly- or not at all. It’s a tough way to live, and the pressure to constantly achieve this standard often becomes so great, at times it’s far easier for them to give up on doing something altogether. This week, we’ll be talking about Scrupulosity OCD, which involves obsessions with morality, being good or evil, or sinning; and Sexual Orientation OCD, obsessions involving one’s sexuality.

I love the word scruples… it’s fun to say. Scruupullzzz. Scruples are the moral principles or beliefs that make you unwilling to do something that seems wrong. Having scruples is kind of like having a conscience… when you’re considering doing something shady, that little knot in the pit of your stomach is brought to you courtesy of your scruples. Fun fact, a scruple is also a unit of weight in old school pharmacy- equal to 20 grains- so sometimes “a scruple” means a minute amount. I drink my tea with a scruple of honey. Okay, sometimes maybe a little more.

Scrupulosity OCD is usually thought of as an obsession with sinning or offending God- common concerns include devil worship, blasphemy, and hell- but it’s not always focused on religion. Secular or moral scrupulosity is more about right and wrong, and being a “good” or “bad” person. While research shows it’s common in orthodox Jews and Catholics, up to 25 percent of people with scrupulosity OCD say that they have no religious affiliation at all. It runs the gamut; I’ve seen very pious, religious people with scrupulosity OCD, as well as people who’ve never even gone to a church service. 

I recall a patient who was not raised in the church, who thought he was never going to find God. This internal doubt turned into obsession, requiring various rituals he had to complete. It started with conquering fears to prove that he was worthy; he had to challenge himself to conquer any fear that came up in his daily life. Then, he started to worry that he had already done something horribly wrong, something unforgivable, and as a result, God would never reveal Himself to him. To fix it, he had to do everything correctly, to be a good person, if he had any hope of finding Him. He was always scared that he was off “the path” and constantly tried to find ways to prove that he was on the path. He got totally obsessed with it, and every little decision that he made became monumentally important for how to do the right thing and be on the right path. He became so obsessed with getting on, staying on, and proving he was on the right path, his life deteriorated. He couldn’t get his homework done, couldn’t complete tasks or chores, or go out with friends. Eventually, his scrupulosity led to complete avoidance; he stayed away from people, avoided churches like the plague, and would even get scared whenever anyone would mention the devil or say the word ‘Satan.’ Until he started treatment, his thoughts only intensified, and he was sure that he was going to go to hell. 

Some other patients I recall include a woman obsessed about whether or not she felt enough empathy for people she saw suffering in fundraising specials on TV. She also obsessed about not recycling every single scrap of recyclable material, thinking it made her a bad world citizen, someone who didn’t care about the greater good. I remember another woman had to imagine the people she loved with a protective halo surrounding them at all times, to prevent them from being harmed. She was convinced that if she imagined them without it, a horrible fate would befall them.

OCD has a knack for latching onto whatever matters to the person, and that’s why scrupulosity can often strike people whose religion matters a great deal to them. And this can also make it hard to design exposures for therapy. The goal isn’t to make someone violate their true religious beliefs; you don’t want to force a kosher person to eat something unkosher. Instead, you challenge them with feelings of doubt; give them something kosher, but don’t allow them to triple check that it is. Or challenge a secular scrupulosity OCD patient from seeking reassurance that they’re not going to hell, or that they’re a good person. 

In my research, I read about an exposure for one scrupulosity patient that was interesting to say the least… he had to go into a church, put up his middle finger and say “F@*k you, God.” Clearly, the idea was to do very blasphemous things, completely contrary to everything he was taught as a kid, in order to show him that God wasn’t going to smite him. In the interview, he said that it was extremely difficult for him to do at the time, but it made him realize that the less he let scrupulosity take over, the more faithful he felt. His therapist told him, “Every ritual resisted is an act of faith,” and those are the words he went by to help stop his compulsions. He decided that listening to the therapist, rather than listening to his OCD, was going to better demonstrate the faith that he was brought up with, as opposed to doing his various rituals. He was at a point where he was willing to do whatever it took, and he amazed himself when he lived through the anxiety. Thankfully, now he notices his thoughts, but doesn’t have to act on them. He can let them go, not dwell on the devil or hell, without reacting compulsively to fix the anxiety. Pretty powerful stuff. 

Sexual Orientation OCD

SO-OCD is characterized by obsessions and intrusive thoughts revolving around a person’s “true” sexual orientation. It has been referred to as homosexual OCD or H-OCD, but this term is somewhat misleading, and is increasingly discouraged due to its lack of sensitivity. In reality, SO-OCD can happen to people of any sexuality, about any other sexuality. It goes beyond just questioning your sexuality; because sexual desire is such a fundamental issue, and sexual orientation is such a big part of a person’s identity, SO-OCD often causes a great deal of internal distress, and sadly, shame. The truth is that though we’ve come leaps and bounds as far as acceptance goes, we’ve still got some ground to cover there. Constantly questioning, while simultaneously hiding the questioning, of something so fundamental causes a great deal of internal strife and anxiety. Keep in mind that OCD has that penchant for latching on to what a person values, so with SO-OCD, it can feel like there’s nearly endless fuel for these obsessive thoughts and anxieties. 

Someone with SO-OCD may experience fears about being perceived or labelled as having a certain sexual orientation, such as gay or straight. Or they might wonder if they’re actually of an orientation other than the one they thought; they may fear they’re in denial of their “true” sexual orientation. Or, they might fear that their sexual orientation could abruptly change, that they could “turn” gay or straight, and worry what this change will mean for their life. For example, will they have to leave their family? Will their relationship end when their partner discovers they’re not who they think they are?

They often constantly assess or question their behaviors and attraction levels to potentially nearly every person encountered, and can be excessively concerned with whether their behaviors align them with a particular sexual orientation. Asking things like: “I was attracted to that guy back there. This must mean I’m gay.” or “He’s attractive. Was I really into that last girl when we dated… or am I more into guys?” or “What if I’m actually straight and I’m not really in love with my partner?” These thoughts can really take hold of a person’s mind, and they won’t let go until they’ve found sufficient proof that their fears are unfounded. But as with all types of OCD, any relief they may find is only temporary, it’s only a matter of time before the cycle begins again. The most common compulsions to quell these anxieties often involve looking at pictures of women or men to see if you’re attracted to them, repeatedly asking people if you seem straight to them, and/ or avoiding people of the same sex altogether to avoid any confusion or complications. 

These intrusive thoughts and compulsions can be extremely distressing, and interfere with a person’s relationships bigtime. And we mentioned religion in our discussion of scrupulosity OCD, and it often plays a role in SO-OCD… it’s fairly common for people to fear going against a religion they were raised in or that their family believes in. Remember in the first blog of this series, I explained that OCD is a disorder of doubt? Well, SO-OCD isn’t so much about their actual sexual identity or orientation, it’s about the doubt that’s common among all subtypes of OCD. It’s really the same uncertainty that exists for everyone, that’s part of human nature… multiplied many fold by confusion and divided by doubt. It’s a tough equation. Nearly every SO-OCD patient I’ve treated has been unconcerned with which orientation fits them, they just want to know with 100% certainty what their sexual orientation is, just as everyone else does. This is how and why people of any orientation can have SO-OCD. Because sexual orientation plays such a big part of a person’s life and identity, and because OCD tends to latch on to what an individual values, it can feel like there is endless fuel for the intrusive thoughts and the anxiety that accompanies them. Altogether, it can make for a debilitating and life altering disorder.

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Dark Side of OCD (Part 4)

The Dark Side of OCD

Hello, people~ welcome back to the blog! The last few installments, we’ve been talking about some of the more unusual subtypes or presentations of OCD. Last week, I told you about POCD, pedophilia OCD. This is a devastating harm based subtype that causes people to worry that they might be attracted to children, and could potentially act on that attraction. To reiterate, these are not predators that actually want to harm or molest children. They are simply- or not so simply- obsessed with the idea that they could. Somewhere along the line, that becomes locked in their brain due to the OCD, and they worry about it incessantly. As a result, they avoid all contact with children, and this can have a huge impact on family dynamics. It causes a great deal of shame and guilt for the person who has it, as they fear being judged by others, while always judging themselves very harshly. And it can also be very damaging to the children in that person’s life, since they miss out on the time and affection that person would have otherwise devoted to them. As you can imagine, all of these things often lead to a great deal of anxiety and depression, and many times, people with POCD suffer through it alone. This week, we’ll be continuing the series with a look at perfectionism. 

Perfectionism is a pretty self-explanatory subtype, the obsession with appearing and being “perfect.” Perfectionism is kind of an unusual trait. It isn’t unique to OCD; not all perfectionists have OCD, and not all people with OCD are obsessed with being perfect. But perfectionism underlies many OCD subtypes, as it can contribute to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, perfectionism can really be thought of as its own OCD subtype; when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, it falls into a class of its own. 

Perfectionism can look very different from person to person, but there are some common overarching themes. Perfectionists feel the need to follow rules very rigidly. I’m sure you’ve heard the addage “Anything worth doing is worth doing right.” Some versions end with “well,” but this isn’t strictly true for perfectionists, it must be right. Things must be done in a certain way- perfectly- or not at all. This is tough to live up to at best, and the pressure to achieve this standard can become so great, that at times it’s far easier to give up on doing something altogether. In addition, perfectionists generally need to feel that they are in control of a situation at all times. By definition, they are excessively concerned with making mistakes, especially when other people could potentially see those mistakes. Ultimately, they think that these errors have some bearing on their overall value as a person, that they define them. They also tend to have an overwhelming need to please others. As a result, relationships with authority figures- people like bosses and parents- can be fraught with anxiety. Perfectionists also have trouble with prioritizing. They can’t make a list of five things they want to accomplish, and then decide which to give 100 percent effort to, 80 percent, and 50 percent. That doesn’t work for them, it’s very all or nothing. Every time they came across a task, whether it’s a strength of theirs or a weakness, whether they have expertise in it or not, they always feel like they must perform it at a high level.

There’s nothing wrong with doing things well, or with being very diligent and detail oriented. These are great qualities, and they work well for people, when they’re functional qualities. But when it gets in the way of getting things done- when it becomes dysfunctional- it’s a problem. I had a patient that was a student, a freshman in college, and he loved school. He was all about it, very intelligent, studied a lot, and worked so hard on papers and projects. Too hard as it turns out. He would begin a lab write up or a paper, but would edit as he wrote. He would then write more, then edit that; then he’d try to stitch them together and get frustrated. Ultimately, he’d have to start all over again. It just went on and on in this way, and it took him forever to do a very simple write up. Something that took his peers maybe a couple of hours tops would take him days of work, because it was nearly impossible for him to write it start to finish, then edit start to finish, a reasonable number of times. There was never an end point- he always felt it needed to be better- and was compelled to improve on it, so sometimes he simply couldn’t finish things. His brain just didn’t want to let him. 

Many years ago, I worked with young children in a hospital setting, with a wide array of diagnoses. One young girl, about nine years old, would undoubtedly have a diagnosis of perfectionism. I remember her very well, but her parents made an especially unique impression. When I gave them my assessment, it was quite clear that her being a perfectionist wasn’t a problem for them- this was written all over their faces. The mother especially, she had a little smile, almost of satisfaction or even pride. It was like I was telling them it was a good thing, or maybe too much of a good thing, like having too much money. She was a great student, very precocious, and a great kid, very meticulous. But if she did something imperfectly, if it didn’t meet her standards- which I suspect she may have learned from her mom, or her mom had a hand in planting- it was a problem. She would begin something with such enthusiasm, which was so great to see given her anxiety; but once she realized the task wasn’t going to be up to par, she would just give up and shut down. It was like watching a bright beautiful flower wilt and wither right in front of you. A sad thing at nine years of age.

