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!
Hello people! Last week was a light one on dark chocolate (ha ha?) but as promised, today marks the start of a new series on thyroid disease. If you’re wondering why I, a shrink, would care about the thyroid, the answer’s simple: because when it’s a problem, it’s a real problem, because it can affect nearly every aspect of your life, including your mental health. But when it comes to the thyroid, you’re about to find out that that’s where the simplicity ends.
Before we can talk about how the thyroid can affect you, first we have to talk about what it is. The thyroid is a butterfly-shaped endocrine gland that’s found in the forward aspect of the middle of the neck, just below the larynx, or voice box. Its two lobes, left and right, lie on either side of the windpipe, and are each about the size of a halved plum. These lobes are analagous to the wings of the butterfly, and they are joined by a small bridge of thyroid tissue called the isthmus.
Notice I said it was an endocrine gland? The endocrine system is made up of glands that make hormones, which are the body’s chemical messengers- they carry information and instructions from one set of cells, glands, and organs to others. In doing so, the endocrine system influences almost every cell, gland, organ, and function of the body. That’s what makes the thyroid so important- because it’s a big part of the endocrine system, along with the other major glands, including the hypothalamus, pituitary, parathyroid, adrenal, pineal, and the ovaries and testes.
The hormones made by the various glands of the endocrine system are released into the bloodstream, and they travel to cells in other glands and organs where they help control organ function, mood, growth and development, metabolism, and reproduction. The amounts of hormones produced and released is highly regulated, and depends on levels of other hormones already in the blood, other minerals like calcium in the blood, the blance of water and other fluids in the body, and external factors such as stress and infection, just to name a few. Because hormone production and levels are all interlinked- one dependent upon another- it’s important that these levels remain normal. Too much or too little of any one hormone affects production and release of multiple others, so it can affect several organ systems, and cause nearly endless physical and emotional symptoms. This can make you feel very ill, a little “off,” or anything in between.
The Pituitary Gland
Even though this series is on the thyroid, I can’t rightly talk about it, or the endocrine system, without mentioning the pituitary gland. The pituitary is a pea sized gland located at the base of the brain, but don’t let its size fool you, because mighty things can come in small packages. In fact, the pituitary is often called the “master gland,” because the hormones it makes control many of the other endocrine glands. The pituitary also happens to be one of my faves- and it should be one of yours too- because it secretes endorphins, the body’s natural feel good chemicals, the ones that act on the nervous system to produce feelings of pleasure and reduce feelings of pain.
The pituitary gland makes many other hormones, including growth hormone, which stimulates the growth of bone and other body tissues; prolactin, which activates milk production in breastfeeding women; corticotropin, which stimulates the adrenal gland; antidiuretic hormone, which helps control the balance of body water through its effect on the kidneys; and oxytocin, which triggers uterine contractions during labor. But the pituitary hormone that’s most germaine to today’s topic is thyrotropin, more commonly known as thyroid-stimulating hormone, or TSH. Once secreted by the pituitary, TSH, as its name suggests, stimulates the thyroid to synthesize and release thyroid hormones.
In response, the thyroid produces thyroxine and triiodothyronine, more commonly known as T3 and T4, respectively. These hormones control the rate at which cells burn fuels from food to make energy. They basically regulate the body’s metabolism- the rate at which the cells of the body use and store energy. I’ll get into that in a moment, but because they control such a basic function, you can clearly see that thyroid hormones are essential for all the cells in your body to work normally. If that weren’t enough, they also play a role in bone growth and development, as well as that of the brain and nervous system. Just to add another level of complexity, there are also four other tiny glands attached to the thyroid gland called the parathyroids. They release parathyroid hormone, which, along with help from another thyroid hormone called calcitonin, controls the level of calcium in the blood. And if you remember, calcium is one of those minerals in the blood that controls the production and release of other hormones. Yikes!
Believe it or not, this is as simplified as the endocrine system- and the thyroid- really gets, people, so if you’re thinking all of this is super complicated, you cannot even imagine if you just go by this! As a matter of fact, there’s an entire (underappreciated) specialty medical field devoted to this alone… so thank you endocrinologists!
Thyroid Function: Metabolism
As I mentioned before, thyroid hormones regulate the body’s metabolism. Many people think that just means how many calories you burn, but metabolism is a complicated process, one that’s happening 24/7, no matter what you’re doing. That’s even reflected in its literal meaning, which is “a state of change.” Your body relies on metabolism to carry out all of its functions, whether it’s storing or burning fat, regulating sugar levels, or keeping your neurons firing; so metabolism has a huge impact on your health. The three main purposes of metabolism are: the conversion of food to energy to run cellular processes, the conversion of food/ fuel to the body’s building blocks, and the elimination of metabolic wastes.
This intricate involvement with such an important, universal bodily process is why diseases of the thyroid have such an extreme and varied impact on human health. But (thankfully) all of it boils down to two basic conditions: having too much thyroid hormone results in a condition called hyperthyroidism, while having too little thyroid hormone is called hypothyroidism. Generally speaking, in hyperthyroidism, when there is too much thyroid hormone, your body processes speed up, and the body uses energy very quickly. And in hypothyroidism, when you don’t have enough thyroid hormone, your body processes slow down, and the body uses less energy.
That’s probably a good place to stop for this week. It’s been a while since I’ve had to write an endocrine overview, people! Next week, we’ll start getting into the meat and potatoes when it comes to thyroid imbalance- how it can affect you. Something to look forward to.
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!
We’ll be starting a new series next week, so this week I thought we’d just keep it light this week- have some fun. Believe it or not, this week’s topic, phenylethylamine, is a good time. Before I tell you why and how, let’s go over how to say it. Phenyl is pronounced just like the green herb fennel. Ethyl is exactly like it sounds- like Lucy’s sidekick. And amine is pronounced with a long a, like Canada, ehh… plus mean, as in “what do you meanphenylethylamine is a good time, Dr. A?” Fennel-Ethyl-ehh-mean. While it’s fun to say, science nerds, myself included, call it PEA to make life easier. I’m all about that, so that’s what I’ll be using hereafter.
So, what is PEA? It’s a naturally produced alkaloid, which is basically a biologically active chemical, with similar pharmacological properties to amphetamine. In the human brain, it functions as a neuromodulator, sort of an influencer of the happy hormones, the endorphins like dopamine and serotonin. While it’s produced naturally in the body, PEA is also found in nature, most notably in a particular strain of blue green algae called Aphanizomenon flos-aquae or AFA. It’s also found in many common foods, and can be easily synthesized in the lab as well.
There is evidence demonstrating PEA’s efficacy as an antidepressant and for ADHD, and it’s also responsible for the brain chemicals involved with “runner’s high” and even love and monogamy. In fact, PEA is commonly referred to as the “Love Molecule.”
That’s my best Barry White voice: luuuvvv mol-e-quuullle.
People who don’t make enough PEA naturally may be helped by taking it as a supplement. That’s where that blue green algae called AFA comes in- it’s loaded with PEA, and commonly taken as a supplemental source. In addition to helping stave off depression, and to improve mood and attention, some people also use PEA for athletic performance and weight loss, because it’s properties are so similar to amphetamine. But for that same reason, taking too much of it can induce side effects that are similar to amphetamine as well.
As I said, it’s found in many foods, but most popularly, it’s found in chocolate. Yum! It’s actually believed to be the component responsible for producing chocolate’s positive effects on mood. One UK study I read looked at over 13,000 people, and found that individuals who reported eating any dark chocolate within two 24-hour periods were 70 percent less likely to report “clinically-relevant depressive symptoms,” as compared to those who ate no chocolate at all. In other words, eating dark chocolate made them feel happier. This is not only because chocolate contains PEA, which induces those happy hormone endorphins, but also because chocolate contains a higher concentration of antioxidants that reduce inflammation, which is directly linked to the onset of depression.
There have been a number of studies that show other health benefits of dark chocolate. Daily consumption of dark chocolate can reduce LDL, the “bad cholesterol” levels we’ve all heard about. By doing so, dark chocolate can help reduce the risk of heart disease by as much as 30 percent. It’s also been shown to reduce the risk of dying from a stroke by nearly 50 percent. Studies even show that eating dark chocolate at least once per week can also improve cognitive functioning.
So is dark chocolate a superfood? Maybe so- especially when you consider that on top of all of the health benefits, it also acts like an aphrodisiac, because it stimulates the production of those endorphins, and they’re the chemicals in the brain that create feelings of pleasure. After all, PEA has earned its reputation as the luuuvvv mol-e-quuullle. But before you reach for a candy bar, there is a small catch- literally. All you need to produce those happy-happy effects is half an ounce of chocolate per day. There’s also a big catch- literally. If you’re watching your weight, even a small amount of chocolate has a big calorie impact. A half-ounce of dark chocolate typically contains between 70 and 80 calories, depending on the percentage of cacao solids- that’s pronounced like Batman’s ka-pow! That’s the paste that results from fermenting, roasting, and crushing the cocoa beans that make it. This cacao then gets mixed with milk and sugar, and tah-dah: chocolate!
Dark chocolate is called dark because it contains more cacoa and less milk and sugar than milk chocolate. While dark chocolate can contain as little as 45 to 50 percent cacao solids, research shows the greatest benefits come from dark chocolates that contain at least 60 percent cacao solids. Some dark chocolates contain as much as 85 percent cacao solids, so if you venture to the darker side, will that make you even happier? Well, that’s the last catch- but this one’s a good one. The evidence suggests that the mood benefits only happen if you enjoy the chocolate you eat. Since that suggests that the experience of eating the chocolate is also an important factor, it’s vital to choose what you like. But keep in mind that white “chocolate” doesn’t count, because it doesn’t contain any cacao solids- it’s not actually chocolate… wah wah wahhh.
The chemical ingredients in the chocolate clearly make an impact, but it’s very interesting to me that the taste matters as well- definitely indicative of a stronger correlation between dark chocolate and mood, so future studies may tell more of the tale. Until then, I’ll happily gather anecdotal evidence. But remember that second catch, people- the big one. If you like dark chocolate, a half-ounce clearly won’t kill you, but it might kill your diet- or at least inflict some damage.
Luckily, I have a simple solution. Enjoy your half-ounce, then take a fifteen or twenty minute walk, preferably with someone you like- a loved one or friend. That way, you’ll burn off the calories while strengthening your relationship, and you’ll be quadruple dipping on the benefits of eating chocolate: you’ll get the enjoyment of eating it, its mood lifting and cognitive benefits, its general health benefits, and all the benefits of exercise. Not to mention how all of those things work together synergistically, because walking positively impacts mood and cognitive ability as well, as does positive interaction with someone you care about.
It’s a win-win-win-win. And win.
Next week, I’m starting a new series on the thyroid. I’ll tell you all about how it impacts just about every aspect of your life, and maybe especially your mental state.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like and subscribe.
Please feel free to share the love- share my blogs and YouTube videos with family and friends!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.
As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.
They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.
To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.
Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.
Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary.
Signs and Symptoms
The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.
Physical Withdrawal Symptoms
As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.
Psychological Withdrawal Symptoms
Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.
Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.
Xanax Withdrawal Timeline
Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected.
Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.
Factors Affecting Withdrawal
Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present.
Coping with Xanax Withdrawal
The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax.
Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.
In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well.
Alleviating Symptoms of Withdrawal
An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.
Xanax Withdrawal Safety
Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death.
People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.
The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.
No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down.
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Alprazolam Use Disorder
Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right.
If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder.
Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction.
This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug.
Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:
-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.
-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.
-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.
-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.
-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.
-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it.
-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use.
-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.
-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.
-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.
As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.
Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:
-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.
-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.
-Continued Xanax use despite hazardous circumstances.
-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.
-Continued Xanax use despite experiencing one or more negative personal outcomes.
-Using more Xanax or using it for longer than recommended or intended.
-An inability to stop using Xanax despite an ongoing desire to do so.
-Obsessive craving for Xanax.
-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.
-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.
-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.
These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week.
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Counterfeit Drugs: Fake Xanax
For this week’s alprazolam blog, I want to know if I can fake you out. We’re going to talk about fake Xanax. Look at the picture above. Can you tell which Xanax are fake? Are you certain? Enough to roll the dice with your life on the pass line? Because, make no mistake- if you get your Xanax from anywhere other than a licensed pharmacy, you are absolutely, positively doing so every single time you take it. By the end of this blog, you’ll definitely know the answer to the first question. As to the second, I’d hope you already know the answer, because even Captain Obvious won’t bother with that one, people.
When you think of counterfeit drugs, you may not be too concerned if you consider them to be just weakened copycat versions of the real thing, made with a bunch of essentially harmless junk. Probably the worst that could happen is it won’t work, right? Wrong! Obviously, the main problem with counterfeit drugs in general is that they’re clearly illegal and therefore unregulated, so you don’t know what you’re getting. I mean, with counterfeit drugs, there’s no truth in advertising. And helll-ooo, they’re produced in somebody’s gnarly basement, so there sure as hell isn’t any quality control. While they can be cut with innocuous things like baking soda or baby powder, they can also be laced with extremely harmful substances, things like rat poison, bleach, and formaldehyde. Unfortunately, many drug users don’t know, or don’t care, how dangerous it is to ingest substances like these. But there are cases where counterfeit drugs are especially dangerous, and fake or counterfeit Xanax is at the top of that list. In late 2015, the entire country learned this lesson the hard way when in three months, there were nine documented cases where people in San Francisco suddenly overdosed from “Xanax.” To be clear, it wasn’t Xanax at all. That number included a baby, who had picked a tab of it up off the floor and put it in their mouth. It also included one person who didn’t even get to live to regret it. I think we got off pretty easily in that singular event, but obviously more have followed.
By the Numbers… Without Numbers (?)
Again, since production and sale of fake Xanax is illegal, underground, and unregulated, there aren’t national or global databases to collect information or statistics as there are with other drugs. But I found some reports from various global sources that were interesting. And by that I mean frightening. Some highlight snippets include a report citing that 25% of 2018 drug overdose deaths in Northern Ireland were caused by counterfeit Xanax. Another report from U.S. Customs and Border Protection stated that in the first four months of 2020, during unspecified smuggling attempts, their CBP officers seized 27 shipments of fake Xanax, totalling over 35 pounds. I also listened to part of a podcast on the subject that featured an officer from Portland, Oregon talking about a spate of teenage overdoses on fake Xanax, and the subsequent investigation. They apparently did a round up of all the street dealers they could find, and busted down doors and did everything they could to clean up the area. The goal was to get every Xanax pill off the street, and he stated that of all the “Xanax” pills they recovered, not a single one was legit. He didn’t say exactly how many that was, but it seemed like a lot. Every pill in the area was fake. That’s huge. And very scary.