This is basically a form of avoidance, which is a common compulsion for perfectionists. Better to totally blow something off than to not do it perfectly. Another example of this is something my student patient would do. If he was late for class, he couldn’t bring himself to go in. If he could see from the window that the professor had already started lecturing, and the students were all sitting there, facing front and listening, he would imagine how it would feel to open the door, and have all those heads turn to look at him. He couldn’t take that, everyone seeing his screw up, so he just wouldn’t go, he’d skip class. Then the next class, he was so concerned about showing his face after missing the previous one, it had a tendency to snowball. Even though he was smart and worked very hard, between his lack of participation in class and his issues in completing tasks, he ended up receiving poor grades, or even failing classes, with shocking regularity. 

Perfectionism is difficult for those with it to gain insight about, because it’s so engrained within their personality. They like to be focused, discerning, fastidious, and detail oriented. Sometimes it works well for them, but when it works against them, it takes much longer to realize it. All of this makes it hard to treat. Despite the suffering it causes, many times, patients initially resist the idea of abandoning their ways completely. And I get that. Some elements of perfectionism backfire, but there are parts that are beneficial, that help people reach their goals. You don’t want to necessarily eradicate it from their lives altogether, throw the baby out with the bathwater. I understand the hesitation. Somewhere in the dysfunction is function. In my student patient’s case, there were times he got A’s on papers. It took him 40 hours instead of two, but the end result was good, no argument there. So how do you find the happy medium, how do you eliminate the dys- from the functional in treatment? We want people to work hard, to be attentive, accurate, and competent. In treating it, and designing exposures, we don’t want to make a person act stupidly or underperform- proofing and editing is good if you don’t want to send out a paper to your professor, or letter to your boss, filled with typos. That would be nearly impossible to get them to do anyway, even if it was designed as an exposure to treat them. We don’t want to weed out the good parts, or necessarily challenge the outcome or the goal, but we need to challenge how they’re getting there. In the case of my student patient, the exposure would be to write without editing, start to finish, one draft, even if there were mistakes. Other ideas would be to show assignments to other people before they’re turned in, as well as to put max time limits on how long a project can take. Practice doing things well, instead of perfectly, to help them see that they can in fact deal with imperfection. That’s the true reality anyway- nothing is ever perfect. If you want perfection, to the point that you reject anything less than that, you’re going to end up rejecting things you shouldn’t, and missing out on a lot in the bargain.  

That makes me think of a book about OCD by Judith Rapoport called The Boy Who Couldn’t Stop Washing. It’s about a law school student with contamination obsessions that agonized over cleaning his apartment. He obsessed about how long the cleaning would take, and especially about how quickly it would get dirty again. He eventually started to avoid going home, so that its cleanliness would be maintained; it wouldn’t be disturbed by the messiness of his living in it. This escalated to the point that he wound up sleeping on a park bench, willingly homeless, all to avoid his apartment. This might seem radically counterintuitive. How could a person with contamination obsessions- who’s afraid of germs- stand to sleep outside, in a park, with all the dirt that goes with it, all for the sake of cleanliness? This is the dark side of OCD when you have perfectionism. 

I was thinking about positive perfectionism, and out of curiosity, read about the top career choices for perfectionists. Clearly, positive perfectionism can give a person a set of traits that can help them excel in life, especially in certain careers. Accuracy, attention to detail, persistence, conscientiousness, and organization lend themselves well to roles where design, math, and very complex procedures are essential to their tasks. Mechanics, inspectors, accountants, surveyors, tailors, and engineers would be top choices. Artists and creative types seem to suffer the most from perfectionism. Claude Monet, the highly celebrated French Impressionist, was a perfectionist… the perfectionist impressionist! I read that he was set for an exhibition in May of 1908, featuring his newest works, the result of three years of work. But when he took his final look, he decided the paintings weren’t good enough. Amid great protests, he took a knife and a paint brush to the paintings- worth $100,000 at the time- defacing them irrevocably. Today, they would be priceless. His actions prompted all sorts of ethics discussions; should an artist have the right to destroy his own work? Evidently at least one expert thought so, and actually praised him for being a true “arteest” and told the New York Times, “It is a pity, perhaps, that some other painters do not do the same.” A similar, but more tragic story is told in a book from 1886 called L’œuvre, translated as The Masterpiece. It tells the story of another artist who becomes obsessed with creating a large canvas that he worked on incessantly, but it never satisfies him. He kept painting on more and more layers, to the point that the canvas was destroyed. Then he would start over, again and again. He became so distraught and depressed that eventually, he went insane.

So how do you tell the difference between healthy and unhealthy perfectionism? The difference is when you move from a detail oriented, conscientious place, to a rigid and controlling one. When the ideas of perfection prevent you from doing anything at all, a healthy sense of perfectionism has been taken over by a dysfunctional one; putting you in a place where mistakes are catastrophic, where they say something about you, where you have to live up to other people’s expectations. This induces such anxiety that it becomes crippling, because eventually everything needs to be perfect- even things that other people would never even notice start needing to be perfect. Once again, the pressure from that becomes so intense, it’s easier to just forget it, to give in altogether. But in my view, the only way to truly fail at something is to not try at all. If you fail at something, it’s not because you’re not perfect, but because you didn’t try. Most perfectionists don’t subscribe to this; they seem to mostly have a fear of being average. They want to succeed perfectly, but if they’re going to fail, they’re going to do so spectacularly. A healthier point of view is to accept that nothing is ever perfect… but it won’t be anything if you don’t do it in the first place.

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

OBSESSIVE COMPULSIVE DISORDER (Darker Subtypes)

Hello, people! Welcome back to the blog, where we’re continuing our discussion of some darker OCD subtypes. Last week we talked about emotional contamination OCD, which is when people become obsessed with the idea that they may become “infected” by the thoughts or beliefs of another person. This can happen any number of ways; through air, electronic media, by touch, by talking about them, or even by being in the presence of someone who’s been in their presence. It’s difficult to deal with- trying to avoid this influence can become so consuming that it completely alters the course of a person’s life. This week, we’re going to talk about a particularly devastating subtype called pedophilia OCD, which features an obsession with the idea that you might be attracted to children, and could potentially act on that attraction. 

Before we get started, I want to make a very important distinction. People with pedophilia OCD or POCD are not people you need to hide your children from. They are not predators, and have no actual desire to molest children. They have an unusual form of OCD where an idea basically gets trapped in their brain, and because of the OCD, it gets twisted in such a way that they worry they may act on it. Maybe they see a news segment that gives details on a molestation case, or they read an article, or participate in a discussion; that may be all it takes. The idea of harming a child is as horrifying to them as it is to you and to me, but unfortunately, the OCD allows the possibility to take root. They wonder if their worry about pedophilia means they have desire. They fear they could act, and they obsess about the fear. It can be very debilitating. I’ve had patients that were so afraid of what they “could” do that they were often unable to get out of bed in the morning. They think these thoughts must mean something… why would they have them otherwise? It can be a real mind screw. 

Pedophilia OCD is an example of harm based OCD, and there may be many variations on that general theme. It may be a fear that they may hurt or kill strangers, or even parents or siblings. For any person with harm based OCD, the biggest fear is that they are dangerous. The object of harm can remain the same for years, or may change for no obvious reason. A patient I consulted on, a 20-something named Heidi, obsessed about harming her boyfriend. She would find herself worrying she might push him down the stairs, stab him with the carrot peeler, or run him over with her car. She worried about it for three years before she admitted it to anyone… three years! Can you imagine? Once she initiated therapy for that, the focus shifted to a pedophilia based fear; she worried she might molest her baby nephew. It was her first time as an aunt, and she loved the little guy. She didn’t want to hurt him, it was just her OCD talking to her, filling her head with nonsense. She constantly wondered ‘Am I attracted to this; do I want to molest him? Why did I have this thought? This must mean something about me…. this must be who I am.’

It was a nightmare for her. She couldn’t trust herself to be alone with her new nephew, and yet was understandably afraid to tell her sister she was having these thoughts. She wasn’t able to sleep at night, worried she would do something to him while everyone was sleeping. Eventually, she confessed what she was thinking to her mother. With her support, she was then able to talk to her sister, and then her whole family, who all supported her. Sadly, not all do; but she was able to turn to them to seek reassurance. This is a fairly common compulsion for people with stereotypical OCD- they compulsively need another person to tell them what they’re obsessing about isn’t true. Heidi would call her sister or mom and tell them when she was having these scary thoughts, and they would reassure her that she was a good person, she wasn’t going to molest him. It helped take the edge off, but only for about ten seconds. Then it was back to worrying. Remember that OCD is a disorder of doubt. Even after she was diagnosed with OCD, at the back of her mind, Heidi was even unsure if her thoughts came from that, or if it was truly something darker. 

Sometimes pedophilia OCD thoughts first center on a parent. People with it may wonder if perhaps they’re attracted to a parent, and/ or if they were molested as children, if something was done to them to cause the thoughts. That’s never happened in any of the cases I’ve been involved in, it’s simply the obsessive mind looking for reason. These thoughts torment people with pedophilia OCD, and many say that they thought they were going crazy before they were diagnosed with OCD. If their fears revolve around molesting children, they will do all they can to avoid them, and not even talk about them. When they can’t avoid the topic, their anxiety and uncertainty is multiplied. They will desperately review every movement they made around a child to help them figure out whether their actions were inappropriate, and they’ll constantly seek reassurance from loved ones, provided they’re aware of it. If not, they suffer alone. They know they would never hurt a child, but they can’t trust themselves, so they really need to hear it from someone else. Self-compassion is often non-existent, self-loathing is more the rule. They believe they should be able to control their thoughts. Since they can’t, they constantly judge themselves, and that often leads to depression. 

As you can imagine, it’s hard for them to seek treatment, because they’re afraid of being judged. They live in fear that family and friends will find out the “true” nature of their thoughts, and they’ll be ostracized, labeled as a pedophile, as disgusting or evil. People with POCD feel extreme shame and guilt for their thoughts. Most people don’t understand that pedophilia OCD is not the same as pedophilia. Imagine this: you see a kid and you’re like, ‘Awww, so cute!’ If you have POCD, your next thought is something like, ‘Oh, my god. Does that mean I’m a pedophile?’ Clearly, babies are cute, everyone knows that, nothing wrong with it. But the POCD tries to spin it, so if you have it, it makes you worry that you’re a deviant. 

Last week, I talked about exposure therapy for OCD, and POCD is treated the same way- it requires putting the person face to face with the ideas and “temptations” of pedophilia. Just reassuring them that they’re not a pedophile doesn’t work; they don’t believe it. Instead, people with POCD have to become comfortable with the uncertainty, with the risk that their very worst fears are true. Then they have to figure out how to live their lives despite that risk. POCD exposures might include going to a park where children are playing, or to a children’s store, maybe handling clothing. They could watch that pageant show with the nutty parents- might as well try to get a laugh while working on it. At some point, exposures might re-introduce behaviors the person has been avoiding- like having someone who has been avoiding changing a diaper or giving a bath start doing so again- even if it makes them anxious and fearful. As scary as it can be for them, not doing these things can be much more damaging to the children in that person’s life, since people with POCD often avoid giving affection, spending time, or caring for children because of their fears. Ideally, as exposures continue, the person begins to understand that what they’re afraid of isn’t true. The goal is for them to learn that they can trust themselves to do these things without molesting a child or hurting them in any way. As hard as it may be to get there, every patient I’ve worked with has been willing to do whatever it took to reach that realization. It may not make 100% of the obsessive thoughts stop, but it gives them the ability to call bs on them and keep it moving. 