Fake Xanax: Beyond the Obvious
“Good” counterfeit Xanax pills look exactly like the real thing. And clearly, by “good” I don’t mean that in the traditional sense. That means they have the same color, size, shape, and pharmaceutical markings, aka imprints, on the pills as the bonafide prescription versions do. While the difference isn’t obvious to the naked eye, there is one huge difference between real and fake Xanax that makes it especially scary: the latter usually contains fentanyl, an extremely potent opioid that is responsible for countless accidental overdoses in numerous counterfeit and legal preparations. In fact, it’s estimated that many thousands of U.S. citizens ingest a deadly dose of each year without ever even realizing it. How horribly tragic and senseless is that?
Fentanyl is a schedule II synthetic opioid that is 50 to 100 times stronger than heroin and morphine, respectively. It is typically prescribed by a specialized physician strictly for patients struggling with severe or chronic pain, and it is such a potent and dangerous drug that the DEA has advised officials to take extra protective precautions, like gloves, even just when handling it, to avoid accidental death. This is because it is easily absorbed through the skin, and takes so little to be lethal. While other opiate doses are measured in milligrams, fentanyl is dosed in micrograms, and an amount equal to two grains of salt is lethal to nearly all individuals. Clearly, a drug that is 100 times stronger than morphine is no joke, and it officially now kills more Americans annually than any drug in history.
People who take fentanyl accidentally will be unaware of what they have taken, or how much, so they face an even higher risk of an opioid overdose. In the case of fake Xanax exposure, if or when a person does overdose on it, in the unlikely event that they’re lucky enough to make it to a hospital, it presents a unique problem. As a physician, I can tell you that when a person’s symptoms present differently from what is expected, it delays treatment, and Xanax overdose and fentanyl overdose present very differently. So when it’s reported that a person took “Xanax,” or some pills are found on their person, but their symptoms don’t look like a benzodiazepine overdose, those few minutes a medic or doc takes to assess the situation may be the few that end up costing them their lives. But that can be the case fake percocet or oxycodone as well, because fentanyl is commonly used in producing counterfeit versions of all of those. Even cocaine- maybe especially so because of the cost differential- fentanyl is so much cheaper that it’s very commonly used to cut it. And talk about presenting differently: cocaine and fentanyl overdose are not even remotely similar to one another. Even if users are aware that fentanyl is in the product, and aren’t that concerned about it, there’s still no way to know how much fentanyl is in it, or exactly how potent that fentanyl is. As a result, it is extremely easy to overdose after consuming any counterfeit product.
Since the pills look exactly like the real thing, it’s nearly impossible to tell the difference. But, if someone consumes counterfeit Xanax made with fentanyl, there will be noticeable symptoms and side effects that wouldn’t ordinarily be present with genuine Xanax. The side effects of fentanyl include excessive itching, slowed breathing, nausea and vomiting, flushed skin, and constricted pupils. These can quickly progress to overdose, and those signs and symptoms are progressively shallow breathing, usually followed by gurgling or choking sounds, or sounds like “snoring,” pale, blue, cold, or clammy skin, limp body or unresponsiveness, and finally suppressed breathing. People often report that they didn’t recognize that someone was overdosing, even though they literally sat there watching it. They usually think they’ve nodded out and are snoring, and then just stop snoring. In reality, they’re really choking, then their breathing is severely suppressed, and when they stop making noise, they’ve simply stopped breathing. Fentanyl also yields some dangerous psychological effects, such as depression, hallucinations, difficulty sleeping, and nightmares. These are all signs to be aware of if you ever take a drug from a questionable source.
Fake Xanax: How it’s Done
Counterfeit Xanax is made using a pill press, which is exactly what it sounds like: it’s a device that is used to press powders together with a binding agent, to make the substance into a solid pill form. Pill pressing devices can be smaller than the size of a person’s palm, or large enough to need a small room for storage. Pill molds are added to the pill press to press the pills into certain sizes and to make markings or indentations. Sometimes they’re called “stamps,” and manufacturers use these to customize the appearance of the pill and mimic the exact imprint used by the legit pharmaceutical company. Currently, it’s not illegal to own a pill press, and in fact, some people use them to make their own vitamins or supplements at home. But it is illegal to own a pill mold that is used in a pill press. As a result, counterfeit pill molds are usually designed in other countries and sold to the U.S. as “spare parts” or “equipment.” This allows street dealers and manufacturers to purchase their supplies without gaining attention from the police, and continue to make fake drugs in their gnarly basements.
Fake Xanax: Why it’s Done
Helll-oooo! People who sell drugs don’t do so because they enjoy it, they do it to earn a profit. It behooves them to find a way to make their drugs cheaper and more potent, because that’s the best way to generate more profit from a smaller amount of product- that’s just common business sense. Believe it or not, many street-level dealers can get their hands on fentanyl very cheaply, either through theft, or through overseas production of cheap, sketchy fentanyl look-a-likes, so they commonly use it to cut their drugs, and this actually makes their products cheaper and more potent. To be clear, these fake products may not even contain the actual primary component. But in cases of fake Xanax, if it does contain actual alprazolam, the combination makes it even more dangerous- but the fentanyl alone can just as easily provide or mimic the effects the user is looking for. The result is a product that looks and feels pretty much like real Xanax, but is infinitely more dangerous; sold at a fraction of the price, as compared to the real thing, brought to you by your friendly neighborhood street thug.
Fake Xanax: How to Avoid It
Clearly, the easiest way to avoid purchasing fake Xanax is to never purchase the drug on the streets in the first place. In fact, the only reason anyone should ever take Xanax in the first place is if they have a prescription for it and are instructed to by their doctor. Unfortunately, some people who are prescribed the medication seek out cheaper ways to fill their prescription, such as purchasing it from shady online pharmacies or from overseas stores. But you’d be surprised how enterprising some dealers are, and a “pharmacy” selling counterfeit drugs is certainly not unheard of. So kids, the take home lesson is that if you have a Xanax prescription, you should always get it filled at a licensed pharmacy.
Fentanyl: The Masked Killer
As a final word of caution, I just wanted to include a short synopsis of three stories I read about counterfeit drugs containing fentanyl. None of them have happy endings.
A 28-year-old smoked “a powdery substance” at his mother’s home, where he was living at the time. His mother found him unresponsive in the living room, and having no idea of what had happened, called 911. He was pronounced dead on arrival. The death investigation determined that the substance had been given to him by a friend, who stated they both thought it was cocaine. Toxicology confirmed that while he had a non-lethal level of cocaine in his system at the time of death, the cause of death was acute fentanyl intoxication- he died of a fentanyl overdose.
A 20-year-old college student suffering from undiagnosed anxiety was panicking about a test the following day, so consumed a single oxycodone pill he had obtained illegally before going to bed. His roommates found him dead the next morning. Toxicology confirmed that he died from a fentanyl overdose.
A 19-year-old purchased two Percocet from a friend. He consumed both pills and subsequently died from an overdose. His friend confirmed the purchase, but then toxicology showed the presence of lethal levels of fentanyl. His friend swore he didn’t know they were fake and was very distraught. That friend was also later found dead of an overdose. It was confirmed that it was also due to fentanyl, but it wasn’t clear if it was suicide or accidental.
These are cases where four individuals died of fentanyl overdose, with all of them consuming a different drug, and three of them never even realizing they were consuming fentanyl. On that note, have you decided which group of Xanax in the picture were fake? I’ll tell you now: both are fake. Guess it’s a good thing you couldn’t actually choose. Get my point?
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Welcome to a brand new blog, people! Last week we talked about mindfulness, so I hope everyone has been trying to practice that in at least some small ways everyday, especially when stressed. If not, the topic of the new series I’m introducing today may be a bit of foreshadowing, as you might need it. Trust me when I tell you that it’s far easier, not to mention more rewarding, just to live a more mindful life. The new topic is alprazolam, which you might better recognize as Xanax, a drug used nearly solely for anxiety, at least when used as intended, but we’ll get to that.
Today as an introduction, I’ll give you an overview on what you should know about alprazolam if you’re thinking about taking it. But my advice? Don’t, because while it works, it can be so sneakily addictive, in a way that seems almost sinister. Insidious. It took me a second to get there, people. My point is, it will creep in and take over anyone’s life if given the smallest opportunity to do so. We’ll talk more about that later. For now, suffice it to say that it’s so abused by so many people, it’s literally become a threat to public health. I hear stories everyday about how it ruins the lives of good people with only the best of intentions. For that reason, plus more that I’ll get into, everyone should really know the basics about alprazolam.
Alprazolam belongs to a group of medications called benzodiazepines, aka benzos. Other meds in this group include Valium, Klonopin, and Librium. You may have seen my YouTube video on benzodiazepines, barbiturates, and alcohol. If not, I’ll put the link at the bottom so you can check it out. Alprazolam, aka Xanax, has a lot of slang names as well, mostly referring to its shape and color. Bricks, zanny bars, blue footballs, and z-bars are the ones that come to mind right now, but there are others used on the street. Speaking of, alprazolam is pretty cheap in the pharmacy. On the street, it’s pretty damn expensive when you consider it can easily cost you your life, but it usually goes for around $3 to $5 per bar or pill, depending on strength. What a bargain.
Alprazolam, like other benzos, is most commonly prescribed for people with anxiety disorders or panic disorder. Sometimes it’s also used short term for treating severe insomnia, alcohol withdrawal, and prolonged seizures. I myself prescribe it for these indications- very short term and as low dose as possible- because it works well and it’s so fast acting. For anxiety and panic attacks, I almost universally try other meds and methods first, because of its aforementioned insidiousness, but occasionally I might use it as a bridge while the other meds and methods start to work.
How Alprazolam Works
Like all other benzodiazepines, alprazolam works by binding to specific receptors in the CNS called GABA (gamma-aminobutyric acid) receptors. GABA is an inhibitory neurotransmitter, meaning it works to decrease nerve activity. The simplified pharmacological mechanism looks like this: when alprazolam binds to the GABA receptors, it enhances GABA’s inhibitory activity. This pumps up the GABA, which greatly reduces neural stimulation. This decreased neural activity produces general CNS depression, and elicits the anti-anxiety and sedative-hypnotic effect that’s felt by the person ingesting it. It’s important to note that alprazolam doesn’t affect everyone in the same way. There can be other factors involved, including the person’s mental state at the time the drug is taken, the dose taken, the person’s age, weight, and individual variances in the metabolism of the drug.
How Alprazolam Feels
Captain Obvious says that this depends on the dose, which I’ll get into next, but when taken as prescribed for anxiety or panic disorders, the idea is that you should feel “normal” after your first dose. The sedative effect should help alleviate the symptoms of anxiety, and calm your body’s response to the anxiety or the stressor. If you take it recreationally, aka without a prescription, the effects you feel would still be dose dependent, and if you take a small dose, in theory you would have the same effects. I say in theory because that would depend greatly on where you get it. If you buy it on the street, you’re probably not taking actual alprazolam. Fake alprazolam is a huge, lethal problem, and I’ll be dedicating an entire blog to that topic in this series. You’ll be shocked. Hint: if you want to live, don’t buy Xanax on the streets! Unlike stimulant drugs like cocaine, which produce a euphoric “high” feeling, recreational alprazolam users describe feeling more relaxed, quiet, and tired, often to the point of passing out for several hours at a time. Some people have memory lapses or amnesia or black out periods, where they can’t remember anything that happened for several hours, even if they’re awake at the time. Equally important is what you should not feel when you take alprazolam, and I’ll cover that below, when I talk about side effects.
Alprazolam is available in multiple milligram strengths, 0.25 mg, 0.5 mg, 1 mg, and 2 mg.
The effects become more significant as the dose increases, so first-time alprazolam users should absolutely start with the lowest possible dose and let your prescribing physician know exactly how it affects you to determine if the dose needs to be adjusted. You don’t ever get to play doctor here, people. Don’t increase the dose on your own, even if you’re an experienced user. This is because higher doses can be fatal for everyone- from first-time users all the way up to people who’ve used it as prescribed for many months or years. Again… don’t take a higher dose than what’s prescribed by your doctor.
In addition to instant death, high doses are associated with a counterintuitive complication known as the “Rambo effect.” This unusual side effect can happen out of the clear blue sky in anyone taking alprazolam, prescribed or not and experienced or not, and generally presents as the user beginning to display behaviors that are very unlike them. These might include aggression, theft, or promiscuity, but can really be any unusual legal or illegal behavior- the key is that it’s very atypical and seems to occur suddenly. It’s not clear why some people react this way, or how to predict who it will happen to, so it adds a very unwelcome guest to the alprazolam party.
How alprazolam is broken down and affects you also depends on those aforementioned factors of age, weight, and individual variances in metabolism, but can also be impacted by the presence of other substances and/ or medications you may be taking. When taken by mouth, alprazolam is absorbed quickly by the bloodstream, so it’s very fast acting. Some people can begin to feel its effects within 5 to 10 minutes of taking the pill, but almost everyone will feel the effects within an hour. One of the reasons why it’s so effective for treating panic attacks and anxiety is that the peak impact from the dose comes so quickly. But, fast acting meds wear off fast too, so the effects are brief. Most people will feel the strongest impacts from the drug for two to four hours, though lingering effects or “fuzzy feelings” may stretch out beyond that for several more hours. Some people even report a hangover type effect as well.
The length of time that alprazolam stays in the body before being excreted also varies person to person by those aforementioned factors. The half-life of alprazolam in a healthy adult averages about 11 hours, meaning that it takes the average healthy person 11 hours to eliminate half of the dose from the bloodstream. Typically speaking, that time would generally be a little shorter for younger people, and longer for older people. It’s important to recognize that you will stop feeling the effects of the alprazolam long before you reach half life.
It is possible, even likely, to build up a tolerance to alprazolam, and this can happen very quickly. If that happens, you may begin to notice it takes longer to feel the sedative effects of the drug, and that feeling will wear off more quickly. As alprazolam wears off, most people will stop feeling the calm, relaxed, lethargic sensations that the drug is associated with. If you take this medication to relieve symptoms of anxiety, like a racing heart, those symptoms will begin to return long before it’s half-life. If you don’t have these symptoms, you’ll begin to return to feeling “normal.” However, some people who take alprazolam for reasons other than anxiety may find they actually begin to experience feelings of depression and/ or anxiety, even if they’ve never had an issue with these conditions, as the chemicals in their brain adjust to the lack of the drug. This rebound anxiety or depression is usually temporary, but will often happen each time it’s taken. I have a Huntington’s patient who never had any anxiety or depression until his specialist put him on alprazolam for severe muscle spasm, and now it’s a real problem. Sometimes it’s hard to tell what’s worse, the disease or the “cure.”
Alprazolam Side Effects
Captain Obvious says that being aware of potential side effects is very important when considering taking any drug. He also says that should you experience any of these, stop taking it and contact your prescribing physician immediately, or seek emergency medical attention if appropriate. Possible side effects of alprazolam include sleepiness, dizziness, headache, confusion, muscle cramps, decreased appetite, weight loss or weight gain, diarrhea, nausea or vomiting, manic symptoms, difficulty walking, dry mouth, irregular heartbeat, low blood pressure, and blurry vision.
How it Shouldn’t Feel
When taken properly at prescribed doses, the effects of alprazolam should be mild, but detectable, and the symptoms for which it is prescribed should be decreased. If the drug appears to be having a significant negative impact, seek emergency medical attention and then contact the prescribing physician later. It should go without saying, but don’t take it again. Symptoms to watch for include extreme drowsiness, muscle weakness, confusion, fainting, loss of balance, and/ or feeling lightheaded. You should also seek emergency medical attention if you experience signs of an allergic reaction. Signs may include swelling of the face, lips, throat, and tongue, and difficulty breathing.
Alprazolam Special Considerations
Some people should avoid alprazolam entirely because they may be more sensitive to its side effects, or it could potentially harm them in some other way. This includes pregnant women, older patients, children and teenagers, people with a history of alcohol or drug abuse, and people with certain medical conditions such as respiratory illnesses.
Alprazolam Tolerance, Abuse, Dependence
I cannot overstate the potential for misuse, abuse, dependence, and addiction associated with alprazolam. And it doesn’t “just happen to junkies” people. Some folks without any reason take it recreationally just because they like the way it makes them feel. Others have undiagnosed anxiety disorder, so they start buying it or taking it. Others are prescribed it for anxiety, insomnia, seizures, or severe muscle spasm, but begin to need higher or more frequent doses of it to achieve the same effect; this is known as tolerance.
Though the routes to get there vary widely, without any intervention, all of these situations usually lead to the same place: dependence and addiction. This happens when the body begins to rely on alprazolam to function normally. Over time, we’ve collected scientific data and anecdotal reports to determine that certain people/ groups are at greater risk for abuse, tolerance, and dependence on alprazolam. These include non-hispanic whites, young adults 18 to 35 years old, people with a current psychiatric disorder, and people with a personal or family history of substance abuse. For these people, taking alprazolam is like playing with fire. If you’re one of them, don’t risk getting burned.
Alprazolam: Synergistic Interactions
A synergistic interaction occurs when the combined effect of two drugs or substances is greater than the sum of the individual activity of each. As a CNS depressant, alprazolam has synergistic interactions with other CNS depressants, and there are lots of those out there. The biggest example is also the most commonly overlooked one: alcohol. Good ole EtOH. Other examples include: other benzos (duh), opioid analgesics ie OxyContin, Vicodin, morphine etc, barbiturates ie Seconal and Nembutal, hypnotic drugs ie Ambien, heroin, methadone, neuroactive steroids ie estrogen and testosterone, and intravenous and inhalational anesthetics. If you take alprazolam and any of these substances, the alprazolam intensifies the effects of that substance and vice versa, so when taken together, they literally become exponentially more potent than if you used either of them on their own.
This is because all of these substances also increase neurotransmitter GABA activity in the CNS, slowing the activity of the nervous system, causing the sedative effect. When alprazolam is mixed with any of these substances, because the effects are synergistic and exponentially more potent than just the two combined, you’re at risk of excessive sedation, extreme confusion, prolonged memory loss, seizure, loss of consciousness, respiratory depression, cardiac problems, dangerous accidents from increased clumsiness and sedation, and unintentional death. Please note that these synergistic interactions occur whenever the substances are mixed- even if it is at prescribed doses.
However, there are some drugs that cannot be combined with alprazolam that you wouldn’t even think about. This includes some oral contraceptives, antifungals, antidepressants, antibiotics, and heartburn drugs. These drugs can affect the pathway that’s responsible for eliminating alprazolam from the body, so that the alprazolam isn’t removed as quickly as it should be. Over time, this can lead to a toxic buildup of the drug, and eventually an overdose. Always speak with your doctor to review meds and discuss potential interactions. In addition, your pharmacist is an excellent resource for any questions about med interactions. Some specific meds that may interact with alprazolam include cimetidine (Tagamet), fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), carbamazepine (Tegretol), diltiazem (Cardizem), isoniazid (Laniazid, Rimifon, Hyzyd, Stanozide, Nydrazid), and cyclosporine (Sandimmune).
Also, not a medication, but important to remember is… grapefruit juice! Grapefruit juice can block the action of CYP3A4, which is a critical enzyme in the body. Mainly found in the liver and the intestine, it oxidizes small foreign organic molecules, like toxins and drugs, so that they can be removed from the body. When CYP3A4 is blocked, instead of being metabolized, more of the drug enters the blood, and stays in the body longer. The result is too much drug in the body. I should add that there is some controversy surrounding this. The FDA says grapefruit juice does slow alprazolam metabolism, but some studies have published results that indicate it is “unlikely to affect the pharmacokinetics or pharmacodynamics of alprazolam, due to its high bioavailability.” Translating this geek speak to plain english, they’re saying their studies found that grapefruit juice had no effect on how alprazolam was metabolized and cleared from the body, because so much alprazolam is absorbed and available for biological activity in the cells and tissues where it’s metabolized. I say err on the side of caution and avoid alprazolam, or grapefruit juice if you just can’t. I should add that CYP3A4 is involved in the metabolism of other meds as well, so if you drink grapefruit juice, keep that in mind- tell your docs and pharmacist.
I touched on the dependence issue associated with alprazolam, but I’m going to discuss that and withdrawal in more detail in next week’s blog. Regardless, even if you have only taken alprazolam exactly as prescribed, and you’re sure you’re not dependent on it- if you want to stop using it, you must do so with the guidance of your prescribing physician or another healthcare provider, because stopping alprazolam abruptly can lead to serious, medically dangerous withdrawal symptoms and rebound anxiety. Don’t stop alprazolam on your own! Depending on how long you’ve been on it and how much you take, your physician will need to taper your dose, meaning step you down on the dosage until you stop it altogether. This is the only way to go. Withdrawal is no picnic, but stepping down makes it so much easier, and it eliminates the dangers associated with cold turkey. Rebound anxiety from abrupt alprazolam withdrawal is no joke- people who experience rebound anxiety report that their anxiety symptoms are at least at the same level, but usually worse, than they were before starting alprazolam- so not only are they not better, they’re worse. You want to avoid this if at all possible, so don’t stop alprazolam abruptly.
Speaking of stopping abruptly, that’s it for this week. Next week I’ll talk in depth about alprazolam addiction and withdrawal. And we may have a guest blogger situation. We’ll see.
I promised you a link to my YouTube video that covers a lot of this information, so here that is. Lots of other vids to check out there too.
Benzodiazepines, Barbiturates, and Alcohol
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At some point in your life, I’m sure someone’s told you, “Life is short, you should stop to smell the roses.” Somebody well intentioned, maybe your Nana, your next-door neighbor Janet, or your favorite uncle Fred, giving you the benefit of their experience, and just telling you to slow down and enjoy every moment. You probably smiled, suppressed an eye roll, noncommittally murmured something in the affirmative, and kept it moving. Nobody actually stops to think about these typically unsolicited pieces of sage advice, right? The very idea is anathema to our frenetic culture of constant multi-tasking and 24/7 connectivity. Well, turns out it might not be the worst idea to actually take it to heart. It seems that science is telling us that there might be something to it- stopping to enjoy the moment may actually be good for your health. It’s a concept called mindfulness, or sometimes mindfulness meditation.
Last week I finished up the remote work blog, and I considered adding mindfulness as a tip for dealing with stress. It’s actually a great technique to use, because it literally takes less than two minutes, so it’s easy to incorporate into your day as you need it. Essentially, mindfulness is a meditative practice where you focus on being intensely aware of everything you’re sensing and feeling in a present moment, without any interpretation whatsoever. However you’re experiencing life, you simply notice each moment as it unfolds, without any judgment or preconceived notions. You just let it flow and let it go. In this way, you take yourself off of autopilot, which is how most people normally operate, and purposefully engage with the world around you. This actively directs your attention away from whatever kind of thinking is causing you anxiety, and that puts you in a more peaceful present place. Whenever you have a few free minutes, you can practice mindfulness throughout the day, no matter where you are, answering emails, sitting in traffic, or waiting in line. All you have to do is become more aware. That can mean focusing on your breath, your feet on the ground, your fingers typing, or the people and voices around you.
Captain Obvious says that the nervous system is always working in the body, but we’re not really aware of everything it’s doing. All of its automatic functions, such as the heartbeat, digestion, and breathing, are regulated by the parasympathetic nervous system. It’s responsible for our normal, relaxed state, where the body and mind can “rest and digest” as they say. Its counterpoint is the sympathetic nervous system, whose most recognized role comes into play during its “fight or flight” mode. During these threatening situations, the sympathetic nervous system automatically releases stress hormones that flood the system, and we experience a physiological and emotional response in a cascade like fashion. Both branches of the nervous system are clearly very important, but if the sympathetic, “fight or flight” mode is activated too often, or for too long, that’s a serious health concern with harmful consequences. In an analogous way, living in a constant high stress state can elicit similar effects and have a negative effect on physical health, emotional well-being, and longevity.
The overall benefit of mindfulness is that it encourages you to pay attention to where you are right now, without any further interpretation. Once you begin learning how to be more mindful, you’ll realize how much your mind races, and how often you focus on the past and the future. Anxiety is often the product of thoughts about where you need to be, what you need to do, what might happen, and “if and when” type thoughts. Mindful redirection without judgement helps you experience thoughts and emotions with greater balance and acceptance, and removes that anxiety and stress from your mind and body. As a result, most people who practice mindfulness report an increased ability to relax, more enthusiasm for life, and improved self-esteem. Mindfulness and meditation have been studied in many clinical trials, and evidence supports their effectiveness in improving many chronic conditions, including stress, anxiety, chronic pain, depression, insomnia, and hypertension. Meditation also has been specifically shown to improve attention, decrease job burnout, improve sleep, increase immunity, and even improve diabetes control.
The concept of mindfulness is simple, but it’s called a practice for a reason. As I said, most people operate on autopilot, reacting to each situation or sensation as they go. When you have too many obligations and too little time, anxiety and stress often undermine healthy habits such as eating well, getting proper sleep, and exercising. This can easily become a cyclical pattern that’s difficult to break. But mindfulness actually pays out twice, because in addition to being relaxing in the moment, it also has a positive cumulative effect over time. So practicing a pattern of mindfulness breaks unhealthy patterns, which allows you to better enjoy positive life experiences, while also minimizing adverse reactions to negative life experiences. The idea of practicing mindfulness on a regular basis isn’t to get better at it. The goal is to make it second nature, so that you are essentially mindful at all times. Ideally, you then automatically become mindful, rather than anxious or stressed out.
In our culture, we tend to place great value on how much and how fast, but mindfulness doesn’t need to be complicated or take a long time to be effective. Just interrupting daily stress with a healthy response is essentially mindfulness for dummies, so by taking just a moment to breathe deep, you’ve become more mindful. If you’re not sure if mindfulness is your kind of thing, there are some simple mindful principles you can incorporate into your life while you look for proof of concept, to see if it’s helpful for you.- Pay attention. It’s hard to slow down and notice things in the middle of a busy day in a hectic world, but try to experience your environment with all of your senses: touch, sound, sight, smell, and taste. – Treat yourself the way you would treat a good friend; with acceptance and care, and without judgement and harsh criticism. – Eliminate the negative. When you have negative thoughts, try to sit down, close your eyes, and actively remove them from your mind to gain perspective. – Acknowledge and redirect yourself as needed to maintain awareness. Anytime you’re trying to be mindful, if you find your awareness slips, or anxiety or negativity continue to creep in, acknowledge them without judgement and redirect yourself to return your focus to the present.
Below are a few quick mindfulness activities you can easily incorporate into your daily life, including at work. Since you don’t need any specific tools, you can try them out on your commute or even at your desk when you feel stressed out.
Close your eyes and slowly breathe in and out. Concentrate on the rising and falling of your chest, and try to empty your mind. If other thoughts pop into your head, acknowledge and dismiss them, then bring your focus back to present.
It’s easy for your mind to wander during conversations. Instead of formulating your response while a colleague is still talking, clear your mind and really listen to what they’re saying. Try not to think about all the stuff on your to-do list, your plans for the evening, or your previous conversations- just be in the moment. This will help you pick up on more information, and can also improve your workplace relationships.
Choose any object nearby- a pen, your computer mouse, or even your tie- and really focus on it for one minute. Pretend it’s brand new to you and try to see it for the first time. Pay close attention to its shape, texture, and how it’s constructed. Try to connect with something positive about it you may have never considered before. This helps you not only clear your mind, but also helps to foster appreciation for the everyday objects that surround you.
This one requires you to get up and leave your desk, but so much the better. When you go on a coffee or lunch break, take a stroll by yourself through a nearby park or green area. If possible, leave your phone and other electronic devices back in the office, and use these few minutes to focus on and listen to the natural world around you. This is a healthy exercise for both your mind and your body, as you also benefit from the physical movement and the chance to get a breath of fresh air.
Those simple mindfulness exercises can be practiced nearly anywhere and anytime. Some of the more structured mindfulness exercises may require you to set aside time when you can be in a quiet place, without distractions or interruptions. You might choose to practice the following types of exercises early in the morning before you begin your daily routine. Here are some examples of more structured exercises you can use to practice mindfulness.
Unlike when breathing is an automatic function, this mindful technique encourages taking a moment to be present, and focusing on completely inhaling and exhaling air in and out of the lungs. Breathe in through your nose to a count of four, hold for one second, and then exhale through the mouth to a count of five. Repeat often, as needed. Over time, this exercise usually leads to a pattern of slower, deeper breathing as a healthy default.
Mental imagery exercises allow you to picture a calming place for relaxation. This technique focuses on a positive mental image to replace negative thoughts and feelings you may be experiencing at any given time. This is the classic “happy place” you can go to in your mind to reduce stress and anxiety.
Progressive Muscle Relaxation
When you have anxiety or stress in your life, one of the ways your body responds is with muscle tension. Progressive muscle relaxation is a method that helps relieve that tension. During this technique, you tense a group of muscles as you breathe in, and you relax them as you breathe out. You work on your muscle groups in a certain order, head to toe or toe to head. The action of tensing followed by relaxation releases physical tension and relaxes you. When your body is physically relaxed, you cannot feel anxious, so this is an effective method to relieve stress.
I imagine you’ve heard of “mindless eating,” where you’re watching television with a bag of cheesy poofs in one hand, and the remote control in the other, and the next thing you know, the giant family size bag is empty. When you eat mindlessly, you shovel food into your mouth without noticing how much you’re actually consuming. Mindful eating is the exact counterpoint to this, and for this reason, mindfulness is a universally recognized tool to help people achieve and maintain a healthy weight. With mindful eating, you only eat when you’re hungry, you make sure to focus on each bite to fully appreciate what you’re eating, and stop eating when you’re full.