Speaking of, that’s it for this week. Next week, another OCD subtype, perfectionism. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Dark Side of OCD

Dark Side of OCD

Hello, people! Thanks for checking out the blog. Last week, I introduced a new series on unusual OCD subtypes, the darker side of OCD, with compulsions that go beyond the stereotypical examples most people think of. While doubt is still the core issue, people with these obsessions aren’t arranging their colored pencils, checking the light switches, or washing their hands until they’re red and raw. These obsessive thoughts often center more on function- am I swallowing correctly? Can I still blink? Those are examples of the first subtype we covered last week, hyperawareness OCD, also called sensorimotor or somatic OCD. This is an obsession with a part of the body, or with an involuntary bodily function. Breathing, blinking, and swallowing are the top three obsessions, but it can involve the location of a mole or freckle, placement of hands, or even how the skin feels, if it’s itchy, for example. This week, I’m going to cover another subtype, called emotional contamination OCD.

Contamination OCD generally revolves around the classic “feeling germy” or disease obsession. I have patients with this that may take 8 to 10 showers a day, sometimes more if they’re really “in it.” Others have to wear cotton gloves because they’ve washed their hands so much the skin has deep, angry cracks that bleed, yet they still worry they aren’t clean. But with emotional contamination OCD, the obsessive thoughts center on “catching” more abstract things from others, like ideas, values, and traits, as if they are infectious. They constantly ask themselves, what if being near this person causes me to lose my values and assimilate theirs… what if I start believing in what they believe in, instead of what I believe in? It’s a scary thought, right? Imagine having to worry that if you sit next to someone on a train to work, when you arrive, you might not think like you any longer, you might be infected with their thoughts. Will you even still know how to do your job? Yikes! What if you meet someone who’s immoral or a criminal? If you stand near them, touch them inadvertently, or sit in a chair they once sat in, those immoral thoughts may transfer to you, like a virus. You might start stealing things, or cheating on your wife. People with emotional contamination doubt the authenticity and stability of their thoughts. If a thought pops into their heads, it’s ‘did I think that? Or did I catch it from that person?’ And once the thought of contamination begins, it’s so hard to stop. 

The obsessive trigger may be a person, a geographical location, or an object, and by touching it, sitting near it, or even going to a place associated with it, people with emotional contamination OCD think they’ll somehow become contaminated with its essence. I had a patient we’ll call John. Great guy- a kid, really- who developed terrible emotional contamination. He was in college on a scholarship, and lived with a roommate, a guy named Mike, who was pretty successful academically as well. They were both business majors, so it sounded like a great setup. Well, as it turns out, Mike was successful because he was entitled and ruthless, and always took advantage of people that offered to help him. This didn’t sit well with John at all, he was a sensitive kind of guy, and he began to worry that he would start to think and act like Mike. He didn’t know why, but he found himself thinking about it constantly, obsessing about it. He was terrified that if he kept living with Mike, or even came into contact with him, that he’d become a ruthless user too. So he started avoiding him, and any friends who interacted with him. He stopped going to the coffee shop where he studied, the bars he frequented, and the restaurants where he ate. He even switched his major so that he and Mike wouldn’t have any crossover. If someone in one of his classes had taken a course in the business building- where Mike took classes- John would have to drop out of that class. Not only that, but he felt so contaminated that he had to throw away the books and study materials, and even the clothes he was wearing when he saw that person. Like many people with emotional contamination OCD, John felt that the traits could also spread through the air, through an association with other people, and even through the internet, so that anything and everything could really become contaminated at any time. 

Before long, John had to give up his scholarship and drop out of school. He continued to get rid of his belongings repeatedly- books, computer, clothes- it had to go if it had any prior affiliation with Mike. He had to move into a room above his parent’s garage, he couldn’t go into the main house because Mike’s name had been mentioned there. But Mike had never been discussed in that room, so that was a “Mike free” zone. When he tried to take classes online, he found that even the internet was contaminated by Mike, because his social media profiles were also on the web. When he reached the point where he was getting ready to move into another apartment in a town fifteen miles from his parents, and he was about to buy his fifth computer, he finally decided to get help, and came to see me. 

People with emotional contamination OCD feel compelled to avoid the person or idea that’s contaminating them, and that quickly becomes a gargantuan task. Not only does it spread through air, people, objects, and the internet, it can spread through language, so even hearing a word or phrase that sounds like the obsession can trigger the fear and feelings of danger. People end up avoiding television, newspapers, radio, the internet, computers- a constantly expanding circle of people, places, and things- completely isolating themselves to avoid any risk of a potential reminder of their obsession. Eventually, that circle can make it nearly impossible to function. 

Imagine you develop emotional contamination around Hershey, Pennsylvania. Very quickly, it wouldn’t be enough to just avoid that town; you wouldn’t be able to go to any towns surrounding it, either. Then you wouldn’t be able to eat Hershey’s chocolate bars, because they share the same name. Then, you’d have to avoid parts of the grocery store, because you’d see the chocolate bars. Then you realize, much to your horror, that Hershey’s makes other food products too, and you need to avoid them. Then you’re stuck in the grocery store for hours, reading labels to make sure you don’t have any contact with Hershey’s products. You can see how it swiftly becomes a big problem. And who knows when and where else you might randomly be triggered. Maybe you go to grandma’s and she asks you to get her favorite hot cocoa from the cabinet, and you discover it comes in a tin that says… you guessed it. You don’t think about the connections between things in life, until they cause you anxiety. When you have emotional contamination, you’re constantly thinking about exactly that, because you have to avoid certain things. But it’s difficult to completely avoid being triggered, even when you’re trying to.

Emotional contamination is rooted in what’s called magical thinking, a psychological concept that your thoughts, imagination, or beliefs will lead to something actually happening in the real world. The phenomenon is present in many subtypes of OCD, but is especially prevalent in emotional contamination. Sometimes people’s thinking can become so “magical” that emotional contamination OCD can even be misdiagnosed as psychosis if a therapist hasn’t dealt with it before. It can be difficult to get a handle on because it’s so nebulous, but the good news is that, like all types of OCD compulsions, emotional contamination can be treated using ERP therapy- exposure and response prevention therapy- which is considered the gold standard for OCD treatment. 

If you’ve ever tried to not think about something, you know how hard it is to control your thoughts. If I tell you don’t think about that dumb purple dinosaur Barney, and definitely don’t sing his silly song in your head. What are you doing right now? Are you singing “I love you, you love me, we’re a happy family…” Exactly. So ERP therapy takes the opposite approach; instead of trying to make yourself stop your obsessive thoughts, you welcome them, and deal with them. The concept behind it is that repeated exposure to the obsessive thoughts, and thus the discomfort that comes with them, affords you the best chance to avoid the compulsion and alleviate that discomfort. When you continually submit to the urge to do compulsions, it only strengthens the need to engage in them. But on the flip side, when you prevent yourself from engaging in your compulsions, you teach yourself a new way to deal with them, and that generally leads to a reduction in anxiety. 

Because doubt and uncertainty are at the core of the obsessions, ERP gives you a chance to live with it, to experience it and get through it another way. During ERP therapy, you discuss and track your obsessions and compulsions, and develop a list of alternative ways to face your fears. A therapist then designs exposures, which slowly put you into situations that bring on your obsessions, and cause anxiety or discomfort. You respond, eventually, hopefully in a way that is not compulsory, and this reduces or eliminates the anxiety. In other words, you regain some control, so you prevent yourself from performing whatever compulsion you normally do, be it a physical or mental compulsion, and that eliminates the anxiety or discomfort. Get it? Exposure and response prevention. It can take time, but with continued exposures, you build toward reaching whatever goal you’ve set. ERP therapy can make a huge difference in an OCD patient’s life, and it has a decent success rate, about 80 percent. 

That’s a good place to stop for this week. Next week, another OCD subtype, one you won’t want to miss. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in officeand on Amazon. 

Thank you and be well people!

MGA

Learn More

OCD SUBTYPES PART 1

The Darker Side of OCD

Hello, people! Last week we finished up our discussion on the importance of vitamin D, so I hope everyone spent a few minutes in the sun over the weekend to get a dose… gotta have it! This week, we’re starting another series on OCD, Obsessive Compulsive Disorder. What’s the first thing that comes to mind when you hear about OCD? It’s probably neatness, everything in its exact place, like making sure all the edges of the silverware are perfectly aligned in the drawer. Or maybe it’s repetitive hand washing, counting steps, or checking the locks on all the doors in the house. While those stereotypical obsessions are definitely common symptoms, in reality, OCD can involve any persistent, intrusive, obsessive thought that causes anxiety; it’s then generally paired with a behavior that attempts to quell that anxiety. But the scope of it can reach much further than worry over germs or counting and checking, as it is limited only by the person’s mind. Some obsessions are much darker, incorporating a person’s deepest darkest fears and worries. How about obsessing about killing your mother? All of your thoughts center on how you’d go about it, how it would feel. While these types of obsessions may be less common, they can clearly be much harder to talk about, and for that reason, can remain undiagnosed for years, even if a person seeks help. In the best case scenario, it can take an average of 14 to 17 years for people to find treatment, even though OCD usually emerges in childhood.

Think about having an obsession centering on a bodily function, let’s say swallowing. How many times do you swallow in a day, whether eating or drinking or not… ever noticed? Probably not, unless that happens to be an obsessive thought for you. Do you ever worry about the ability to swallow when you need to… do you doubt it? Can you imagine how debilitating something like that could be? And most people have more than one obsession that draws their focus. I did have a patient with OCD who thought he was Jesus, so all of his obsessions centered on that. He dressed like Jesus, wore his hair and beard like Jesus, and acted like Jesus- or how I imagine Jesus would act- with this “peace, brother” persona that he never dropped. He was court ordered, but totally harmless. The total effect was, well… honestly, kinda eerie. That could’ve been me- for some reason, it gave me flashbacks to confirmation classes as a kid. Anyhoo, he was so sure of his true identity that he would only date women named Mary. Yep. Sometimes in OCD, all of the obsessions are present in the mind at once, competing for attention, while at other times, one will take center stage, while the others wait in the wings. Depending on the year, the day, or even the minute, OCD can look completely different, even within one individual.

At its core, OCD is a disorder of doubt. A person can’t be sure that their thoughts aren’t indicative of something that may happen in real life. They can’t be sure of their safety, their intentions, their motives, or even their true realities. And yet, most people with OCD are completely, and usually painfully, aware that what they’re thinking isn’t true. For example, a person with a contamination obsession knows deep down that they don’t need to wash their hands for the 100th time, but they cannot get past the possibility that there could be germs lingering there. They’re haunted by the reality that there could be. Are those germs dangerous… could they make them sick, even kill them? That doubt is what they obsess over. So they continue to wash. When people find out what I do, at cocktail parties and the like, they’ll sometimes ask me, what’s the weirdest/ worst/ scariest symptom or diagnosis you see? Well, when it comes to OCD, there’s really no hierarchy to suffering- one obsession isn’t necessarily inherently worse than another- the worst obsession is the one that’s right now. Still, some forms of OCD are more challenging to deal with, diagnose, and treat. To start with, the content of some obsessions are so taboo that people simply won’t divulge it, so they suffer without finding the help they need. Sometimes they don’t even know that they have OCD, that that’s what’s driving these obsessive thoughts. So this week we’ll be talking about the darker side of OCD, examining some lesser known types you may have never heard of. 

Before we start, a note on these subtypes. Although all forms of OCD have symptoms in common, the way these symptoms present themselves in daily life differs a lot from person to person. Usually, OCD fixates around one or more themes, and some of the most common themes are contamination, harm, checking, and perfection. The content of a person’s obsessions isn’t ultimately the important part, though it’s certainly what feels important in the moment. Someone’s subtype is really just their manifestation of symptoms- the particular way their OCD affects them. What does the mind focus on, and what thoughts and actions result from this focus? Psych geeks like me call a condition like OCD “heterogeneous” because it varies so much from one person to the next, but there are a few common “clusters” of symptoms. There’s a lot of discussion about these symptom clusters, and even more debate about whether or not they should be classified as more specific categories or subtypes. But there are clear groups of obsessions and compulsions that pop up regularly in people with OCD. Many clinicians try not to talk about subtypes because there isn’t any real research backing them. They’re not perfect categories or neat little boxes you’re supposed to fit into, so if you have OCD, it’s not worth spending too much time trying to figure out which subtype you fit into if it’s not immediately apparent. That said, for lots of folks with OCD, the immediate recognition of their own experience in a list of subtypes is a powerful thing, and may actually be the start of the treatment process. 