Walking is such an established, habituated action that this is yet another thing we tend to do on autopilot. The moment we step out the door, our minds wander and get caught up in planning, worrying, and analyzing. But it’s pretty amazing how different you feel when you pay attention to your movement and what’s going on all around you, rather than all the stuff swirling in your brain. A walking meditation is a great way to take your mind for a walk with you, and the idea is to focus on your gait and the physical experience of walking. Pay attention to the specific components of each step, being aware of the sensations of standing, and the subtle movements that help you keep your balance as you move. Research indicates that engaging your senses outdoors is most beneficial, so try to find a big green space outside and take a mindful walk.
Ideally, you should aim to practice mindfulness in multiple ways each day. By that, I don’t mean you have to do a progressive muscle relaxation technique each day. I’m saying you can just incorporate the basic principles into your life each day. Eat mindfully instead of mindlessly. When your mind swims with everything you have to get done in a day, slow down and breathe. When you start to criticize yourself, stop the negativity and gain some acceptance. When you walk to work, try to do it mindfully. Remember that it’s far better to make small changes you can sustain than it is to make grand changes that don’t stick, so apply little mindful touches throughout your day. That way, you’re providing a break from stressful thoughts multiple times each day, allowing you to gain more perspective, and you’re also reinforcing this as a response to daily stressors so that it becomes more automatic. Over time, mindfulness becomes more second nature, and this effectively reduces stress and anxiety in the future.
Please note, it takes time and practice to learn to slow down and live in the moment. So if it seems to take longer than you “think it should,” you’re kind of missing the point, and you should drop the judgement and continue the effort. With regular practice, you’ll find that rather than operating on autopilot, reacting as you go, with your emotions influenced by negative past experiences as well as fears of future occurrences, mindfulness will allow you to root your mind in the present moment and deal with life’s challenges in a calm, clear, assertive way. As a result, you’ll develop a fully conscious mindset that frees you from the bonds of unhelpful, self-limiting thought patterns, and this will allow you to focus on the positive emotions that increase understanding in yourself and others. And that’s never a bad thing. So the next time someone tells you to stop and smell the roses, before you roll your eyes, take a mindful moment to be present, and then say thank you.
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Working Remotely, Part Trois
Hello, people! The last couple of weeks we’ve been discussing working remotely. I was prompted to do this series after noting the ways some of my patients evolved, or devolved, after working remotely in a ‘rona world. When I did some research, I read studies and reports from years BR, before ‘rona, and saw that remote workers regularly reported higher stress levels than their office worker counterparts. According to a 2017 United Nations study involving 15 countries, 41 percent of “highly mobile” employees (defined as those who “most often,” or “more often…worked from home” as opposed to “in office” or “onsite”) rated themselves “highly stressed,” as compared to only 25 percent of the office and onsite cohort. This was of obvious interest to me, given what I’d been seeing in my patients, so I thought it warranted further investigation and discussion. And a baby blog was born. Awww…
Captain Obvious says that mental health and work are intertwined, because work is such an integral part of our lives. Remote work has a somewhat unique ability to get to people, even the mentally healthiest of individuals, because when you work from home, you may feel like you live at work. The work-home and work-life lines can blur, especially if the switch is abrupt and unavoidable. Thank you, ‘rona. Last week I talked about some of the issues that can come along with this type of remote arrangement, and the fact that they generally present as some level of SADness, so you may find you feel stressed, anxious, and even depressed as a result. You may feel these impacts within a widely variable range as well as pattern; acutely, chronically, or as more of a cumulative or building phenomenon. Just to make it more complicated, you can also have a pink cloud situation as well. After making a switch, the novelty of the setting can alter how you value certain associated factors. You may find that any negative impacts you feel from one issue are offset by the positive impacts of another. But this can be a little insidious if you’re not careful, because it’s a transient phenomenon. Once the novelty wears off, that pink cloud goes **poof-bye bye** and suddenly, the equation is altered again! It’s not really worth it anymore, and that can make you SAD.
Sometimes the effects can be so low level, you might just generally feel blah, or ‘some kind of way,’ as the kids say, but you can’t seem to put your finger on why. There are nearly innumerable ways that stress can manifest, regardless of where you work, and it usually doesn’t just affect your work. It often seeps over into your private life as well, but this is especially true when you’re working from home, because of those annoying blurred lines.
So if you’re a remote worker and feeling some kind of way, how would you know that it might be your remote work at the heart of it? Clearly it’s difficult to pinpoint it exactly in a generalized blog setting, because each person is different; but there are some ways stress can manifest in both your personal and professional life, some things you may start to notice. The most common things can include: insomnia and poor sleep patterns, an inability to ‘switch off’ from work, headache, feeling disconnected from other people, an increase or decrease in appetite, having difficulty concentrating, having difficulty becoming and/ or staying motivated, having difficulty prioritizing workload and daily tasks, and feeling insecure or unsure of standing or spread too thin/ pulled in too many directions in your work and/ or personal life.
Last week I likened work, and life, to an equation. Everything has a value, and you decide what’s worth what, give and take, in order to decide what works for you. Last week I focused on the negative side of said equation, so this week will focus on the more positive side. Today will be about addressing issues I brought up last week, presenting some additional factors, and suggesting some steps you can take if you think that working remotely is having a negative impact on your life. Clearly, you don’t have to wait for that to happen, and everyone knows what they say about an ounce of prevention, people. When we’re talking about stress, it all comes down to minimization and mitigatation. I’ll try to address each issue in the same order I did last week, and make some strategic suggestions for solutions. Some of these may have been mentioned in the first blog of this series, so people that might’ve missed it can still follow along. If you didn’t miss it, please bear with me.
I’ve joked about how many patients I’ve seen in bed during facetime appointments, but I think far too many people are both working and sleeping there. Seems like a lot of people’s morning routine is just rolling over to grab the laptop. But there are good reasons why this is concerning to me. Humans need sleep, and studies show that working from home, just in and of itself, can already interfere with sleep. But this is especially true for people who find it difficult to switch off from work. Working from your bed, or even bedroom, makes it very difficult to do just that. Not only does it encourage the late night blue light exposure that has been shown to interfere with sleep, but it also makes your brain associate that place with being alert, awake, and switched on. And that’s not the association you want- your bedroom should be the place you rest and recharge.
If you find yourself working remotely full time, you want the best possible experience. You’ll certainly be more comfortable and productive, not to mention a lot happier, if you create a dedicated space to work. Preferably, a separate room with a door you can close for privacy, and to minimize distractions and physically separate your work from your home life. If you just don’t have a separate room, find a corner or nook in your house that you can commandeer, and transform it into your home office. The goal is to make it feel detached from the rest of your house, so if it’s a small space, consider a room divider, or think about using just an area rug as a means of creating a division. Once you have “the office” location, be it a separate room or just a corner, set yourself up for success. Buy new- or check out used shops or thrift- for a desk that’s wide enough to support your wrists, arms, and elbows to keep carpal tunnel at bay while you’re tapping away at your keyboard. Better yet, go tetherless and get a wireless mouse and keyboard. Also look for a comfortable, ergonomic chair that supports your lumbar back, neck, and spine. Few paychecks are worth an orthopedic problem. Big bonus points if you can kit out your space with a sound system and other creature comforts. Try to also get some life into the space. Consider some plants and maybe even a little fish tank if you have room- they’re very soothing. If you’re only working remotely temporarily, and you just don’t have the space at home for an office, even going to a local library or cafe to work may be better than just converting your bed to one. When you have a clearly defined working space and time, it’s far easier to finish your tasks for the day, and leave work at “the office.” That way home remains home, and you avoid being “on” all the time.
Once you’ve done what you can to create a dedicated work space, make sure to do what you can in the way of technological assistance. If you need a new laptop, smartphone, wi-fi, or cell booster, communicate that with your employer, if appropriate. If they provide the equipment, or some sort of assistance in purchasing it, then score! If not, investing in tech that will save you time and aggravation is always a good move, so do that as soon as is feasible. If you’re all set up and ready to roll and find you’re still having technical difficulties, most definitely communicate that with your company’s IT department, if that’s not you, to fix the issue. If that is you, take the time to deal with it as efficiently as possible, call a “geek” to come out for a diagnosis. The sooner your systems are running smoothly, the fewer the tech migraines you’ll have later.
Coming at this from a different direction, once you’re properly setup, working from home can give you an opportunity to be proactive, learn something useful, and make friends with technology. There are apps out there that do all sorts of cool things that can be helpful in a remote work environment. You can set timers and reminders for break activities, track your social media usage, like if you need some help to use it less, remind yourself to get back to work when you become distracted for too long, and you can create to-do lists and schedules galore to help stay on top of things, simplify tasks, avoid frustrations, and be more productive. There’s nothing more encouraging than getting your mundane tasks done as quickly and efficiently as possible, so check out all the options available and learn to use tools like these to your advantage.
And just as the expansion of the internet has made remote work possible from nearly all corners of the globe, novel programs and platforms have also been developed specifically for remote workers. If you work for an organization, they may offer access to automated online courses that will allow you to keep honing your skills, so contact human resources and make some inquiries. If those opportunities don’t exist, you can always look for other free or paid online courses for virtual and remote workers. When I searched it, the number of them available was impressive. There are courses designed to give you the skills necessary to start a new career, or to grow an existing one. Remember that any time you work to broaden your horizons, you further your personal identity and make yourself more valuable in every professional application.
A significant issue revolving around working remotely involves its management. How do you adequately supervise- and support- multiple employees, when they’re potentially thousands of miles away? Both managers and employees face a different set of challenges when working remotely. From what I hear from remote worker patients, the decreased feedback from managers and supervisors boils down to making some employees feel insecure. As I mentioned last week, it makes them feel mistrusted, and as though they have to prove that they’re actually working from home and not goofing off. I think the remoteness gives them no benchmark to judge their own progress, and that leads to increased anxiety and concerns about being up to standards. In short, they may not be getting the attaboys they did in the office, and that makes them wonder if they’re doing a good enough job. Obviously, employees need to adequately document the hours they work, and maintain regular communication with supervisors to keep them up to date on what they’re working on. More on communication later.
On the supervisory side, I think the solutions to these issues requires an open mind. Remote companies need to start thinking about how they can ensure that employees aren’t overworked, and also utilize management courses for remote team leaders to help train them for this new working environment. They should set aside more traditional ideas that no longer work, in favor of developing more flexible policies that better correspond with a more modern arrangement. Maybe implement the concept of management by objectives accomplished instead of by time. I can tell you from years of listening to people that helicopter monitoring- actually helicopter anything- and micromanagement won’t work. Management should consider allowing some employee input into the creation of novel management methods as well. Employee happiness and engagement increases productivity by 31 percent, so getting them involved in making suggestions benefits everyone.
Some other simple steps that management can take include encouraging employees to communicate amongst themselves, to take PTO days, to stay out of their “office” after hours, and to enjoy a hobby that does not involve a computer screen or technology of any kind. Also, performing technology and work station audits to confirm reasonable working conditions, and giving regular updates regarding organization standards and plans for future work performance will help alleviate a great deal of employee insecurity. Management also needs to be proactive in helping remote employees avoid undue stress, and allow them to feel comfortable reporting stress without worrying about repercussions. Two psychologists created the Yerkes-Dodson Law, which points out that stress can be productive up to a point, and then it results in reduced productivity. Being overly stressed without the ability to report it is detrimental, as pressure will eventually outweigh an individual’s ability to cope over time. Contrast that with the findings of one recent study, which reported that colleagues who spend just 15 minutes socializing and sharing their feelings of stress had a 20 percent increase in performance. Clearly, this demonstrates how it behooves management to implement measures for employee stress sharing and reporting.
Given the negative impact of stress in a remote work environment, management should also avail themselves of training to learn the warning signs that signal that remote employees are feeling workplace stress. Opening up a line of communication is a good first step, so that when they are starting to experience burnout, they’ll be comfortable discussing how they feel. Management should learn to ask questions about how they’re feeling and listen closely to the answers. Do they mention having a difficult time concentrating? How about their interests in things they used to like? Are they experiencing any feelings of frustration, irritability, or hopelessness? These would all be indicators of stress that management needs to catch before employees reach a breaking point. An increase in negative language is another indicator. The use of phrases such as: “there are no options,” “I can’t do anything,” or “this is impossible” are examples of catastrophizing, and should be red flag indicators of employees having more workplace stress than they know how to deal with. There are other signs as well. Make sure to speak with employees that are starting to make mistakes, missing deadlines, or getting sloppy, as they are often the first signs of struggle. And instead of cracking down on staff that’s having a hard time, organizations must offer support through stress management initiatives in the workplace. In my opinion, management and employees making all of these efforts would result in big strides on the road toward improving the remote work experience for everyone.
Isolation and Loneliness
The solitude of working remotely can be a double-edged sword. It can be easier to focus when you’re in your own home, with no annoying coworkers randomly stopping by your desk, or your boss breathing down your neck. Aah…sweet freedom! But when there’s no social interaction during a full workday, that also means there’s no one there to ask a work related question to, or bounce an idea off of, or un-stick you at a crucial point. Social isolation was another factor associated with increased stress levels mentioned in the UN study. In addition, without personal communication, more emphasis is placed on deadlines and routine information, so remote workers can feel like a cog in a machine, rather than an essential part of a team. This just adds to the sense of isolation that naturally comes with working remotely, and the two together can make it difficult to have as much energy to be productive. In addition, it can be very unpleasant, if not impossible, to sustain this for the life of a career. A top priority should be to maintain relationships with coworkers and managers, especially if you are one who is energized by these relationships. It is critical not only to work performance, but to emotional and mental wellness.
Technology can serve as an assist, and there are plenty of platforms like Slack, Zoom, and even good ole facetime to facilitate this. Lots of companies have established ‘virtual coffee breaks’ and even ‘watercooler’ channels to encourage break-time chatter during work hours, to foster collaboration and create a more comfortable work environment. If your company has outlets like these, take advantage of them. If they don’t, then maintaining connections is essentially up to each individual. Because everyday encounters with colleagues don’t spontaneously happen when working from home, you need to be proactive to maintain positive relationships. Think about scheduling a few minutes for informal banter at the start and end of video calls to emulate the normal casual talks you would have with coworkers when walking by their desks, or in the kitchen at the office. It may not seem productive, but it helps build internal relationships and boost morale. These connections will help you feel less isolated, reduce stress levels, and stay productive.
You can always facetime, Zoom, message, and email people, but that’s not the same as having face-to-face interactions with them. So make it a point to meet with coworkers or friends for lunch, coffee, or drinks a couple of times a week. If you find you’re still feeling isolated and lonely while working remotely, consider meeting other digital nomads at a coworking space, or work together from one of your home offices twice a week, or more often if it’s helpful. But remember what all work and no play did to little Johnny. Make social commitments with friends and get outside of the house at least once a week. Ultimately, if you work from home and feel isolated or lonely, it’s important that you take responsibility for your own social interactions. The key is to make an effort and be proactive to do things to decrease the isolation that can come from the remote work setting.
One of the biggest challenges in working remotely is finding a healthy work-life balance to avoid blurring those lines I mentioned earlier. Surveys show that 51 percent of employees report stress and burnout as a result of working at home. Just as an interesting aside, the most often cited reasons for burnout are, surprisingly, the very things that made remote work seem attractive to most people. The dressing! Or not. The surveys indicated that when people dress in sweats because they are not seeing anyone, they then find that comfort makes it difficult to fully engage. Their clothing signals fun chill time, while their tasks are anything but. And while remote work seemed liberating, many employees relied on supervision and structure to manage their workday. Without it, many people fing it hard to be as productive, and are stressed about not completing tasks in a timely manner, and these cause them to overwork and risk burnout.
Not all people can achieve proper work-life balance when they work from home, and in fact, the UN study also noted that this is one of the many negative impacts of the remote work arrangement. For some, working from home feels like a special privilege that’s been granted to them, so they feel like they should work harder, and that’s how stress and burnout are escalated. I’ve noted that some patients, who definitely seemed to have a solid, healthy work-life balance when they worked in an office, suddenly started to become work obsessed after going remote. They work ridiculous hours at home, unable to even define the end of a day, much less switch off at it. I’ve seen it happen- watched it happen- to people who had a previously healthy balance, so imagine what happens to someone with workaholic tendencies when they go remote. From what I’ve observed, working remotely is to workaholism what bar hopping is to alcoholism. If you’re in a place that facilitates a bad habit, that’s a bad place to be. In other words, workaholics probably need not- or should not- apply for a remote position.
When working in an office environment, there are often clear signs and symptoms if somebody is burning out. These commonly manifest as increased emotional reactions to situations, a general lack of motivation, and the appearance of small, seemingly minor mistakes. There are also some visible physical signs, such as bags under the eyes and even weight loss, that can be seen. When working from home, there isn’t anybody to notice these telltale signs, apart from family members or friends. But if that person lives alone or is isolating themselves, then they’re not even there to see them. So remote workers have to be able to police themselves to avoid burnout.
Flexibility is a double edged sword. It can be liberating to set your own times as to when you need to get up, when you go to bed, when you need to start work, and when you need to stop. But this feeling of freedom can gradually morph into a feeling of being out of control, especially if you don’t expect it. It sounds great to eliminate a structured office setting, but once that structure is gone, where it might have felt stifling before, it can start to feel like the scaffolding on which your whole life was built. When there’s no one there to monitor or guide you, and structure has to be self-imposed, it can be difficult to create. It can also be more challenging to function as efficiently without it.
The solution is to set a schedule and put it on a calendar. Look at it as an opportunity to exercise the flexibility that is a prime benefit of working remotely. It can be vital to not only save you from burnout, but also from distractions that will swallow up your time. More on that in a bit. There are several useful tricks for creating a schedule, and you can always use an app to help you to make one in a format that suits you. If you are free to set your own hours, meaning it doesn’t matter when you work, then decide when you work best. Many people find that working in the morning when they feel rested can provide a more productive experience than beginning work halfway through the day after cleaning the house and doing other non-work-related activities. This isn’t true in all cases, so feel free to experiment if this advice doesn’t seem to ring true for you. If it were me, I would not only start work first thing in the morning, but I would also prioritize the most challenging tasks first. Rather than letting unpleasant or difficult tasks hang over your head and create stress when you think about them, pushing yourself to get the most difficult jobs done first will give you a sense of accomplishment and increased energy to get you through the day.
To be productive and avoid burnout, you not only have to set a schedule for balance, but you have to stick to it. Make sure to maintain reasonable office hours. As I mentioned last week, your home is now your office, so you’re not technically ‘leaving’ work unless you turn off all communication platforms. Sign out of your email, close the laptop, put the phone down at the end of the day, then leave “the office.” Make sure to include time to step away from your desk to take a lunch break, and eat something sensible to avoid being distracted by hunger later. If you have children or family at home, this is a good opportunity to spend some time with them. Since you probably spend a lot of time indoors, try to have lunch outside.
In addition to a lunch break, schedule short breaks during the day. Scheduled breaks are better than just working until you lose focus, then randomly giving in to distractions. Everyone is different, so the length and number of breaks can vary slightly, but within reason. Some people would do better taking 15 minutes mid-morning, and then again mid-afternoon, while others would rather two shorter breaks in place of one longer one. During these breaks, try to step away from your desk to disconnect for a few minutes; this is a very effective method for avoiding/ managing stress. Go outside to get some fresh air, maybe take the dog out to get the mail. The idea is to use these times to clear your head to help you focus on work when you come back.
When you take time off, take it completely off. If you’re guilty of working on PTO days or of bringing your laptop on vacation, you’re missing the point and need to disconnect more fully. It might seem like bringing work with you means you’ll have less to catch up on, and therefore less stress, when you get back, but in reality, you aren’t allowing yourself to recharge. This goes for weekends too. Keep the laptop closed, resist the urge to check emails, and concentrate on the life part of the work-life balance during your time off.
Focus, Motivation, Distraction
Creating structure and setting boundaries are critical in a remote work setting, not only to avoid blurring the lines between work life and home life, but also those between productivity and leisure time, and socializing time and working time, in order to avoid distractions. But this can be more challenging than many people expect. If you live with family, setting boundaries with others can be difficult when people expect that you should have time to talk when they do. You may feel pulled between competing loyalties and overwhelmed by the responsibilities of your various roles. Not only is it difficult to set and communicate boundaries, but in some situations, such as when there are children in the home, those boundaries may also be constantly challenged. If you live with other people, especially children, make sure to have set office hours and communicate them to everyone. You can even show small children your schedule, and explain that you have break times and lunch time scheduled, and you’ll see them during those times. Also clearly communicate what circumstances warrant an interruption of work time in order to avoid random needless interruptions. Apparently some companies actually provide employees with do not disturb signs to hang on their office doors in order to remind others you’re actually working. It’s not the worst idea ever. I say if you have kids, and your company doesn’t provide you with one, get out the markers, glue, and glitter and them involved- ask them to create a sign for you. If they make it, they’ll be more lilely to respect it when they see it hanging on the door.
Setting and sticking to boundaries with yourself may be even more difficult than with others, especially when you are feeling a lack of motivation. Without other coworkers around to hold you accountable, you may have a little tougher time motivating yourself, but resist random distractions in favor of taking your scheduled breaks. In addition to sticking to your schedule, you can avoid distractions by not taking personal calls during the middle of the day and avoiding the endless rabbit hole of social media. Turn off notifications and/ or mute your devices while you’re working. Just don’t go on social media if you don’t want to be Alice. It’s easy to lose sight of tasks and deadlines, especially when your superiors can’t physically see you, but you can monitor your own productivity by planning ahead of time and using time management techniques. At the end of each day, make a list of tasks to be done for the following day. On the next day, review your priorities and tackle high-value tasks first. By following this, you’ll stay organized by keeping your schedule and calendar straight, and learn how to prioritize to get your work done. It should also help you learn one of the golden rules to working remotely: don’t procrastinate! If you need more help with time management techniques, google it. There are methodologies available on the interwebs to help maintain your focus throughout the day, and I’m sure there are apps for that, as well. Aren’t there for everything?
To keep your motivation up, it’s a good idea to break big tasks down into smaller, workable goals. You can also setup project milestones, working with a manager to establish objectives when needed. Sometimes communicating those goals out loud to others can help to motivate you, so consider sharing those goals with coworkers or family members, because sometimes making public commitments to others about what you will accomplish that day helps hold you accountable. If you need to really pump up the motivation factor, you can always reward yourself for accomplishing goals as well. But this doesn’t mean a food reward, people. Maybe schedule a massage, a special lunch with a friend, or an ice cream with the kids. Okay, I guess that’s technically a food reward… so make it a yogurt if you’re trying to be healthy. At any rate, put planned rewards on the calendar so you can see it as a motivator. It doesn’t even have to be a real reward that costs anything. Sometimes it’s rewarding enough to imagine something you’re working toward, and reward yourself by taking whatever the next step is in attaining it. Maybe you want a new kitchen; you can go to the tile store and get different samples to bring home and mull over. The point is that it’s up to you to be productive, while also making your work experience pleasant. Try to keep yourself feeling appreciated, even if you yourself are the only one who appreciates you.
If you’re freelancer, your monthly workload and income can be unreliable and constantly changing. This is an obvious source of anxiety and stress, as sometimes you may be swamped with too much work, while at others, not have enough; it can be very difficult to find that middle ground. And because jobs aren’t usually long-term, you need to spend much of your time searching for new opportunities, while simultaneously completing the work you have. Not only are these conditions stressful, but freelancers are independent contractors that usually have to handle everything, so switching hats from sales to service to invoicing and bookkeeping adds to the stress. Not every personality is well suited for this variability. While researching this blog, I found a lot of resources available- job boards, apps, communities, and blogs for freelancers that look like they would make their lives quite a bit easier. One blog I came across had a list of various applications with descriptions of exactly what they do, along with links to everything. If anyone is interested, the blog was called skillcrush, and can be found here: https://skillcrush.com/blog/useful-resources-for-freelancers/
Communication can be very sensitive territory, and learning how to navigate it is an essential skill to avoid misunderstandings and misinterpretations in every work situation, but especially in a remote work setting. With electronic communication methods that don’t allow for visible body language, it’s difficult to convey the true meanings of messages, leaving them open to individual interpretation. Misunderstandings can lead to hurt feelings, decreased productivity, and issues with your corporate culture. For these reasons, it’s best to have an assortment of communication and collaboration tools at your disposal for use in different circumstances. Email and instant messaging are convenient, but more complicated communications should always take place using some sort of video interface, such as Zoom or Skype, as it allows people to interact with each other in a format that provides body language and non-verbal cues that other forms of correspondence don’t express.
When communicating with a group, make sure that any messages you share are very easy to understand. On that note, if you receive a message that isn’t understood, don’t be shy about asking for clarification. For collaboration to work properly, the right information needs to be passed along efficiently and comprehensively, so this makes proofreading especially important.
Keep in mind that etiquette matters in all communication. Jokes and sarcasm have their place, but that is not in professional group applications. Also, remember to check your tone. Without that face-to-face connection, tone is important, so take the time to double check your phrasing before hitting send. Spending a few extra seconds to go over what you’ve written to make sure that there aren’t mistakes, omissions, or other factors to get in the way of what you’re trying to say helps keep you from having to backtrack and explain things again later. This can also keep incorrect presumptions from influencing the results of your efforts. Given that your coworkers could be located anywhere around the world these days, try to be extra aware of time zones, and remember that waking up to 20 Slack notifications/ instant messages is stressful! Try to be respectful of the different time zones that your team are working from, and keep communication to those hours whenever possible.
Conduct regularly scheduled video chat meetings to maintain good communication with your colleagues and managers. This is the best way to keep lines open and make sure everyone is on the same page about whatever projects you’re currently working on. Make sure the video chat platform includes features such as file sharing, screen share, and multiple user interfaces in one chat. Be sure to always “show up” to your organization’s online meetings and be heard. If you need to communicate with your manager about sensitive topics, such as evaluations, progress reports, or even workplace stress levels, always do it over a video conferencing platform. It’s much easier to connect and fully emote how you’re feeling when your manager can see you.
Stressbuster Tip: Mobile Devices
Probably the biggest overall culprit common to all remote workers in causing stress is device use, especially smartphones. I’ve been yelling about this forever. While all of the sources of stress I’ve mentioned are significant, the UN study that prompted this blog found that frequent use of mobile devices appeared to be a “significant source” of added stress. Part of the reason has to do with blue light exposure from device use late at night, which remote workers are more prone to, and the serious impact it has on sleep schedule. In fact, this study found that it was linked with frequent waking at night: 42 percent of those who work from home report frequent night waking, while only 29 percent of office workers reported the same. This is especially important because poor sleep can add a significant amount of stress throughout the day.
Research has also connected higher levels of stress to the habit of constantly checking one’s phone. Remote workers certainly check their phones often, but what else might make people constantly check their phones? Hello, social media. Not only that, but surprise, social media use itself can also lead to stress, because of increased social comparison. I’m sure I’ve mentioned that before. Ultimately, the increased use of devices, and the constant checking of devices- whether for work or social media silliness- is absolutely associated with higher stress levels, insomnia, and ironically, social isolation. Okay, rant over. The solution for this one is pretty simple: limit the number of times you check your phone for non-work reasons, ie social media, each day, make it a point to put the devices down at the end of the work day, and declare a minimum 90 minute moratorium on all device and screen use, for any reason, before bed.
Stressbuster Tip: Make it Routine
Just as you create a schedule to keep you on track at work, design a morning and evening routine unrelated to your work, to tell your brain when it’s time to work, and when work is over for the day. This will help your brain create a distinction between work and home, which helps you switch off and decompress. Yet another good reason to get dressed for work, even though no one will see you- it helps you create that division. If you have young children at home, seeing you “dressed for work” will also help them to understand the distinction. Be sure to use time spent away from work for yourself, for family time, exercise, and self care.
Stressbuster Tip: Get Comfortable Saying No
Working from home, you’ll be faced with many requests, many of which you may need to refuse if you want to have enough time to get everything done. It can be surprisingly difficult to say no to people you don’t really owe your time to, simply because most of us can find reasons why a “yes” is a perfectly reasonable answer. We may think of their needs and see ourselves as a great answer for them, and not realize that saying yes to them means saying no to ourselves. We may also have our egos involved in having a solution for them. Whatever the challenge, realize that saying no to the time drains you didn’t plan for often means saying yes to the healthy life you truly want and need. For freelancers, learning to say no is an especially important skill. You may want to take on as much work as you can, but there’s only so much you can complete in a day. Know your limitations, set boundaries based on your schedule and workload, and don’t extend yourself beyond them. Be assertive, yet courteous, and your clients will still respect you.
Stressbuster Tip: Protect Your Sleep
A good night’s sleep rejuvenates the body so you can tackle the day ahead and can help lower the effects of stress during your workday. Because healthy sleep is vital for your productivity, do what you need to do to get it. It may sound like kindergarten time, but this includes setting a bedtime for yourself and sticking to it. Believe it or not, keeping a sleep schedule is one of the hardest things for most of my patients, even the ones I lecture to about it. In any case, when you do it for a while and feel the effects of getting adequate sleep, you’ll see that it’s well worth the effort. You already know that this is a no-no, but it bears repeating, as so many people blow it off: using screens and devices late at night alters your sleep patterns; it makes it very difficult to not only get to sleep, but to stay asleep at night, because it elicits brain patterns of wakefulness. So skip the screens before bed for a minimum of 90 minutes.