So ultimately, I’ve chosen to go with calling these subtypes, but you can call them forms of OCD, or whatever you want, really. The point is that the symptoms seem to fall into groups naturally, and the info just needs to be out there so there’s more awareness of what lots of folks with OCD struggle with on a daily basis. Imagine that you’ve thought of yourself as truly- and totally uniquely- messed up for a long time. No way anyone has ever had the thoughts you have, or so you think. All of a sudden, you’re crusing the interwebs and see a list of symptoms that match yours exactly. Recognizing yourself in this OCD subtype, you’re not alone anymore- there are enough people like you out there to have your own type. Maybe you don’t have to feel hopeless anymore, because other people have clearly faced similar struggles, with similar types of obsessions and compulsions. There’s no realization that comes close to that kind of hope. Listing subtypes may be an imperfect way of categorizing OCD, because people may mistakenly think of them as distinct conditions rather than common manifestations of the same diagnosis, but I think it’s the way it should be. All of that said, keep in mind that there are hundreds of different ways OCD can show up in someone’s life- people don’t fit in boxes, they can have more than one subtype, and while the subtypes are relatively stable over time, they can change- new symptoms can appear and old ones might fade. Not a lot of rules when it comes to the brain’s capacity for imagination and change. So now, finally, we’ll begin discussing some unusual OCD subtypes, just to illustrate the mosaic of experiences associated with the diagnosis, and to illuminate some of what goes on in the OCD mind. 

Hyperawareness OCD

Hyperawareness OCD is an obsession with a part of the body, or with an involuntary bodily function. The patient I mentioned earlier, with the swallowing obsession, had hyperawareness OCD. It’s also called sensorimotor or somatic OCD. At any given moment, your brain, through your entire CNS, is sending and receiving signals about what different parts of your body are doing- like where your hands are, what your heart rate is, or if your stomach is empty or full. These are done subconsciously, so most people don’t pay attention to them. Everyone blinks and swallows, but very rarely do you give it any consideration. With sensorimotor OCD, a function like this can become an obsession. A person can get stuck in this place where they become hyperaware of some part of their body, or of the signal controlling it in their brain. I had a patient obsessed with blinking. Every morning, her first thought upon waking was to check to make sure she was still blinking, or still able to blink. And the thought persisted throughout the day… am I blinking now? It was consuming her life, not only was it the first thing she thought about, but also the last. She even kept herself awake with it, because she would close her eyes to sleep and would have to open them and make sure she could still blink. 

When anyone starts to think about things like involuntary processes- even for people without OCD- they can become heightened. If thinking about “it” makes it happen, and if “it” happening makes you think about it… well, you can see how easily this could lead to an obsession in the mind. To make matters worse, a lot of the anxiety in OCD lies in the person’s fear that they’ll never stop thinking about the blinking or swallowing, or whatever the obsession may be. And of course, the more they monitor it, the more they try to control it, the less automatic it feels, the more controlled it feels, and the more it seems like they’re never going to stop thinking about it. It’s a never ending cycle, and it produces a lot of other obsessions like, what if this drives me crazy, what if I never stop, if I’m permanently distracted by it? And in fact, my blinking patient also had a tendency for projection, so she imagined obsessing over blinking for the rest. of. her. life… ife… ife… ife…. I should point out that I make light of it, because one of the ways to combat an obsession is, oddly enough, to examine it in detail, so that includes looking at the futility of obsessing over an automatic bodily process that you cannot control… forever. It sounds counterintuitive, but dealing with it that way is a form of mindfulness- for those of you who read my blog on that many moons ago- examining whatever the thought may be, and the body part it involves, in an effort to soothe and assure. It can’t control it, but it can help lead to acceptance of the thought, which can take away its power. 

While sensorimotor OCD is relatively rare, in addition to blinking, the top three obsessions also include swallowing and breathing; but it can focus on the function of literally any part of the body. It can even involve non-functional parts, like the location of a mole or freckle, or hyperawareness of normal occurrences like itching or heart rate. As you can imagine, it can be very debilitating and isolating. My swallowing patient had a very hard time eating in front of anyone- these obsessions tend to be very self-propagating- and she was too anxious over being anxious about her swallowing. And it’s very difficult to talk about these symptoms, even with a therapist or a shrink, so unfortunately, people really suffer. It’s easier to just keep it simple and tell people that you have OCD and let them think you spend all your time straightening silverware or washing your hands, rather than risk being judged for the other manifestations. It’s a tough situation- while I understand it may be easier, it’s not necessarily better in the end. Some clinicians don’t understand sensorimotor OCD, or recognize that people with it have compulsions. Compulsions are the actions or rituals the person is basically “required” to complete in order to make the obsession, and therefore the resulting anxiety, stop. For instance, in contamination OCD, the obsession is germ exposure, and the compulsion is the continual hand washing. But in sensorimotor OCD, the compulsions are there, but they’re just not obvious. It’s more about the mental rituals taking place in sensorimotor, like reviewing or checking to see how that bodily sensation feels, or maybe trying to actively replace the obsessive thought with another thought. 

Given the lack of understanding, one of the biggest barriers to treatment is the isolation that the patients feel. Meds are helpful, and there are specially licensed therapists for treating serious OCD. Regardless of the subtype, treatment essentially the same. The gold standard of treatment is exposure and response prevention therapy, or ERP, which is sort of a combined approach. I’ll talk more about that later, but as with anything else, acceptance is key. If you’re a person that thinks about blinking, then you’re a person that thinks about blinking. Hopefully treatment stops that, but if it doesn’t, are you going to let it run your life? Once there’s acceptance, that then becomes the question, as opposed to being concerned about it. That’s where mindfulness comes in. If you pay attention to your blinking, then that’s one thing, but if you’re worried about it, that’s kind of pointless. You’ve proven you’re doing it right, and that your blink isn’t broken, about 18 times in the last minute alone. Did you know that that’s the average number of times a person blinks in one minute, 18? Sounds like a lot. Anyway, there’s a difference between watching your behavior in a mindful way, and not trying to change it, versus actively thinking about it and trying to figure out if you’re doing it the “right” way. Personal acceptance of anything means being less judgmental about the internal experience of it. Admittedly, it’s a lot easier said than done. There shouldn’t be any trivializing how upsetting it would be to think about blinking, or swallowing, or where a mole is. These things may seem banal to you, but they may be the center around which another person’s life revolves. When you think about accepting anything, but especially OCD, maybe just ask yourself, what would my patient Jesus do?  

Next week… more OCD subtypes! I hope you enjoyed this blog and found it to be interesting, and of course, educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Vitamin D Part Two

Hello people… hope everyone had a great weekend! This week, I’m going to finish up our discussion on the big D… vitamin D! Last week, we talked about how it’s not actually a vitamin, it’s really a hormone. And unlike most vitamins, it can be synthesized in the body, provided there’s sufficient skin exposure to the sun- it doesn’t take much- maybe 10 minutes two or three times a week. If you spend all your time inside, have very dark skin, or constantly wear high spf sunscreen, you may need to take a vitamin D supplement. Maintaining adequate vitamin D is essential for many basic processes, far beyond the bones and teeth. Vitamin D helps the immune, muscle, and nervous systems function properly, and a surprising percentage of the population are chronically low. Last week, I mentioned that the elderly population are especially at risk of severe D-ficiency, and this increases the risk of several brain-related disorders. Vitamin D alters cholinergic, dopaminergic, and noradrenergic neurotransmitters systems, and abnormalities in these neurotransmitters have been implicated in various neuropsych diseases and disorders, such as schizophrenia, depression, Parkinson’s disease, dementia/ Alzheimer’s disease, and multiple sclerosis, MS. This week, I’ll finish discussing what researchers know about vitamin D deficiency and these disorders thus far. 

Dementia

A 2014 study found that moderate and severe vitamin D deficiency in older adults was associated with increased risk for some forms of dementia, including Alzheimer’s disease. Dementia involves a decline in thinking, behavior, and memory that negatively affects daily life. Alzheimer’s disease is a neurodegenerative disorder and the most common form of dementia, accounting for as many as 80 percent of dementia cases. When compared with people who had normal vitamin D levels, the study found that people with low levels of vitamin D had a 53 percent increased risk of developing all-cause dementia, while those who were severely deficient had a 125 percent increased risk. In addition, people who had lower levels of vitamin D were about 70 percent more likely to develop Alzheimer’s disease specifically, and those who were severely deficient were over 120 percent more likely to develop it. These findings may seem alarming, especially considering the devastating toll that dementia can have on patients and their families, but don’t panic- this was an observational study, meaning it cannot prove a direct cause-and-effect relationship between vitamin D deficiency and dementia and Alzheimer’s. You have to consider that the risk of both Alzheimer’s and dementia already increase with advancing age, and vitamin D deficiency increases with advancing age, so you have to wonder if the relationship is incidental, or if there’s a causal mechanism at play. Researchers are trying to tease out the findings to answer that. Nonetheless, the theory is that the “sunshine vitamin” might help literally clear the patient’s heads- the vitamin D may protect against dementia by helping to break down and sweep out the protein plaques commonly linked to dementia and Alzheimer’s disease. This would increase blood flow to the brain as well, which is a good thing. 

Multiple Sclerosis

Vitamin D receptors are present throughout the central nervous system, and research has shown that maintaining adequate levels of vitamin D can have a neuroprotective effect. When a person has multiple sclerosis, MS, the immune system attacks the myelin coating that protects the nerve cells, damaging them and affecting transmission of signals. But studies show that vitamin D may lower the risk of developing MS. A number of studies have shown that people who get more sun exposure and vitamin D in their diet have a lower risk of MS, so vitamin D levels are considered to be an important modifiable environmental risk factor for development of the disease. For people who already have MS, some studies suggest that vitamin D may offer some benefits- it may lessen the frequency and severity of their symptoms, which improves quality of life, and lengthens the time it takes to progress from relapsing-remitting multiple sclerosis to the secondary-progressive phase. At this point, the evidence isn’t conclusive, more research is needed, but the connection between vitamin D and MS is strengthened by the association between sunlight and the risk of MS. Studies have shown that the farther away from the equator a person lives, the higher the risk of MS. This suggests that exposure to sunlight may offer protection from MS. Therefore, researchers theorized the link to vitamin D and set out to explain it.

A team of Harvard researchers conducted a study and reported that women who ingested more vitamin D from food (approximately 700 IU/day) had a 41 percent lower risk of MS as compared to women with lower intakes; those who took vitamin D supplements (400 IU/day or more) had a 33 percent reduced risk of developing the disease, as compared to those who did not. In another Harvard study, researchers discovered that some people, specifically caucasians whose blood levels of vitamin D were above 40 ng/mL (meaning levels were sufficient) had a 62 percent lower risk of developing MS. More recently, researchers have linked higher blood levels of vitamin D with reduced risk of relapse, less active lesions on MRI, and possible neuroprotective effects. Although it’s not clear what role vitamin D plays in MS, hypotheses involve its impact on the immune system, and question potentially faulty vitamin D receptors in people with MS.

Parkinson’s, Preliminary Association

Most evidence on the link between vitamin D and Parkinson’s disease (PD) has been from animal studies, but human trials have also uncovered a potential connection between chronically deficient levels of vitamin D and the development of PD. A Finnish follow up review of 3,173 men and women without PD found that those with higher blood levels of vitamin D showed a reduced risk of the disease. An Emory University publication found that more people with PD, 55 percent, had a vitamin D deficiency than a control group, 36 percent. Scientists still don’t know how exactly vitamin D levels affect Parkinson’s risk, but the findings are generating interest in more research. 