Stressbuster Tip: Accentuate the Positive
Another cause of work-related stress is focusing on the negative, and all of the things going on that are beyond our control. The best cure for stress is to concentrate on what is going right and the progress that is being made. I’m sure I’ve mentioned in various blogs that laughing and smiling lowers stress hormones like cortisol, epinephrine, and adrenaline, and can act sort of like a natural antidepressant that releases healthy hormones. When you’re working remotely, learn to take a few minutes to concentrate on positive things, and do what makes you feel calm and happy, even if these things may not be so productive and useful all the time, you’ll find you’re less stressed.
Stressbuster Tip: Slow Down
Life can come at us way too fast at times, and while you can’t just stop, you have to learn to pace yourself if you want to be a great remote worker. Slow down and remember that the best decisions are never made in a rush, and rushing is never the best decision. When you’re stressed, take a few minutes to breathe and clear your head. Try inhaling for five seconds, holding five seconds, and exhaling with another five. Do this a few times in succession if necessary. This will help you stay calm and focus, like a 90-minute yoga class, but in three minutes or less.
Stressbuster Tip: Eat Right
Diet does matter. Eating poorly will stress your body out, while eating right will restore balance and reduce pressure. Sometimes working remotely can be a recipe for a snack attack when you get distracted or don’t eat properly, so that’s double trouble. When you work remotely, make sure to eat three decent, well balanced meals each day.
Stressbuster Tip: Share Stress
Remember the two kinds of stress, good and bad, how they work for and against you, and the Yerkes-Dodson Law. Share your stress with coworkers to lighten everyone’s load. I’m not saying concentrate on it, just spend a few minutes each day releasing it, and then keep it moving.
Stressbuster: Keep it Moving
Speaking of which, you should absolutely be doing something to move your body everyday, so incorporate exercise into your non-work routine. I personally exercise every morning, first thing, to get my blood pumping; and I also use that time to think about what I have coming up in my day. You don’t have to spend two hours at the gym, even just 30 minutes of walking per day can help boost your mood and reduce stress levels, and you can do that on a treadmill if you have one, or just in your neighborhood if you don’t. That way you also get some fresh air and kill two birds with one stone. In addition, a pre- or post-work workout will help enforce those divisions in your brain to keep your work life separate from your home life, and prevent those lines from blurring.
Mental Health Benefits of Flexible Work
Yes, remote work can cause and exacerbate mental health issues, but it can also act as a support mechanism. I read a survey of over 3,000 professionals conducted in 2018 on flexible work options, which includes remote work, flexible hours, and reduced schedules; and the results were interesting. It demonstrated that flexible work options have a lot to offer in supporting mental health at work, and in life in general. In fact, the impact that work flexibility can have is so great that 97 percent of people surveyed said that having a more flexible job would have a “great,” “positive” impact on their quality of life. That same survey also found that work-life balance and commute-related stress are two of the top factors that make people want a job with flexible options. For people with mental health concerns, caregivers, and professionals at large, flexible work options appear to support efforts to improve the mental health of everyone. It should be noted that this study included people who self-identified as living with a chronic physical or mental illness, making up 16 percent of those surveyed; and also included people who were caregivers of someone with a physical or mental health issue, making up 10 percent of those surveyed.
There other notable way flexible work can positively affect mental health is directly related to commute-related stress. Even if a person loves their job, sometimes what they have to go through to get there is so stressful that it can negate that positive impact and result in added stress. The average commute time in the U.S. is approximately 26 minutes each way. But according to this survey, people who are most interested in flexible work options have even longer commutes, with 73 percent of respondents reporting commutes exceeding one hour. And 71 percent said they’d like to work from home just to eliminate commute-related stress, so this is clearly a huge factor in the appeal of remote work.
Other interesting findings from the survey on specifically how remote work could help respondents “reduce stress and improve productivity” included: 75 percent indicated by generally reducing distractions during the work day; 74 percent indicated by eliminating interruptions from colleagues, 65 percent indicated by keeping them out of office politics, 60 percent indicated by allowing for a quieter work environment, 52 percent indicated by giving them a more comfortable work environment, and 46 percent indicated by a giving them a more personalized work environment.
Remote work also provides more job opportunities in economically disadvantaged areas. Living through the decline of an industry or long-term high unemployment can negatively affect mental health. High rates of depression and anxiety are found in rural areas, especially among older adults who have often had their lives greatly affected by their community’s economic decline. Those living in rural or economically struggling areas may miss a key piece of the human experience: engaging in the workforce in a meaningful, long-term way. Remote work may be an solution to all of these issues by providing options to people in economically disadvantaged areas that may have mental health issues. It shows huge promise in bringing people in these situations back into the workforce, and there are partnering programs established to help spread the awareness of these opportunities.
Another population that would reap great benefit from flexible work options are neurodivergent individuals. For example, employees on the autism spectrum and people with mental disorders like OCD can benefit from more time working from home, as loud noises, distractions, and pressure to appear “neurotypical” in front of colleagues and coworkers takes an emotional toll and impacts performance. By working remotely, they can benefit greatly, both professionally and personally.
All professionals put a huge amount of time, energy, and focus toward work each day. By offering flexible work options, companies are signaling to their employees that they can, and should, devote more time to health and wellness. And that’s never a bad thing.
The other top factors that make people want a flexible job, in addition to better work-life balance and eliminating commute related stress, were family time savings. The constant pull that people feel between time spent with family versus time spent at work can negatively affect mental health, and flexible work options allow those priorities to coexist more peacefully. But this isn’t just a benefit for employees, because companies also benefit when their workers are healthier. Multiple studies have demonstrated that employees in unhealthy workplaces are likely to experience higher stress levels and lower engagement, and that these feelings actually spread throughout the workplace, negatively affecting productivity and corporate culture. Companies that give employees more control over when, where, and how they work by offering flexible work options, are supporting the health and wellness of their workers and enhancing the company’s culture and productivity, all at the same time.
The only demonstrable good thing ‘rona did was to reveal the opportunities that working from home poses for many companies that may not have considered it an option otherwise. Maybe it helped them realize how important health, both physical and mental, is as well. Nothing like a pandemic to set your priorities straight. Ultimately, mental health at work must remain a priority for employers, regardless of whether that takes place at the office, or at the employee’s home.
The news that remote work can actually be as stressful as working from an office, if not more so, may have come as a shock to many people who considered a work-from-home lifestyle to be one that’s less stressful just because it offers more personal freedom and eliminates a commute. Part of the stress experienced by remote workers may be due to the fact that those who work from home face a host of challenges that are unique to this particular setup. While there are certainly pitfalls, there are also a number of benefits. As remote working becomes more popular, it’s very important that companies adapt and put the right policies in place to ensure their employees don’t experience any undue stress or burnout, and still feel like a valued part of a team. The right kind of communication is key to overcoming the challenges, as is being proactive about using it. Everyone involved in the remote work equation, top to bottom, needs to think about what makes them productive, happy, and successful in everyday life, and try to replicate those things in a remote setting. When you implement ways to mitigate and manage the stress associated with working remotely, then you’re free to enjoy all of the many benes.
Hopefully now that you know how common some of these stressors are, you may feel less isolated in what you face, and more energized in tackling these challenges in the remote work environment. While employers should make the mental health of their employees an important priority, remember that ultimately, we’re all responsible for monitoring our own mental health, so if the simple exercises and routine changes I’ve suggested here are not enough, and workplace stress becomes too much for you to handle, it’s important to talk to somebody about it, so please seek professional help if that’s the case.
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Thank you and be well people!
Working Remotely, Part Deux
Last week I discussed some of the more personal issues I’ve noticed in remote workers, aka digital nomads, and made some suggestions (lectured?) on some things they should be doing for themselves in order to help ensure a better, more fulfilling life. As a global workforce, ‘rona allowed us, or forced us, depending on your point of view, to embrace the remote work concept. So much so, that many companies are progressively implementing it into their current strategies, and/ or incorporating it into their expansion plans. But given my profession, I have to ask, how psychologically healthy is it? It seems to me that as it stands in some companies now, not very. But certain personality types are somewhat uniquely suited to remote work, and thrive in the independence associated with it. Even if you aren’t necessarily one of them, humans are supremely adaptable beings. The questions then become, are you a person that could be happy working remotely, or could you make it work for you?
Many of my patients say remote work has been an answer to their most ardent prayers. But a disturbing proportion of them say it through a mouth of unbrushed teeth, from a face covered with scraggly unshaven beard, and topped with a head of tangled unkempt hair, so I’m just not buying what they’re selling. So what’s up with that? Why are some digital nomads, who are usually neat and tidy, suddenly messy and… messy?! The answer is deceptively simple: they’re SAD. Stressed, Anxious, and Depressed. But why, when most people’s greatest wish, to ???work from home??? has suddenly been granted? Can you hear the angels sing? Visual sound effects! I’m absolutely positive that it might become a thing.
Well, as with so many things in life, the remote work format is like an equation, with positives and negatives to take into account. In order to know if it works for you or not, you have to know the factors involved in order to effectively evaluate them. Today will basically focus on the more negative side of that equation, and some of the reasons why some people might feel SAD, even though they ???work from home??? Just wanted to test them to make sure they still worked.
I know I make a lot of jokes, maybe as the result of a coping mechanism that morphed into a habit, but there can be real and unanticipated mental health consequences as a result of the stresses associated with working remotely, and it is important to be aware of this fact. I should also note that it’s equally important to remain aware of it, as sometimes it can seemingly sneak up on you, or can even be a building phenomenon. While they can have a serious impact on mental health, these effects can also be very subtle, or happen within a dynamic and fluctuating range. The best idea if you start to notice that working from home is bumming you out, is to make some changes to improve your situation right away, because you don’t get extra points for spending more time miserable. Toward that end, next week’s blog will discuss some solutions to the issues I’ll be posing here today, along with the positive side of the remote work equation.
The Work Experience
Clearly, the actual experience of working from home is very different from doing so in a public office. But it also differs amongst each person who works remotely as well. On a basic level, the work experience is vastly different, because the quality of the home working experience largely depends on the home. Captain Obvious says it’s a much better experience for people that have dedicated rooms within their homes than it is for people in small apartments, or those who share homes, and therefore have to work in their bedrooms. Please note the five extra letters denoting the compound word- bedrooms– not beds, people. At any rate, companies must consider what they can do to help even that playing field a bit, if they want to improve productivity in a remote work situation for all of their employees.
Another huge difference in the remote work experience comes into play when we talk about technology. When it doesn’t work at home, it’s a bigger problem than when that happens at the office. One specific concern focuses on the speed of technology- or lack thereof- when working remotely. Most organizations demonstrated great agility in switching to remote working nearly overnight, but it’s common knowledge that technology never works as well remotely as it does in an office, where it’s laced together with high-tech cabling and hardware. Here in the good ole US of A, if our wi-fi drops out, we feel pretty indignant, but in some places on the planet, just getting a good enough signal to even access the internet can be challenging enough. It may not sound like a big deal, but internet connectivity is important, because it’s how technology talks. As a human, if you’re speaking with someone, and they choose not to respond for ten or fifteen minutes, or not at all, that would be frustrating, no? Especially if it happened all. the. time! All. day. everyday! That’s why connectivity is a big deal when working remotely; because the lack of it is very frustrating to humans, especially when we’re working.
If you’re working from home and faced with problems with wi-fi or getting a decent signal, it’s usually a persistent and pervasive issue. Because it can extend timelines and destroy deadlines, it affects your everyday business, and sometimes can even affect your employment. All of that of course impacts your stress levels, so you can’t really afford to underestimate it. The short answer solution is that you have to do whatever you can to mitigate the issue. Communicate with your supervisor, if you have one, and call whomever you need to call to have the issue resolved. Captain Obvious says your supervisor has a vested interest in making sure you’re adequately equipped, because they want you to get your projects done too. Or build an office entirely out of wi-fi hotspots and boosters, and maybe wear a tin foil hat. You decide.
No matter where you are, if your computer decides it doesn’t want to play ball, forget feeling indignant, we feel screwed. If you’re from a conventional office environment, and now working from home, any tech problems you may have probably won’t get resolved as quickly off site as they would in the office, and unfortunately, that can make it difficult- even impossible at times- to work remotely. The time it takes the IT software and people to diagnose and fix any issues further disrupts processes and extends timelines, adding to everyone’s frustrations. That’s if you even have IT people, people. If you’re the IT department, president, and janitor, that makes it a little more frustrating, and time consuming, to solve tech issues. Because bringing the office home depends so much on remote technology, when you multiply networking issues by slow running apps and software, working from home can equal big tech stress.
But it’s not just IT that has a long road to hoe in the remote work equation. Management also has to make big changes if the remote work equation is going to balance, because you can’t manage people the same way if you’re not with them. If nothing else, ‘rona proved to management that most employees do have the capability to adapt to remote work, and fairly productively and effectively, to boot. But in reality, management and supervisors themselves have to adapt as well. For it to work effectively, they have to learn to trust and enable their staff, rather than interrogate and demand. One of the biggest complaints I hear from employees is that while working remotely, they sense an implied, or sometimes more direct, mistrust from supervisors and management. They feel like every minute must be accounted for, like they have to prove they were working during the day, not just watching television or doing their nails. That said, one of the biggest complaints I hear from supervisors and management types about working remotely, is that they suspect that their employees are taking advantage of a remote work arrangement. I wonder if maybe they suspect they’re watching television or doing their nails instead of working?
This dichotomy would be funny, if it didn’t have the capacity to be so inherently stressful and anxiety producing in all parties involved in the equation. I think the concept of how to manage a person you’re not watching poses interesting psychological questions. When you feel like you’re “losing control” over something, or someone, a natural human response is to grip it tighter; evolution has built that into our brains. In a remote work environment, when a supervisor can’t see what an employee is doing for eight plus hours every day, that equates to the dreaded micromanagement. And in the minds of the employees or people being supervised, that often comes across as suspicion, and can feel accusatory. Taken together, this tends to breed mistrust; and so the problem begins. If the problem sounds complicated, imagine the solution. Personally, I can easily see both sides of this issue, but I know that traditional management methods aren’t the answer to a modern remote work problem, and that for the equation to balance long term, we have to take big strides on the road toward improving the remote work experience for everyone.
Isolation and Loneliness
As I mentioned briefly last week, isolation and feelings of loneliness are among the most commonly reported issues that remote workers face. While working remotely has some benefits, like allowing you to effectively bypass distracting and/ or annoying coworkers, it also prevents you from sharing pleasantries with your boss, clients, and the coworkers you doenjoy camaraderie with. You miss out on the more social aspects of traditional work life, like water cooler venting, office gossip, and bouncing ideas off of one another. These interactions simply don’t translate to tech like Zoom very well, and this lack of interaction between coworkers can be a detriment to team building and corporate culture. In a prolonged state, such as occurs in a remote work environment, this disconnectivity contributes to isolation and loneliness in individuals, and is associated with higher rates of anxiety and depression, as well as somatic symptoms, such as headache and generalized body pain.
If you’re a person who is already accustomed to, and appreciative of, conventional office life, and the steady rate of social interactions at work, the effects of switching to remote work might have a surprising effect, because our daily interactions help us reinforce our sense of well-being and belonging in a community. Researchers have demonstrated that loneliness as a result of isolation is actually twice as harmful to physical and mental health as obesity. One study I read found that 19 percent of people who work remotely report loneliness; and as with many such conditions or feelings, this poses a bigger risk when it becomes chronic. As you can imagine, people who not only work remotely, but also live alone, are especially at risk for feeling lonely, though I certainly see a fair amount of it in digital nomads who live with others.
Working from home can also feel like never leaving work, and another commonly reported cause for concern is burnout. I read a 2019 US study that polled remote tech workers. It found that 82 percent reported feeling burned out, 52 percent reported that they believed they work longer hours than their in-office counterparts, and 40 percent reported feeling as though they were required to contribute more than their in-office counterparts. These points are very common themes that people considering remote work, and new to remote work, should definitely keep in mind. In my experience with patients, this near compulsion to work longer hours is almost universal. I assume it’s the result of attempts to prove their ability to be productive from home, despite the presence of distractions and the availability of “extracurricular” activities that can accompany working from home.
For many people, it’s already difficult to maintain a healthy work-life balance when working from an office, and it seems that this is also the first thing to go when work goes remote. The lines start to blur, and every hour in a day becomes a work hour. If you’re behind on a project, you figure you can afford to spend the “extra” hours in your day on completing it. But not for long. After a much shorter period of time than you’d think, that becomes a dangerous practice. Five minutes for one more email becomes hours, and when you stop to look up, you’ve spent far too long working, and you haven’t moved for 13 hours. My response to burned out, remote workers is to remember that home is also your office now, so you’re not really leaving work unless you turn off all communication platforms. You have to make a concerted effort to leave work, just as you would if you worked in an office. So just as you would walk out the office door about nine hours after you walked in, when you’re working from home, you turn off the devices after about the same amount of time…or else risk the ravages of burnout. Besides, when you’re mentally and physically exhausted, you’re not at your sharpest, not doing your best work, and you’re bound to make mistakes.
Focus, Motivation, Distraction
Any number of factors in a remote work situation can make you lose focus and motivation, and chief among them are distractions. These are the things, intended or not, that distance you from your work. But the reverse is also true. When you’re not focused and motivated, it’s easy to fall prey to the siren’s call of distraction. Remember last week, I said that just because the refrigerator is a short distance away, that doesn’t mean you should constantly make the trip? Eating can be a distraction you act on when you’re bored. If snack o’clock happens every hour, or you’re having multiple versions of lunch, you’re distracted, or maybe looking for something- anything- to do, other than work. When you’re working remotely, you have a lot of freedom, which is generally a good thing in life. But understand that distraction is really the blacksheep cousin to burnout, and it’s all too easy to get sidetracked by it.
Some other favorite classic distractions include wanting to sleep in, kids, myriad chores, online surfing and social media, calling friends or vice versa, pets thinking playtime is whenever you’re breathing, and good weather tempting you to ditch work and go to the beach, mall, spa, movies, etc. It’s easier to become distracted because you may be the only one managing your time, and this is one of the big reasons why people may not be as productive at home as they would be in a traditional work setting. It’s also the biggest reason why employers and management don’t generally like the idea of working remotely. While it might seem that the only way to be a successful remote worker is to be a self starter with superhuman focus who is impervious to distraction, there are ways to manage distraction, focus, and motivation. I’ll get into all of that next week, but here’s a hint until then: having a door to shut is an incredibly helpful head start.
Working remotely can also be stressful because of the inconsistent wages that may be associated with it. The term freelancing is the one most commonly used for positions of this type, though you may better recognize the alternative terminology of independent contractors. It essentially means that they are self-employed, rather than being directly supervised or employed by someone else; as a result, they typically follow a remote arrangement. No matter what you call it, when you compare freelance work to a regular full-time job, there are some important distinctions. In a regular job, you know that no matter what happens, you’ll be paid (at least) the same amount each month; and since you took the job, I can only assume it’s sufficient to cover whatever bills it’s supposed to. But with freelance positions, because getting paid is typically based on contracts and invoices, payments can be pretty variable, and you don’t have any guarantees that your invoices will be paid on time. If the payor is unreliable, or decides to dispute, you have to expend time, and sometimes even money, to collect. Understandably, these variables and unforeseen complexities can result in cash flow concerns, and we all know that can lead straight to stressville. Not only is income variable, but workload is too. The temporary, variable, too much or too little nature of freelance assignments is intensely anxiety producing, and can wreak havoc with your sense of well-being.
Communication with coworkers, supervisors, and clients can be a minefield, as things can easily be misconstrued under the best of circumstances. In a remote work arrangement, when you often keep in touch through non-visual methods like email and instant messaging, communication is further complicated, and this can have some very unwanted effects. Fortunately or unfortunately, depending on how you look at it, the amount of damage that can result from ineffective communication falls along a spectrum, from “uh oh” to “oh no!” One big problem in general, not just in a work setting, that may serve you well to remember, is that you can’t really get a sense of a person’s tone via typed electronic communication, because they can’t read facial expressions or hear your tone of voice. To the recipient, words read the same way regardless of whether you were smiling or yelling when you typed them. I can’t tell you how many times I’ve heard a complaint from a patient start with, ‘And then he texted…’ because instant messaging, while convenient, can also be a recipe for instant miscommunication.
In a work setting, most tone concerns have to do with accuracy; that the words you’re using are literally sending the right message. Do you have a tendency to be very lighthearted and positive, and therefore potentially at risk for sounding like perhaps you’re not serious enough about a certain topic with a client? Or maybe you have a tendency to be sarcastic and risk that same issue? You might be most vulnerable to this when the person doesn’t really know you, or in circumstances where you may be sending an instant message you don’t give as much thought to as you would a more formal email. As you might imagine, these are situations where the smiley face in cool shades emoji doesn’t really cut it. ?
Probably the most common communication issue I hear about is the lack of communication. Just as with the tech issue I mentioned previously, when a coworker is unresponsive, humans get frustrated. And understandably so. When you need an answer, but the person you need it from is uncommunicative via whatever digital channels you try, it can pose a problem. In the office, you could simply visit that individual’s desk and see them in person, but in a remote setting, that’s not an option. Since it’s work, you may have a deadline to complete a project, so not having that answer might make it late, and that may have a negative impact on your reputation. It can be a gnarly domino effect, I get it. But I can tell you that the answer is not to sendthem a message you may regret later, because chances are very good that’ll have an even bigger impact on your reputation, than the original lack of communication on their part would’ve had.
Another thing to keep in mind when communicating electronically is not to set yourself- or anyone else for that matter- up for disappointment, by asking questions that really can’t be answered satisfactorily via these methods. If you’re seeking appreciation or other “feelings” on job performance in a text, you’re nearly bound to read disappointment in the reply, whether it was intended or not. Save the sticky wickets for more personal communication methods, even if they’re not necessarily the easiest choice. While some sarcasm or jokes may be funny, some people may not think so, and that can lead to all sorts of misunderstandings that can have a serious effect on company culture, productivity, team dynamics, and relationships with coworkers, supervisors, and/ or clients. Remember that nothing dies on the net, and everything leaves a digital trail, especially in a remote work setting, so things can come back to bite you later. Lastly, I would suggest that you always think twice whenever you instant message someone in order to avoid instant embarrassment and instant regret, proofread messages to make sure nothing’s getting in the way of what you’re trying to say, and save the complicated stuff for face to face when possible, or at least for video chat when it’s not.
Next week, the working remotely blog continues- I’ll address some solutions to all of the issues I mentioned today, and then I’ll tell you about the positive side of the remote work equation.
I hope you enjoyed today’s blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
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When Home Becomes Work: Challenges of Working Remotely
Captain Obvious says that while coronavirus is responsible for thrusting us (with IT people kicking and screaming) into working remotely as a necessity, it was already a fairly common practice BR (before ‘rona). In fact, a statistic I read indicated an overall global trend toward remote work long BR, with a global increase of 159% between 2005 and 2017. As far as US stats on remote work go, 17% of US employees report that they worked from home five days or more per week BR, but that jumped to 44% DR (during ‘rona). As for the future, polls indicate that totally AR (after ‘rona) a minimum of 16% of American people who had previously worked outside the home BR will switch to working remotely from home at least two days per week AR. In addition, more than one-third of US firms that had employees switch to remote work DR believe that it will remain more common at their company AR. Globally, polls now predict that 25% to 30% of the earth’s workforce will work remotely multiple days per week by the end of 2021. In short, the genie is out of the bottle, and it’s not likely to go back in.
Many employers and business leaders think that going remote is as simple as sending an employee away from the office with a laptop and a to-do list, but unfortunately, it’s not that simple. In truth, there are real life consequences associated with working remotely. It may sound like a dream come true, but from where I’m sitting, it’s become more like a nightmare. A lot of people have gone back to their outside offices now, but many are still working from home. This is either because they- or their employers- are still too reluctant to make the switch and return, or have found it beneficial enough that it behooves them to continue remote operations. Regardless of why you may find yourself doing so, working remotely does present its own set of challenges, not the least of which is that companies were essentially forced into it overnight, without benefit of true preparedness and system checks.
But in any event, if you are still working remotely at this point, you may find yourself continuing to do so indefinitely. I find that most of my patients enjoy lounging in their pajamas all day as they work from home, never leaving their house because it’s such an effort to get dressed; though they fail to understand why they’re so anxious, irritable, and depressed. The good news is that there is a way to do this work from home deal effectivelyand happily, and even excel at it, while still having a personal life and functioning appropriately. The bad news is there are some not-so-nice ramifications and consequences associated with the routine, and a lot of people are starting to recognize this after far too long being “trapped” at home. Spoiler alert: most people actually are not. The bottom line is that your whole world doesn’t have to change just because you’ve eliminated a commute. Out of necessity DR, it did change for a time, but at this point, it’s time to get out and reclaim some normalcy. Some of the issues that come up with working remotely are more rooted in the personal realm, and deal with basic self care and psychological health, while others center more on professional matters. But don’t kid yourself, there’s a lot of overlap and cross reactivity betwixt and between them. So this blog marks the beginning of a series dedicated to identifying the issues surrounding working remotely, and discussion on how to address them appropriately, with some tips and tricks and coping methods thrown in for good measure.
Today’s blog will deal with some problems that I’ve noted in video calls and appointments with my patients. I sometimes call them “duh!!” issues, because a lot of you are going to be like, “Duh, Dr. Agresti, we all know that!” Well, what some people know and what they do are two very different things. If you’re depressed, and you haven’t brushed your hair or gotten dressed for a week straight, then you might hear me say, “Duh, go brush your hair and get dressed, you’ll feel better.” I suppose you could also call them “helll-ooo!!” issues, as in, “Helll-ooo… you really need to take a shower!!” That’s a real thing, people. Not all of the things I’ll discuss are quite that extreme, but my list of remote work must-do’s includes some personal care requirements that must become- and remain- second nature to you; they must be part of a regular routine, regardless of the fact that you may be all alone, with nobody even there to see (or smell) you. So that’s where we’re starting; with just some very basic, very simple recommendations for a better life and more success in a remote work situation. Most of these you probably already know, but you may not be doing them. Allow this to be your kick in the can if that’s the case.
-Sleep in your bed, but then get out of said bed when you get up in the morning. Don’t just wake up and roll over to reach for your laptop to start your day. I cannot tell you how many patients I talk to while they’re working in bed; they’re literally in bed 24/7. Get out of bed!
-Create a dedicated office, preferably with a door you can close to keep things quiet and help you avoid distractions. If you don’t have a spare room, then at least create a dedicated work space. Even a corner of a room will do if that’s all you can spare. You really just need room for a table or desk large enough to hold a computer and whatever supplies you need, and a chair. Try to make it as comfortable- and functional- as possible.
-Make a schedule and stick to it. And be sure to keep an accurate account of the hours you work. I’ll be discussing supervisory micromanaging in the next blog, but if you keep a regular schedule and good records of your hours, you’ll have all the info you need if you are questioned by a micromanaging supervisor.
-Now that you aren’t commuting to and from the office, you’re going to be physically moving a lot less. So you must make time each day for exercise. So many of my patients that have switched to working remotely have gained a fair bit of weight and almost all of them have lost serious muscle tone. When you’re working from home, it’s easy to get comfortable and complacent, and turn into a flabby flaccid couch potato. Do something to move your muscles every day.
-Eat three square meals each day, and no more 24/7 snack attacks. Just because your refrigerator is mere steps away doesn’t mean you should make the trip every 30 minutes. A small midmorning, midafternoon, or late night snack is okay, but that’s it. Note my word choice: or not and. Three decent meals and one small snack each day is acceptable- just try not to go too crazy- and try to make it reasonably healthy, maybe a yogurt, cottage cheese, or piece of fruit. Like, a box of girl scout cookies is not a snack, people.
-Because you aren’t commuting to and from the office, you’re also rarely going to be required to go outside. So you must make a special point to go outside every day, even if it’s just for 15 minutes after lunch. Human bodies require vitamin D, and nothing’s a better source than sunlight. Try taking a walk around your neighborhood after you have lunch, just something where you’re exposed to the sun.
-A lot of my patients are complaining of decreased intimacy and a lack of sexual energy since they started working remotely. So my next suggestion is to do whatever you can to be close to your partner. Emotional and physical intimacy are important, so have sex, but maybe don’t combine this suggestion with the one above it, unless you have an excellent privacy fence.
-When work is over, stop working. It can be tempting to work more hours when you’re at home. This may sound counterintuitive, but it’s true. To avoid this trap, work the same schedule and number of hours each day at home as you would if you were commuting to an office. Don’t try to cram jam in four16 hour days days a week in order to take a 3 day weekend, unless it’s an unavoidable situation, and/ or you receive permission or clearance from a supervisor if applicable.
-Make sure to get adequate sleep. Go to bed at a reasonable time, get up at a reasonable time, and try to stick to a sleep schedule. And remember to avoid blue light exposure for at least two to three hours before you go to bed, otherwise you’ll have a hard time falling asleep.