Depression

Most people are familiar with seasonal affective disorder (SAD), which happens during seasons with less light exposure. The relationship between sunlight and depression is no accident, so it’s no surprise that vitamin D deficiency may be linked to a higher risk of depression. After all, the nickname for vitamin D is the sunshine vitamin, and that’s not just because many people generate much of their required amount thanks to sun exposure. Vitamin D status is also connected to a sunny, or not so sunny mood. Research has previously demonstrated a relationship between low mood and low vitamin D levels, and in fact, I see many patients with depression that have low vitamin D levels. The two seem to go hand in hand, which is why this is an important topic. A study I read not long ago utilizing high dose vitamin D found that participants had a significant decrease in depression and anxiety, and an improvement in general mood. I’ve found vitamin D supplementation to be very helpful in patients with mood disorders, even treatment resistant depression, especially in those who also have other inflammatory-related conditions. I have one patient that just started a D3-K2 supplement I suggested that also has rheumatoid arthritis, and I’m hoping it will improve symptoms of both. K2 is menaquinone, a micronutrient supplement that works synergistically with D3. I’ll talk about it in a moment.

Risk of Schizophrenia

Schizophrenia is a severe brain disorder that affects less than one percent of American adults. Symptoms commonly appear between ages 16 and 30, and include delusions, hallucinations, incoherent speech, withdrawal from others, and trouble focusing or paying attention. A scientific review from 19 observational studies suggests that people who are vitamin D deficient may be twice as likely to be diagnosed with schizophrenia, as compared with people with sufficient vitamin D levels. Schizophrenia is more prevalent in places with high latitudes and cold climates, and studies suggest children who relocate to colder climates appear to be at a higher risk of developing it. While the researchers observed a link between the two factors, I should note that we need some randomized controlled trials to better define the link and to determine if supplementation may help prevent it. Probably couldn’t hurt. Considering what we know about the role of vitamin D in mental health, the findings seem to have merit.

Diabetes mellitus 

Vitamin D deficiency has been implicated in the pathogenesis of multiple autoimmune diseases, including diabetes mellitus type 1.

The connection seems clear, but why it exists is not. Some researchers believe the link is related to the role of vitamin D in insulin sensitivity and resistance, which results in increasing blood sugar. The hormone insulin helps control the amount of sugar, or glucose in the blood. With insulin resistance, the body’s cells don’t respond normally to insulin, and glucose can’t enter the cells as easily, so it builds up in the blood. So you have high blood glucose levels, and this can eventually lead to type 2 diabetes. Researchers theorized that low vitamin D levels change glucose “homeostasis,” which just means it affects how you maintain a proper level. Studies have found that when vitamin D is deficient, many cellular processes in the body begin to break down, and this may be what sets the stage for the onset of diseases like diabetes. In animal studies, vitamin D deficiency has been shown to have a detrimental effect on insulin synthesis and secretion, and some human observational trials have also indicated a correlation between pre-diabetic states and vitamin D levels. But in the randomized controlled trial on vitamin D in pre-diabetic states, not all the evidence supported that increasing vitamin D levels through supplementation results in improvements in insulin sensitivity. In some cases, it didn’t improve. So the jury’s out as far as proof of the influence of vitamin D on glucose homeostasis. Most of the data suggests it’s helpful, but we don’t have a definitive answer as yet.  

Rhematoid Arthritis, RA

Vitamin D has been found to have immunomodulatory actions, meaning it may help keep the immune system in balance. Autoimmune diseases like RA occur when the affected person’s immune system attacks their own tissues, hence the name. It’s been previously established that reduced vitamin D intake has been linked to increased susceptibility to the development of RA. Deficiency has also been found to be associated with disease severity in patients with RA; low vitamin D can lead to more severe disease. As I mentioned last week, vitamin D deficiency can cause bone loss and diffuse musculoskeletal pain, similar to that which occurs in RA. Science is always looking at common links to exploit them therapeutically. They also knew that vitamin D supplementation may help prevent osteoporosis, so they put that all together and theorized that vitamin D may also help decrease pain associated with flares of RA. “Flares” are periods of time when the disease is active, when the person’s immune system is attacking their bones and joints, and they can be extremely painful. So they started looking at vitamin D and RA disease states. Researchers of one large study found that only 33 percent of the people with RA they studied showed satisfactory vitamin D levels- 77 percent were low. And the people who had active RA at the time, who were experiencing more severe symptoms, their vitamin D levels were even lower. While the link between vitamin D and RA is well known, this was the first study to look at the impact of levels on the course of established disease. So those of you at risk of RA or with constantly flaring RA, make sure to get your D checked!  

Prostate Cancer

A published 2014 study found a link between low blood levels of vitamin D and aggressive prostate cancer in European American and African American men. Researchers looked at vitamin D levels in 667 men, ages 40 to 79, who were undergoing prostate biopsies. The connection between low vitamin D and prostate cancer seemed especially strong in African American men. The results suggested that African American men with low vitamin D levels were more likely to test positive for cancer than men with normal vitamin D levels. These findings were observational- meaning that they didn’t prove that low vitamin D led to prostate cancer, just that the two factors may be linked- it does suggest you may reduce your risk by ensuring adequate vitamin D levels. Captain Obvious says you should also make regular doctor’s visits, and watch for common prostate cancer symptoms, to make sure you get an early diagnosis and treatment if you’re affected. Common symptoms are difficulty starting and maintaining a steady stream of urine, frequent urination, excessive urination at night, urge to urinate, and/ or weak urinary stream. Prostate cancer occurs mostly in older men, and the average age of diagnosis is about 66 years of age. Other than skin cancer, it’s the most common cancer in men, and the second most common cause of cancer death in American men, per the American Cancer Society. Just a friendly PSA from MGA.

Severe Erectile Dysfunction, ED

A small 2014 study of 143 subjects found that men with severe ED had significantly lower vitamin D levels than men with mild ED. The researchers theorized that vitamin D deficiency may contribute to ED by impeding the arteries’ ability to dilate, another “ED” condition called endothelial dysfunction. Captain Obvious says that one of the requirements for achieving an erection is proper function of the arteries, as they’re responsible for supplying the penis with blood so it can become engorged. Ironically, arterial stiffness may be the cause of the endothelial dysfunction that causes the erectile dysfunction… basically, if the arteries are too stiff to dilate, something else won’t be. And in fact, a totally separate study suggested that a lack of vitamin D was indeed linked with general arterial stiffness in healthy people. Another PSA: ED is the most common sexual complication among men, and according to the National Institute of Diabetes and Digestive and Kidney Diseases, it affects up to 30 million American men. It can stem from other health conditions, including diabetes, prostate cancer, and high blood pressure. Common ED treatments include hormone replacement therapy, counseling, and lifestyle changes like quitting smoking, limiting alcohol, and eating a balanced diet. Yet another reason to check your D.

Breast Cancer

It’s not just prostate cancer that shares a link with low vitamin D levels, there’s also a link between vitamin D deficiency and breast cancer. A 2017 published review found that “most” vitamin D studies support the “inverse association” between vitamin D level and breast cancer risk. That’s nerd speak for saying that women with low levels of vitamin D have a higher risk of developing breast cancer. A 2019 in vitro study, meaning “in glass” in a lab, found that high concentrations of vitamin D inhibited breast cancer cell growth. In addition, studies and statistics indicate that women with breast cancer that have adequate or high vitamin D levels seem to have better outcomes- fewer cases of metastases, fewer deaths. So it appears that vitamin D may play a role in controlling breast cell growth, and that high levels may be able to actually slow or halt growth. It’s exciting stuff, but cells isolated in a petri dish in a lab are one thing, and cells in a walking talking human with all of the additional influences are quite another, so human trials are needed before we celebrate with a giant vitamin D cake. But it’s a start. The American Cancer Society estimates that in 2021, 281,550 new cases of invasive breast cancer will be diagnosed in women, not including about 49,290 new cases of ductal carcinoma in situ (DCIS) and about 43,600 women will die from breast cancer. Horrible.

D3’s BFF, K2

This isn’t a math formula, this is a quick note on vitamin K, a micronutrient that most people haven’t ever heard of. K vitamins are critical cofactors for a variety of proteins in the body, including factors involved in blood clotting, calcium transport, insulin regulation, fat deposition, cell proliferation, and DNA transcription. Vitamin K comes in many different forms, traditionally divided into two groups. Vitamin K1, aka phylloquinone, is the most common form of vitamin K. It’s found in plants, notably leafy greens like kale, spinach, turnip greens, collards, Swiss chard, mustard greens, parsley, romaine, and green leaf lettuce. Vitamin K2, aka menaquinone, is mainly found in fermented foods like natto, miso, and sauerkraut. Because K2 is found in so few foods, it’s most commonly found in supplement form. K2 is D3’s BFF. They work synergistically, so current prevailing wisdom says you should take them together. While vitamin D3 improves your calcium absorption, vitamin K2 allocates where that calcium can be used. It’s responsible for depositing the calcium at the right places in the body, like in the bones and teeth. It also prevents calcification, the accumulation of calcium in places where it is not required, like in the arteries and other soft tissues of the body. You definitely don’t want it there. Also, vitamin D needs calcium for metabolism, and when you aren’t getting enough calcium from your diet or from supplementation, vitamin D may pull the calcium it needs from your bones. That’s clearly not the best thing. Taking vitamin D stimulates the body to produce more of the vitamin K2-dependent proteins that transport calcium. These proteins have many health benefits, but can’t be activated if insufficient vitamin K2 is available, so anyone who’s taking vitamin D needs more vitamin K2. Deficiencies in both are extremely common, and more and more people are taking both D3 and K2 together as a daily dietary supplement. This raises the question of how they’re best combined. The current dietary guidelines don’t distinguish between vitamin K1 and K2. There are many D3-K2 combination supplements widely available. If for some reason you choose to take K2 but not D3, 45mcg of vitamin K2 a day is generally enough for healthy people under the age of 50, but again, this recommendation only applies if there is no additional vitamin D3 intake from dietary supplements. If you do take a D3 supplement, the recommended dosage is increased to 100mcg – 200mcg vitamin K2 per day. The higher dosage of 200mcg is recommended for people who have a history of cardiovascular disease or osteoporosis in their families. I recommend the combination product to my patients, as long as it’s not contraindicated. Please note: vitamin K helps your blood clot, so if you are taking anticoagulant medication like coumadin to prevent blood clots, please consult your doctor before taking it. Generally speaking, if you do take an anticoagulant, 45 mcg vitamin K2 per day is a safe dose, but talk to the physician who prescribes the anticoagulant first. 

So that’s the deal on vitamin D. The moral of the story is that the vitamin that’s not a vitamin is very busy in the body… it’s not just about the bones anymore. Having adequate levels of it may mean the difference between developing a debilitating disease one day and avoiding one, so make sure you get enough. Check your levels, and consider a supplement if you need it. And don’t forget its best friend K2. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

The Deal on Vitamin D

The Deal on D

Hello, people! Last week, we finished our series on personality disorders. Now that everyone has “properly diagnosed” their coworkers, friends, neighbors, and family, we’ll be having a quickie two part piece on vitamin D before starting a new series. 

Chances are, your parental units always told you “Drink your milk!” Why? Because it contains vitamin D, which is essential, along with calcium, to maintain healthy bones and teeth, just like they said… but vitamin D does a whole lot more than that. More on that in a few. First, let’s talk about what it is. 

Adolf Windausin was awarded the Nobel Prize in 1928 for his role in the discovery of vitamin D. Everyone thank Adolf… Thanks for that Adolf, good job! But despite its name, vitamin D isn’t actually a vitamin, it’s really a neuroactive steroid. It’s a hormone, just like testosterone, estrogen, corticosteroids, and our thyroid hormone friends we talked about in a series several weeks ago. Vitamin D is required to absorb and metabolize calcium, but it’s about more than just bones and teeth. Almost every cell in your body has a receptor for vitamin D, and it’s essential to many processes. Vitamin D is a transcriptional regulator for a large number of genes important for brain function, meaning it influences their expression, and is required for normal brain development. It’s involved in homeostasis, and it regulates melatonin production, the hormone involved in the human circadian rhythm and sleep patterns. It supports good lung function and cardiovascular health, and is involved in regulating insulin levels. And it happens to be responsible for stimulation of the most important antioxidant in the brain, the neuroprotectant glutathione, or GSH. Antioxidants like GSH help to counteract free radicals, the nasties that contribute to aging and some diseases, possibly even cancer. As it increases GSH production, vitamin D helps protect the body from their damaging effects.

Generally speaking, vitamins are nutrients that the body cannot create on its own, so a person must consume them in their diet, or boost intake through supplements. However, vitamin D is a little unusual, in that the body can produce it as a response to sun exposure… as long as you’re not wearing sunscreen or are covered by clothing head to toe, mind you. Sensible sun exposure on bare skin for 5 to 10 minutes, two or three times per week, allows most healthy people to produce sufficient amounts of vitamin D. Even though it’s easy to get a dose of D, many healthy people are D-ficient ha ha. Depending on the reference, anywhere from between 42 and 64 percent of the American adult population has low levels, but hypovitaminosis D has been shown to be even more common among older adults, with some references indicating it affects up to 90 percent of the elderly population. Deficiency is fairly common across the board, but is of special concern in pregnant women, as the fetus relies completely on maternal stores. More on the potential effects during pregnancy will be discussed in a moment. Studies have demonstrated that deficiencies play a role in a wide range of diseases and disorders, including autoimmune/ inflammatory, cardiovascular, neuropsychiatric, and more. Supplemental vitamin D has been shown to be beneficial as part of a treatment regimen for some of these conditions. On that note, I should mention that two forms of vitamin D exist, D2 and D3. D3, or cholecalciferol, is the more powerful of the two types, and this is the supplemental form that’s naturally present in the human body.

Where and How Much?

Getting sufficient sunlight is the best way to help the body produce enough vitamin D. Otherwise, it’s always best to get nutrients from natural dietary sources, but good D3 supplements are inexpensive, and that may be the way to go if levels are low. Plentiful food sources of vitamin D include fatty fish, such as salmon, mackerel, and tuna; egg yolks, cheese, beef liver, mushrooms, fortified milk, and fortified cereals and juices. How much vitamin D you need depends on many factors, including age, ethnicity, latitude, season, and amount of sun exposure. Dosage is measured in micrograms (mcg) or international units (IU). One microgram of vitamin D is equal to 40 IU. The National Institutes of Health (NIH) recommends an average daily intake of 400 – 800 IU, or 10 – 20 micrograms, but some studies indicate that the daily intake needs to be higher if you’re a couch potato, aren’t exposed to the sun, or have darker skin tones. Please note that everyone processes and absorbs substances differently, and your levels can be checked in an annual physical, or sooner if you suspect you’re low. Home test kits are undoubtedly available on the interwebs. Don’t forget the kids when it comes to supplements. Children younger than 12 months old need 400 IU each day, while children 12 to 24 months old need 600 IU. Drops are available for ease of dosing.

Depending on who you ask, blood levels above 20 ng/ml or 30 ng/ml are considered as “sufficient.” One study of healthy adults showed that a daily intake of 1,120 – 1,680 IU was needed to maintain sufficient blood levels, but the same study showed that deficient individuals needed 5,000 IU each day to reach the same level. It’s all relative, people. Studies in postmenopausal women with vitamin D levels below 20 ng/ml found that ingesting 800 – 2,000 IU raised blood levels above 20 ng/ml. However, proportionally higher doses were needed to reach the 30 ng/ml level. People who are overweight or have obesity may also require higher amounts. All things considered, a daily vitamin D intake of 1,000 – 4,000 IU, or 25 – 100 micrograms, should be enough to ensure optimal blood levels in most people. 

For people with vitamin D deficiency, it may be appropriate to use up to 50,000 IUs weekly for up to three months, or until levels become normal, and then switch to a maintenance dose, usually between 2,000 and 5,000 IU daily. But Captain Obvious says that needs to be documented and handled by a physician. If you don’t have a deficiency and you take that much, you might be sorry. According to the NIH, the safe upper limit is 4,000 IU. Make sure not to take more than that without consulting with a healthcare professional. Excessive consumption of vitamin D supplements can lead to over calcification of bones, and the hardening of blood vessels, as well as kidney, lung, and heart tissues. The most common symptoms of excessive vitamin D include headache and nausea, but it can also cause loss of appetite, dry mouth, a metallic taste, constipation, and diarrhea. 

D-ficiency

Although the body can create vitamin D, a deficiency can occur for many reasons. Darker skin, sunscreen use, and the time of year reduce the body’s ability to absorb the ultraviolet radiation B (UVB) rays from the sun, and this is critical to produce vitamin D. Deficiency during pregnancy is especially concerning, as it may lead to a greater risk of mom developing gestational diabetes, preeclampsia, and having preterm birth. 

Recent evidence in clinical literature suggests that the development of autism spectrum disorders may be attributable to maternal vitamin D deficiency. In addition, vitamin D is a critical contributor to immune function during pregnancy, and the placenta contains the considerable amount necessary for fetal development. Vitamin D deficiency can also increase risks of inflammatory and infectious diseases given its role in innate and autoimmunity. There are receptors for vitamin D throughout the entire central nervous system and in the hippocampus of the brain. It activates and deactivates enzymes that are involved in neurotransmitter synthesis and nerve growth. Studies suggest it protects neurons and reduces inflammation, and deficiency is associated with several medical conditions, including Alzheimer’s disease, dementia, Parkinson’s disease, autism, OCD, sleep impairment, infectious/ inflammatory diseases, and autoimmune disorders such as diabetes and rheumatoid arthritis. Symptoms of vitamin D deficiency may include regular sickness or infection, fatigue, bone and back pain, low mood, impaired wound healing, hair loss, and muscle pain. If vitamin D deficiency continues for long periods of time, it may result in serious illness, including cardiovascular conditions, autoimmune problems, neurological diseases, infections, pregnancy complications, and certain cancers, especially breast, prostate, and colon.

Illnesses Linked to D-ficiency

Skeletal/ Bone Health Issues

Vitamin D deficiency in children can cause rickets, a disease which leads to a severely bowlegged appearance due to the softening of the bones. In adults, vitamin D deficiency manifests as osteomalacia, or softening of the bones, a condition that results in poor bone density and muscular weakness. One of vitamin D’s primary roles is to maintain skeletal health through a synergy with calcium, and low levels of vitamin D decrease calcium absorption, lead to low bone calcium stores, and increase the risk of fractures. Ultimately, vitamin D deficiency can lead to osteoporosis, which over 53 million people in the United States either seek treatment or face an increased risk for. Osteoporosis occurs when new bone doesn’t generate at the same pace as the loss of old bone, it’s lost faster than it can be replaced. Bones then become brittle and more prone to fracture.

Neuropsychiatric Disorders 

Over the past several years, vitamin D deficiency has been associated with an increased risk of brain-related disorders. Vitamin D alters cholinergic, dopaminergic, and noradrenergic neurotransmitters systems, and abnormalities in these neurotransmitters have been implicated in various neuropsychiatric diseases. These include schizophrenia, autism, depression, Parkinson’s disease, dementia/ Alzheimer’s disease, and, most compellingly, multiple sclerosis, MS. As I mentioned in the intro, depending on what reference you believe, a large percentage of people fall short of the 30 ng/mL sufficient threshold of vitamin D, but these numbers skyrocket among people with brain disorders. An estimated 80 percent of people with multiple sclerosis (MS) and 90 percent of people with dementia have vitamin D levels of less than 20 ng/mL. Researchers suspect that people with Parkinson’s or Alzheimer’s disease and the elderly are similarly deficient. Why are the aged so deficient? Aging reduces skin thickness, which inhibits the body’s ability to make vitamin D from sun exposure. When this is coupled with reduced dietary intake of vitamin D and the impaired intestinal absorption that also accompanies aging, deficiency is almost inevitable. More research is needed to elucidate the mechanisms involved, the how and why. Unfortunately, a simple vitamin D supplement isn’t the answer to these neurodegenerative diseases. Someday we’ll get it figured out. 

Next week, I’ll continue with illnesses of D-ficiency. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Personality disorders Cluster C

Hello people, welcome back to the blog! Last week, we finished with the Cluster B personality disorders, borderline, histrionic, and narcissistic personality disorders. This week, we’ll complete the entire series with the Cluster C “anxious and fearful” disorders: avoidant personality disorder, dependent personality disorder and obsessive compulsive personality disorder, not to be confused with obsessive compulsive disorder OCD. 

Avoidant Personality Disorder

AvPD or APD is characterized by extreme shyness, feelings of inadequacy, and extreme sensitivity to criticism. The key word here is avoid. People with AvPD are often unwilling to get involved with other people unless they’re certain they’ll be liked, otherwise, they’re not going to take the chance of being rejected. They’ll sooner avoid all social interaction than risk being ridiculed, humiliated, or disliked. They’re constantly preoccupied with how they’re being perceived, are hypervigilant of criticism, and may view themselves as not being good enough or socially inept. They typically avoid new activities or meeting strangers like the plague. For many of them, just the thought of something as simple as asking a stranger for the time is inconceivable. As a result of these constant fears, they’re extremely restrained, even in their intimate relationships. They can appear very socially awkward, not only due to lack of experience, but also because they tend to excessively monitor internal reactions, their own and everyone else’s, and this keeps them from engaging naturally in social situations. As with many personality disorders, a vicious cycle can take over in which the more they monitor their internal reactions, the more inept they feel; and the more inept they feel, the more they monitor their internal reactions.

Signs and symptoms of AvPD may include:

-Anhedonia, lack of pleasure in activities

-Self-isolation

-Severe anxiety in social situations

-Avoiding conflict, being a “people-pleaser”

-Avoidance of social interaction despite a strong desire for intimacy

-Avoiding interaction in work settings or turning down promotions

-Avoiding making decisions

-Avoiding situations due to fear of rejection

-Easily hurt by criticism or disapproval

-Extreme self-consciousness, lack of assertiveness

-Fearful and tense demeanor, lack of trust in others

-Constant worry about being ridiculed, shamed, or ‘found out’ and rejected

-Feeling inadequate, inferior, or unattractive

-Misinterpreting neutral situations as negative

-No close friends/lacking a social network

-Unwilling to take risks or try new things

AvPD affects about 2.5 percent of the population, with roughly equal numbers of men and women being afflicted. As you can probably guess, AvPD is strongly associated with anxiety disorders, especially social anxiety, and can be associated with actual or felt rejection by parents or peers in childhood. In fact, childhood emotional neglect and peer group rejection are risk factors for development of AvPD, but it can occur without any notable abuse or neglect history. Generally speaking, people with the diagnosis are typically very shy as children, but Captain Obvious says that not every child who is shy goes on to develop the disorder, and not every adult who is shy has it. We all have people, places, and things we don’t like, or which make us anxious, that we’d like to avoid. The difference lies in how the person experiences them. With AvPD, even just the fear of rejection or disapproval can be an extremely painful experience, and this makes them struggle to maintain relationships in their personal and professional lives.  

Dependent Personality Disorder

DPD is characterized by an inability to be alone. People with DPD rely on other people for comfort, reassurance, advice, and support regarding all areas of their lives. They develop symptoms of anxiety when they’re lacking these outside sources of guidance. They fear separation, and are most often described as clingy or needy. They are submissive and passive by nature, and allow others to direct their lives because they are unable to do so themselves. They tend to be indecisive and unable to take the initiative, allowing other people such as spouses or parents to make all the major life decisions, including where to live, what type of career to pursue, and where to work. They have difficulty initiating projects or doing things on their own due to a lack of self-confidence in judgment or abilities, as opposed to a lack of motivation or energy. Because of their reliance on others, they may not learn the skills of independent living, and this perpetuates their dependency. Being often preoccupied with the thought of being left to fend for themselves, if they ever do disagree with any decision made for them, they would rarely express it; they would simply adjust their opinion to match that of their champion for fear of abandonment. In fact, the idea of being alone may cause such discomfort that some will go to considerable lengths to secure and maintain relationships. As you can imagine, this can be a big problem if they get roped in with an individual who doesn’t have their best interests in mind. This can be a very dangerous and destructive situation, especially when they believe that they are under the protection of someone who they idealize as competent and powerful, someone who’s their hero champion, and towards whom they behave in a self-effacing and ingratiating manner. People with DPD often end up with people with a cluster B personality disorder, as the latter feed on the unconditional regard in which the former holds them. I’ve had many patients that have coupled up in this manner, and it can be an unholy nightmare to untangle. Generally speaking, people with DPD maintain a naïve perspective, and have limited insight into themselves, and certainly even less into others. This entrenches and perpetuates their dependency, leaving them vulnerable to abuse and exploitation.

Signs and symptoms of DPD may include:

-Difficulty making everyday decisions

-Requiring others to assume responsibility for most major areas of his or her life

-True fear of having to provide self-care or fend for themselves if left alone

-Submissive or clingy behavior

-Tendency for naiveté

-Lack of self-confidence, requiring excessive advice and reassurance from others 

-Instinctively agree with others for fear of disapproval

-Going to excessive lengths to obtain support from others, even if it includes unpleasant tasks

-Tolerance of poor or abusive treatment, even when other options are available

-Feeling uncomfortable, anxious, bored, or helpless when alone

-Difficulty doing projects due to lack of confidence in abilities

-Urgent need to start a new relationship when a close one has ended

People with DPD normally first show signs in early to mid-adulthood, and males and females are generally equally diagnosed. True DPD is somewhat rare, with an estimated prevalence ranging from 0.49 to 0.6 percent. People with DPD are very prone to separation anxiety, and can become devastated when relationships and friendships are severed. When alone, a person with DPD may experience severe anxiety, panic attacks, and hopeless despondence. Clearly, some of these symptoms are the same for people with anxiety disorders, but people with medical conditions such as depression or even menopause may also experience some of these symptoms. Some factors that might contribute to the development of this disorder include having a history of a neglectful or an abusive upbringing, having overprotective or authoritarian parents, and

having a family history of anxiety disorders.

In addition, having a diagnosis of separation anxiety disorder or a history of chronic illness during childhood can increase the risk of developing DPD. Most people deal with feelings of insecurity at some point in their lives. It’s natural and perfectly normal to need other people to care for us or give us reassurance at times. The difference is that people with DPD require reassurance from others to simply function in their daily lives. A healthy balance involves being able to both depend on others as well as being independent enough to fend for oneself.

Obsessive Compulsive Personality Disorder

Aka Anankastic Personality Disorder

OCPD is characterized by a preoccupation with orderliness, perfectionism, and mental and interpersonal control, even at the expense of efficiency. People with OCPD have an obsessive need to follow rules and regulations, and they have a strict moral and ethical code from which they will not deviate… they’re always right. They often have such a level of perfectionism that they cannot finish tasks because they become too fixated on the details. They generally have an unwillingness to delegate or share tasks, unless the person they’re working with agrees to perform them exactly as they ask. They may be so preoccupied with details and order that the major point of the activity is lost. The rigidity that accompanies having OCPD often interferes with the person’s ability to relate to others and vice versa. While they can often improve their quality of life if they seek treatment, they rarely perceive that there’s a problem, so the condition tends to go untreated. As you can imagine, people with OCPD can be extremely difficult to work with or have a relationship with because they typically only see things their way. They believe that their approaches are the best way, and usually cannot understand another person’s point of view. They are often excessively devoted to work and productivity, to the exclusion of leisure activities and friendships. They generally have a miserly spending style toward both themself and others; money is something to be hoarded for future catastrophes. They are often unable to discard worn-out or worthless objects, even when they have no sentimental value. OCPD should not be confused with OCD, obsessive compulsive disorder. While some mannerisms and compulsions are similar, there is a BIG difference: people with OCD are aware that their compulsions are illogical, while people with OCPD are not. In fact, in their way of thinking, their thinking is logical, and if other people followed their rules, everything in their life would be fine. Just ask them, they’ll tell you… sometimes you don’t even have to ask! The problem comes in especially when rules and procedures don’t dictate the correct answer; decision making can become a painful, time-consuming process. In this case, the person with OCPD may have such difficulty deciding which tasks take priority or what’s the best way of doing a certain task, that they may never get started on anything, let alone finish. They’re prone to anger in situations in which they’re unable to maintain control of their physical environment, although they don’t typically express it directly. They’ll often find a more passive aggressive way to express it; for example, leaving a poor tip at a restaurant instead of speaking to management. When anger is expressed, it’s usually done with righteous indignation, often over a seemingly minor matter.

Signs and symptoms of OCPD may include:

-Overwhelming need for order and perfection, such that it interferes with task completion 

-Fixation on organization, detailed schedules, list making 

-An overwhelming need to be punctual

-Strict personal moral and ethical codes

-Excessive devotion to work at the expense of family or social relationships

-Often seen as ungenerous or frugal

-Display hoarding behaviors, such as refusing to throw things away

-Significant rigidity and stubbornness

-Inability to share or delegate work due to fear it won’t be done right

-Often feel righteous, indignant, and angry

-Socially isolated

-Stiff, formal, or rigid mannerisms

In relationships, people with OCPD are very aware of their relative status, and they tend to display excessive deference to an authority they respect, and excessive resistance to an authority they don’t. When they express affection, it’s done in a very controlled manner, and they’re very uncomfortable when they’re around other people who are emotionally expressive. Their everyday relationships have a formal quality to them, and they’re usually very stiff in situations where most others are smiling and happy. They’re often so preoccupied with logic and intellect, they tend to carefully hold themselves back in conversations until they’re sure that whatever they say will be the perfect thing. 

As with most personality disorders, the intensity of OCPD symptoms will decrease with age, and the most extreme symptoms have usually nearly ceased by the time the majority of people are in their 40s or 50s. OCPD is approximately twice as prevalent in males than females, and occurs in between 2.1 and 7.9 percent of the general population, making it the most prevalent personality disorder. A childhood with very controlling or protective parents or caregivers, or one in which they were often unavailable, may increase the risk of developing OCPD. But Captain Obvious says a person may have OCPD without any of the above factors as causes. In some case studies, adults can recall experiencing OCPD from a very early age. They may have felt that they needed to be a perfect or perfectly obedient child. This need to be good and follow the rules then carries over into adulthood. People with OCPD often experience anxiety that occurs with depression; and OCPD is generally seen as a coping mechanism, a way for the person to establish order in their lives and deal with their feelings. People experiencing OCPD often don’t recognize that their behavior is problematic, so they generally take some convincing before they agree to seek treatment. This can be very overwhelming to family members, especially if they’re dealing with constant criticism. The good news is that with time and treatment, many people with OCPD can find the motivation to change.

Personality Disorder not otherwise specified 

Each person is an individual and behaves in unique ways, so not everyone fits neatly into the personality disorders I’ve discussed. If a person doesn’t have enough symptoms to fully meet the criteria of a specific type, PD-NOS is the diagnosis used in this case. This may also be known as personality disorder trait specified PD-TS. These names can sound like opposites, but they both focus on the fact that the person has some personality disorder traits, but not enough of one specific type to fit in the box.

And as for personality disorders, in the words of Porky Pig… that’s all folks! 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Personality Disorders

Personality Disorders

Hello people, I hope everyone had a great holiday weekend! Did everyone set off a bunch of fireworks? Did you grill some burgers or dogs, have some baked beans, and a scoop of potato salad? Top it off with some apple pie? Me neither. Can I just ask, why do people shoot off fireworks on Saturday day, like before the sun sets? Are they testing them to see if they’re loud enough? Just wondering. Maybe they can’t wait. Anyhoo, last week, we talked about Antisocial Personality Disorder, the first Cluster B personality disorder, the dramatic and erratic disorders. If you recall, ASPD is the official diagnostic term for the colloquial terms sociopathy and psychopathy. That’s the big takeaway. So this week, we’ll be continuing with the Cluster B’s with Borderline Personality Disorder. 

Borderline Personality Disorder

BPD is also sometimes called Emotionally Unstable Personality Disorder, or EUPD, but I prefer Borderline. It always reminds me of that 80’s song. BPD is the most commonly diagnosed personality disorder, and was so called, because it was thought to lie on the “borderline” between neurotic disorders (meaning anxiety disorders) and psychotic disorders, such as schizophrenia and bipolar disorder. BPD is characterized by difficulties in regulating emotion. People with BPD experience big mood swings, and they feel a great sense of instability and insecurity. They feel emotions very intensely, often for extended periods of time, and it’s generally harder for them to return to a stable baseline after an emotionally triggering event. This difficulty can lead to impulsivity, poor self-image, and intense emotional responses to stressors. Struggling with self regulation and having a poor self-image essentially equates to a lack of a sense of self, and as a result, they often experience feelings of emptiness and extreme fears of abandonment, whether these are real or just perceived. They generally have a pattern of instability in their relationships, and there can be violence involved, especially in response to criticism. These unstable personal relationships often involve “splitting,” where the person alternates between idealization “I’m so in love!” and devaluation “I hate him!” Suicidal threats and acts of self-harm are common, and this is how and why many people with BPD frequently come to medical attention. Extreme stress responses can lead to dissociative feelings, meaning they feel disconnected from their thoughts or themselves, have “out of body” type feelings, potentially even psychotic episodes. They basically check out, and may not remember these events well afterwards. 

BPD signs and symptoms may include:

-Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, reckless driving, gambling, overuse of substances, and binge eating

-Distorted and unstable self-image affecting moods, values, opinions, goals, and relationships

-Wide mood swings, often as a reaction to interpersonal stress

-Unstable and intense relationships

-Suicidal behavior or threats of self-injury

-Intense fear of being alone or abandoned, may be real or imagined

-Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days

-Ongoing feelings of emptiness

-Frequent, intense displays of anger, often followed by shame and guilt

-Stress-related paranoia that comes and goes; when stress is severe, it can lead to brief psychotic episodes

It has been suggested that BPD often results from childhood sexual abuse, and that it is more common in women, in part because women are more likely to suffer sexual abuse. However, some argue that BPD is more common in women simply because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behaviors tend instead to be labeled with ASPD, Antisocial PD. More recent research seems to back this up. Women are more likely to receive the diagnosis, because it is commonly thought of as a “female” disorder, even though there’s no such thing. In fact, of the estimated 1.4 percent of the adult U.S. population with BPD, nearly 75 percent of them are women.

Histrionic Personality Disorder

HPD is characterized by a pattern of excessive emotion and attention seeking. People with HPD generally like to be the center of attention at all times, and may actually be uncomfortable when they’re not. They often use physical appearance to draw attention to themselves, are often flirtatious, and can employ exaggerated or rapidly shifting emotions as a means to reach this goal. The surprise is that they usually lack a sense of self-worth, and they depend on attracting this attention to seek the approval of others in order to boost their wellbeing. They often seem to be dramatizing or playing a part in a bid to be seen and heard. The word “histrionic” is derived from the Latin histrionicus, meaning “pertaining to the actor.” People with HPD may take great care of their appearance, and behave in a manner that is overly charming or inappropriately seductive. Because they crave excitement, they tend to act on impulse and are easily suggestible, and they may place themselves at risk of an accident, or fall prey to exploitation. Their dealings with others often seem insincere or superficial, and in the long term, this can adversely impact their social and romantic relationships. They find this to be especially distressing, as they are very sensitive to criticism and rejection, and they react very poorly to loss or failure. It can result in a vicious cycle in which the more rejected they feel, the more histrionic they become, and the more histrionic they become, the more rejected they feel. Achieving any emotional or sexual intimacy may be difficult, and they may play a victim role, potentially without being aware of it. They may also try to control their partner using seduction or emotional manipulation, while becoming very dependent on them. They tend to be too trusting, especially of authority figures who they think may be able to solve all their problems. They often think relationships are closer and more intimate than they really are. They crave novelty and tend to bore easily, so they may change jobs and friends frequently. Delayed gratification is very frustrating to them, so their actions are often motivated by obtaining immediate satisfaction. 

HPD signs and symptoms may include:

-Constantly seeking attention

-Into instant gratification

-Excessively emotional, dramatic, or sexually provocative to gain attention

-Excessive concern with physical appearance

-Speaks dramatically with strong opinions, but few facts or details to back them up

-Makes rash decisions

-Easily influenced by others

-Shallow, rapidly changing emotions

-Believes relationships with others are closer than they really are

-Gullible and easily influenced by others

-Excessively sensitive to criticism or disapproval

-Low tolerance for frustration, easily bored by routine, often beginning projects without finishing them or skipping from one event to another

-Self-centered, rarely showing concern for others

-Good social skills, but use them to manipulate others, to be the center of attention

The estimated prevalence of HPD is less than 2 percent of the general population. It is usually evident by early adulthood, and is diagnosed more often in women than in men, but this may simply reflect the higher prevalence of women in clinical settings. There is a clear tendency for HPD to run in families, which suggests a genetic susceptibility, but the child of a parent with the disorder might simply be repeating learned behavior. Other environmental factors that might be involved include a lack of criticism or punishment as a child, and unpredictable attention given to a child by his or her parent(s), which tends to lead to confusion about what types of behavior earn parental approval.

Narcissistic Personality Disorder

NPD is characterized by an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. The person is envious of others, and expects them to be the same of him. They typically lack empathy, and readily lie, exploit, or take advantage of others to achieve aims. To others, they may seem self-absorbed, controlling, intolerant, selfish, and/ or insensitive. If they feel ridiculed or obstructed, they can become very angry and even vengeful. Fueled by a belief that they’re special, and more important than others, they can have a reaction called “narcissistic rage,” which can have disastrous consequences for all involved. It’s human nature to be aware of and express our own needs, as well as want others to be aware of our abilities and achievements. These aren’t bad things, but people with NPD take this to the extreme. At the heart of it, they have fragile self-esteem, so they rely on others to recognize their worth and their needs. They are generally unhappy and disappointed when they’re not given the praise or special favors they believe they deserve. This can cause problems in all areas of life, work

school, and relationships. People with NPD usually put themselves on a pedestal, where they can look down on others and direct them, as they believe they are better than. They exaggerate their own talents and accomplishments, while downplaying those of others. They are usually preoccupied by power, success, and beauty, and may engage in impulsive behaviors, such as risky sex and gambling, in their pursuits of these goals.

NPD signs and symptoms may include:

-Fantasies about power, success, and attractiveness

-Entitled, conceited, snobby

-Exaggeration of achievements or talents

-Expectation of constant praise and admiration

-Exaggeration of intimacy with others, especially those with wealth or VIP status

-React negatively to criticism

-Show great charm but quickly become irritated or angry

-Talking at length about their own concerns but lacking interest in those of others

-Show aggression when faced with a threat to their ego

-Resent the successes of other people

-Arrogant, dismissive, or unaware of other people’s needs

-Perceived superiority that covers a deep seated insecurity

-Unreasonable expectations of favors and advantages

-Envy of others accompanies belief that others envy them

-Unfulfilling relationships; become unhappy, angry, and confused when things don’t go their way

-Typically have ongoing issues with work, school, relationships, finances, alcohol, substances

Research indicates that NPD affects 6.2 percent of the U.S. population, and is much more common in men than women, affecting 7.7 percent of men and 4.7 percent of women. There may be cultural influences associated with NPD, but this may be a stereotype. Diagnosing NPD specifically can be challenging, as the features tend to have so much overlap with other disorders. In addition, a person with NPD may not recognize that problems in their life stem from their own behavior, and they may blame others instead. Narcissists can be especially difficult to deal with. I’ve done a lot of family counseling for it, but the person with the diagnosis must accept it to make headway. Some NPD traits may appear similar to confidence, but healthy confidence and NPD aren’t the same thing. People who have healthy self-esteem are usually humble, while people with NPD, by definition, never are. It takes a lot of work on the patient’s part to modify behavior, but it can be done with sufficient motivation.

That’s the end of Cluster B Personality Disorders. Next week, we’ll tackle Cluster C disorders. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Personality Disorders

Personality Disorders

Hello people, welcome back to the blog, people! I hope everyone had a fantastic father’s day. Last week, we started getting into the signs and symptoms of personality disorders. We talked about the Cluster A odd and eccentric disorders: paranoid, schizoid, and schizotypal personality disorders. This week, we’ll be getting into Cluster B disorders, the dramatic and erratic disorders. 

Cluster B disorders are characterized by overly emotional or unpredictable thinking or behavior, and include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. People with these disorders typically have difficulty regulating their emotions, as well as maintaining relationships, as others often see their behaviors as threatening or disturbing. Treating any personality disorder is challenging, but Cluster B has some of the most difficult to treat disorders for a variety of reasons, not the least of which is the stigma associated with the diagnosis. Another factor has to do with the affected person’s propensity to give an inaccurate account of signs and symptoms. These can be especially true for antisocial personality disorder or ASPD.

Antisocial personality disorder is characterized by a pervasive pattern of disregard for the rights of others. People with this disorder consistently show no regard for right and wrong, and ignore the feelings of the other people around them. This generally begins in childhood or early adolescence and continues into adulthood. After treating many people with ASPD, I can tell you that they can be the most charming, entertaining, witty, and fun to be around people you’ll ever meet. But in severe cases, they can live to exploit others in something akin to sport. ASPD makes people uncaring. They can act rashly, unsafely, and destructively, without an ounce of guilt when their actions hurt other people. That may even be the goal. They tend to be callous, cynical, and contemptuous of the feelings of others. They can be very manipulative, and due to these tendencies, it’s often difficult to tell whether they’re lying or telling the truth.

Speaking of, let me correct a myth. Two common terms affiliated with ASPD are psychopath and sociopath, but these terms are not interchangeable. Neither psychopath or sociopath are actual diagnoses in the world of psychiatry. They are colloquial terms to describe people with impulsive or reckless personalities who lack empathy for others. A psychopath is someone whose actions more tend to reflect calculation, manipulation, and cunning. They are deceptively charismatic and charming, and tend to mimic rather than experience emotions. They can do so with ease, as this is their stock in trade. By contrast, sociopaths are more able to form attachments to others, but they still tend to act insensitively, or in an unfeeling manner, and generally disregard social rules. They are also more easily agitated, and have a tendency to be more impulsive. Psychopaths are usually thought of as more deviant and violent, and less likely to blend into society than sociopaths. Everyone has their own definitions of the words psycopathy and sociopathy, and they probably come from movies and television. In reality, in the world of psychiatry, both carry a diagnosis of ASPD, and psycopathy is just a very severe form of ASPD. These are the individuals I was referring to that can be the most charming. Believe me, they make it easy to want to lower your guard, but with some, you may do so at your peril. 

ASPD signs and symptoms may include:

-Disregard for right and wrong

-Persistent lying or deceit to exploit others

-Callous, cynical, and disrespectful of others

-Criminal behavior

-Applying charm or wit to manipulate others for personal pleasure

-Arrogance, a sense of superiority, extremely opinionated

-Lack of compassion and empathy for others

-Unremorseful when confronted with wrongdoing

-Inability to admit mistakes

-Bullying demeanor, use threats to deal with personal conflict

-Impulsiveness or failure to plan ahead

-Unnecessary risk-taking or dangerous behavior 

-No regard for the safety of self or others

-Instability when it comes to work and home life

-Hostility, irritability, agitation, aggression, intimidation, violence

-Consistently irresponsible and repeatedly fail to fulfill work or financial obligations

-Mental health issues, may include talk of suicide or threatening suicide

ASPD affects approximately 2 to 4 percent of the population, often occurs alongside problems with drugs and alcohol, and is much more common in men. Some research has suggested when ASPD does develop in women, the condition may become more severe; and women with ASPD are even more likely to abuse substances than men. That said, research also indicates antisocial behavior may persist longer in men, and men with ASPD have an increased risk of early death. People with ASPD frequently fail to consider the negative consequences of their behavior, and they don’t generally learn from them either. In addition, they often violate the law, and behave violently or impulsively, becoming criminals. They are commonly unable to fulfill daily responsibilities related to family, school, or work. For all of these reasons, the highest prevalence of ASPD- 70 percent- is found among males who are in jails, prisons, or similar institutions. 

The risk factors associated with ASPD have been better studied than some of the other personality disorders. The genetic component applies, especially family history of ASPD or another personality disorder. But of note, adults with ASPD typically show symptoms of another disorder in childhood called conduct disorder, before the age of 15. Signs and symptoms of conduct disorder include serious, persistent behavioral problems, such as aggression toward people and animals, serious violation of rules, destruction of property, lying, cheating, and theft. Although ASPD is considered lifelong, in some people, there are certain symptoms- especially destructive and/ or criminal behavior- that may decrease over time. It’s not very clear on whether this is due to aging, or an increased awareness of the consequences of their behavior. Speaking of, some of the complications associated with ASPD can include homicidal or suicidal behaviors, low social and economic status, homelessness, and premature death, usually as a result of violence. Behaviors have consequences, that’s the lesson many people with ASPD fail to learn. 

Like anything else, symptoms occur on a spectrum, and vary in severity. ASPD doesn’t have to mean a person is violent or evil. The stigma associated with personality disorders in general, and ASPD in particular, may make it even more difficult for people who want to improve to get the help they need. More than 90 percent of people diagnosed with ASPD also live with another mental health issue, most often depression and/ or anxiety. Early intervention may be the key to treatment, so the ability of caregivers and educators to spot childhood conduct disorder is important. Negative attitudes toward “delinquents” may reinforce ideas such as, “I’m bad,” “I’ll never amount to anything,” or “No one cares what happens to me,” and these play a role in the development of ASPD. 

When people with ASPD do enter treatment, it’s more often to get help for a co-occurring condition, or because a legal authority or family member has required to do so. Among those who do get help, many drop out of treatment early. Negative attitudes and ineffective treatment methods can contribute to this. It’s important for people with ASPD to work with therapists who are willing to try a range of approaches to find the most effective treatment. A key factor in successful therapy is recognizing individual fault. People with ASPD who can’t admit or accept that their actions are harmful may not be able to improve. Exploring state of mind, including emotions, desires, and feelings toward others is critical for progress. Once the person better understands their thoughts, they can use this understanding to address their impulses, and potentially help control them. Research has shown treatment can help improve many of the behaviors associated with ASPD, with the strict caveat that the person is willing to work toward change. When successful, treatment not only improves the quality of life for the person with ASPD, it also has a positive impact on the people in their lives. 

Next week, we’ll continue with cluster B disorders, starting with borderline 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

Learn More

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

Learn More

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

Learn More

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

Learn More

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

Learn More

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

Learn More

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

Learn More

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

Learn More