-Keep your regular grooming routine- you’ll feel better about yourself. If you didn’t get the hint, shower every day. Brush your hair, and your teeth. Shave and put on makeup if you’re about that life. Work is not a pajama party, so get dressed in appropriate clothing. You don’t have to wear a suit or heels, but make an effort to be presentable, even if there’s no one to present yourself to.
This isn’t rocket science, people. Basically, you should follow the same routine you always have, and do everything you would do if you were going to an actual outside office or workplace: go to bed at a reasonable and regular time on work nights, get up at a reasonable and regular time each morning, and resist the urge to hit snooze 97 times. Shower, shave, get dressed in decent clothing, and eat breakfast. Then go to work in your in-house office space, just as you would if you were going to commute to an office. Avoid distractions and get your work done. Take a one hour lunch break maximum, and make sure to actually eat something reasonable, but avoid eating at your desk. Think about taking lunch outside for some fresh air, vitamin D, and a change of scenery, and you can kill multiple birds with a single stone. After lunch time is not nap time- and it hasn’t been since kindergarten- so after lunch, go back to work until it’s time to stop at the end of the day. Make sure to put in a full day’s work, while also being careful not to overwork. Behave as if you owned the company and were paying employee salaries. Supervisors will be less likely to micromanage you to death if you give them no reason to mistrust you or doubt your motivations.
No Nearly Naked Zooming
Captain Obvious says that videoconferencing has become a big part of our lives DR, and will continue to be long AR. Here’s a fun fact for you, Zoom saw phenomenal growth in 2020, and ended the third quarter of 2020 with an astounding report of 367% year-over-year revenue growth. If you had stock in Zoom Video Communications BR, which I did not, that’s a very fun fact for you. And get this… Zoom hosted an average of 300 million meeting participants per day throughout 2020. That’s 300 million people that don’t need to see you in your underwear, people. Same goes for gnarly, used-to-be-white, ripped t-shirts with yellow pit stains. Get it? If you didn’t, here’s the simple concept: put on a shirt. One with at least two buttons at the top.
Drinks, not Zinks
Even if you dress appropriately for video conferencing calls, there’s really no replacement for real deal interaction, because shockingly, humans are hardwired for human connection. Even Captain Obvious wouldn’t bother with that one. It’s just not possible to simply erase our evolutionary zeitgeist and replace millions of years of in-the-flesh interactions with technologically mediated virtual communications. While Zoom and its brethren have helped us in our attempts to recreate a certain degree of face-to-face experiences, that’s really as much thanks to the power of human imagination as it is to technology; and nothing stifles human creativity and imagination like isolation and loneliness. As a society, we spend a lot of time creating tech to replicate real-life experiences, but it’s a cheap substitute. In most situations, we’re better off spending a larger portion of that time experiencing real-life personal experiences. If you live alone and work from home, you could literally spend days without any human contact. You should make an effort to socialize, but remember to do so responsibly and wear your mask, people. Call a friend and suggest you meet for dinner, coffee, or lunch, or go on a date night. Drinks are hands down better than Zinks, so arrange to meet a friend IRL.
Loneliness or isolation is one of the most commonly reported issues that remote workers and digital nomads face, along with anxiety, stress, and depression. Next week, in part deux of this remote work blog, I’ll talk more about those, as well as some professional issues that can come into play when working remotely, and I’ll make some suggestions on how to deal with them. Then in part three, I’ll talk about some specific anxiety and stress busting techniques you can incorporate into your routine during the day, as you need them, and they won’t complicate or derail your work schedule, or negatively affect your productivity. In fact, they’ll do just the opposite.
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How You “Catch” Feelings
You’ve probably heard the expression “Smile and the world smiles with you,” or at least heard Louis Armstrong’s rendition of the song that refers to it, When you’re smiling, in the movie Analyze This with Robert De Niro and Billy Crystal- which, being a shrink, I of course found very amusing. Expressions don’t become embedded in the public’s consciousness for no reason, so where does this one come from?
Maybe you’ve experienced a situation where “contagious laughter” has swept through a room, or even been the catalyst for it yourself, because of your “infectious laugh.” If you watch the news, you’ll eventually hear a reporter describe how “panic ensued” while covering certain events involving “mob mentality.” But what do these things really mean? How can feelings be shared or transmitted between people, even when they’re all strangers to one another?
The answer is a phenomenon called emotional contagion, or EC, the subliminal process by which emotions are transferred from one person to another, such that the receiving individual experiences the emotions as their own. Living in a covid-19 world, we’re all too aware that it takes just a cough or a handshake to spread germs from one person to another, but you can “catch” feelings far more easily than you can catch covid, and far faster. The process takes just milliseconds, faster than the blink of an eye. EC is an important and primitive instinctual process that forms the basis of interpersonal communication, but don’t let that confuse you, that doesn’t mean it can’t or doesn’t occur amongst groups, because it absolutely does. I should note that EC can also be induced in people via some inanimate objects and cultural artifacts, such as photographs, movies, cartoons, and music. Think about crying at sappy movies or dancing in the car when your favorite song comes on. Not only that, but EC isn’t a “humans only” phenomenon; studies have demonstrated that it also occurs in all other primates, some birds, and it’s even been demonstrated in rats.
To further the covid analogy, the “virulence” of EC and the susceptibility to EC vary by individual. That is to say, some people can be more effective at transmitting it, and some can be more prone to feeling its effects, i.e. susceptible, but everyone is essentially both to varying degrees. EC isn’t type specific, meaning that research has found that both positive and negative emotions- enthusiasm, joy, sadness, fear, and anger- are easily passed from person to person, typically without either party being aware of it. You can be going about your business, feeling whatever you’re feeling, and have an encounter with someone doing the same thing; then afterwards, you feel differently, for reasons that you can’t specify. That can be a bad thing or a good thing, depending on a number of factors that I’ll get into. So apparently Forrest Gump’s mama was right… life is like a box of chocolates- you never know what you’re gonna get. Covid and chocolates- it’s a mixed metaphor day, people.
How Emotional Contagion Happens
At the most basic level, it works like this: if someone is happy and smiles at you, it tends to cause you to smile back, and that act of smiling back actually improves your mood and causes you to feel happier. But how and why? You might’ve noticed I’ve said that EC is a process; in fact, it involves three stages: mimicry, facial feedback, then contagion.
As people communicate, they express themselves not only through language, but also through gestures and facial expressions. Throughout a communication exchange, individuals constantly read each other’s faces and body language, then instinctively and unconsciously tend to reflect it i.e. copy it; that is called mimicry. When a person then displays the emotion on their face through mimicry, those muscle movements trigger the actual feeling associated with the emotion, and they then get a subjective experience of that emotion i.e. they start to feel the emotion as their own, which is sometimes referred to as adoption. This is because the area of the brain that is activated through the unconscious act of mimicry is the same area that normally would’ve been activated if the person had initiated and performed the action themselves. Same area of brain activated equals same response, regardless of the catalyst for the activation. Handily, this phenomenon is explained by “mirror neurons” in the brain. These neurons fire whether an individual initiates the act themselves, or observes the act being performed by another individual. So the act of mimicry causes the observer’s neurons to fire, and thus “mirror” the activity of the first person’s neurons. It’s sort of like monkey-see, monkey-do for neurons.
When you put all of the stages of the EC process together, it works like this: when someone is happy and smiles at you, you will typically smile back (mimicry) and that act of smiling back actually improves your mood (facial feedback) and ultimately causes you to experience that happiness as your own feeling (contagion).
Role of Emotional Contagion
Humans are social beings. We are born equipped with the evolutionary capacity of EC to help synchronize our emotions and express our wants and needs. A simple example would be a newborn baby crying to be fed because it’s the only way they know how to get food from their caregiver. When they cry and are then fed in response, it reinforces the mechanism. In this way, EC acts as a primitive tactic that continues to develop, and later assists in the recognition and processing of feelings, and a cumulative understanding of how to deal with them in an appropriate manner.
Emotional contagion contributes to empathy, and there is a direct correlation between the two. In other words, decreased sensitivity to the EC results in a decrease in empathy. They are also linked by the fact that both involve the monkey-see, monkey-do mirror neurons, but they are not technically the same thing. Empathy is the capability to share and understand another’s emotion and feelings that is often characterized as the ability to “put yourself into another person’s shoes,” in an effort to experience what the other person is feeling. But it is a conscious choice, so you know the source of the emotions you feel. In contrast, EC is an automatic, subconscious and subliminal process, generally mediated through mimicry of facial and/ or vocal expressions, whereby your feelings or emotional states are influenced by those of another person, such that you experience, or adopt, those feelings as your own. This is also termed emotional convergence or synchronization, and the source of the feelings is typically unknown, and often unexamined.
Scientists agree that there is an emotional climate and culture that tells us which emotions we should or should not display and when. Our understanding develops over time, and guides us in making behavioral decisions according to what is and is not socially acceptable. Imagine that you somewhat reluctantly made plans with an acquaintance, but then they see you and tell you they need to cancel them. Inside, you may actually feel some sense of relief, but instead, you noncommittally say, “Well, that’s too bad, but okay.” On the other hand, if you are insensitive to EC, and therefore are lacking empathy, you might say, “Phew, because I didn’t want to go anyway.” But because you realize that saying that would probably hurt the person’s feelings, and/ or would make you look like a cad, you respond appropriately. This is an example, albeit an extreme one, of how EC allows you to instinctively know what is appropriate, and alter your response and exhibit the correct emotional behavior to maintain success in relationships. In fact, because the automatic processes of EC happen so quickly, you have the ability to change your reply on the fly, even mid-sentence, based solely on the other person’s emotional response as communicated by their facial expression, in order to avoid a social faux pas. All brought to you, in a matter of milliseconds, courtesy of emotional contagion. Which gives you an idea of how important it is in avoiding problems and.
Factors Influencing Emotional Contagion
As I mentioned in the beginning, some people can be more effective at transmitting emotional contagion, and some can be more susceptible to its effects, but nearly everyone is affected, albeit at varying levels and times. There are many factors that influence susceptibility to EC; most of them essentially boil down to the common bases of individual differences, such as age, genetic predisposition, personality traits, gender, and early emotional experience. But it has also been found to vary between interactions, based on the type of interaction, intensity of the expressed emotion, mood at the time of the interaction, and the level of empathy and power dynamics between the individuals involved. All of these influence the intensity of the contagion and have an impact on how likely a person is to “catch” an emotion.
But in fact, you don’t really have to guess how susceptible you may be to EC, because there is an accepted way to accurately measure it, called The Emotional Contagion Scale. Designed in 1997, it takes the form of 15 questions that measure individual differences across five basic, cross-cultural emotions: love, happiness, fear, anger, and sadness, by determining how likely a person is to mimic those emotions. I’ve included the scale and scoring instructions at the end of this blog if you’re interested in taking it. In the meantime, I’ll continue with the factors that tend to influence EC.
Some personality types generally have greater awareness of emotional states, their own as well as those of others, and are therefore more open to the process of emotional contagion in general, in both transmitting emotions to, and receiving emotions from, others. They are also generally more sensitive, attentive, and skilled at reading non-verbal cues.
Other people who are more expressive, meaning that they wear their hearts on their sleeves- and their faces- may be more likely to transmit or share their emotions because they telegraph their feelings more powerfully. Not only that, but the more expressive someone is, the more likely another person is to notice that expression and mimic it. And remember those mirror neurons? They come into play here bigtime, because when that emotion is reflected through mimicry of the associated facial expression, those muscle movements trigger the actual feeling in the brain, brought to you by mirror neurons. On the other hand, people who have a stronger internal response to emotional events- whose hearts may race when they’re nervous, even if they seem calm on the outside- may be more susceptible to catching other people’s moods.
EC is also influenced by the level of intimacy, and therefore empathy, between the individuals involved. People who know one another well and are in frequent contact are typically more affected by EC; this is generally true whether they are the transmitter or receiver. Have you ever found yourself tearing up when you see someone else crying? It’s perfectly fine if you have, and can even be considered a very good sign in relationships where it serves as an indicator of the level of emotional investment. It is more likely to happen when the person crying is someone close to you, such as a spouse, child, parent, or close friend. In fact, studies have shown that emotional convergence occurs more often in relationships that are more cohesive and less likely to dissolve. Not surprisingly, people living under the same roof are especially likely to catch each other’s emotions and moods, as they are the types of relationships where individuals tend to become more similar in their emotional responses.
That said, studies have shown that mere acquaintances, or even strangers, can catch each other’s moods, though the degree to which it happens does depend more on their individual susceptibility. But if you bump into someone in your neighborhood while getting the mail or taking out the trash, and they smile and just say hello you, they can make you feel a mood boost. Or if you’re in the elevator in the morning on your way to work, and someone is impatient and grumpy because the door opens to let someone new on board, they can easily influence your mood, even if no words are exchanged. Normally that’s not amusing, but loyal blog readers may be chuckling if they recognize that as a little DISC humor from last week. If you don’t know what on earth I’m thinking right now, read last week’s blog on the DISC model, because even this instruction is laced with it!
Researchers have also found that language and word choice drives some part of the contagion process, as negatively charged words, i.e. strong language, like “hate,” “worthless,” “anger,” and “sad” are more likely to increase susceptibility to the emotion being conveyed. So strong language generally induces a stronger EC response, which isn’t always great news. There’s enough of that in the world, no need to propagate it.
We’ve learned that age plays a role in influencing EC. Scientists very recently published research describing how the moods of teenagers were affected by those of other teenagers around them. If you’ve ever raised a teenager, this definitely resonates; but more not-so-great news, bad moods were more potent. They also found that when a teenager “catches” a bad mood from a friend, the friend’s outlook becomes more cheerful. That’s a very interesting finding with very mixed news- good for the friend that’s transmitting, but bad for the person that catches it. So much for sharing means caring… more like take this away and don’t stay! Remember that I’m a shrink, not a poet, people.
EC is influenced by gender as well. I should preface this by saying that the relationship of gender to emotional contagion can be a pretty thorny one, as it’s a complicated issue. You’ve probably noticed that I used the word “appropriate” to describe the ideal effects EC has on the expression of emotion, i.e. behavior. The issue is that behavior is often governed by cultural rules which actually vary according to gender; that makes it difficult to make hard and fast “rules” about which gender “should be” expressing which emotion(s), and how and to what level it “should be” expressed. Using a purely theoretical example, women “should be” nurturing caregivers, so they are more susceptible to EC. In other words, it’s super biased, sexist, and constrictive.
Probably as a result of this issue, the research into gender differences in EC has had mixed results. An early study hypothesised that because women were more emotionally expressive than men, they would be more susceptible to catching emotions; and indeed, the results from the EC scales of the participants confirmed this. In contrast, another study found that there were only minor differences between men and women in their experience of “caught” emotions. However, it also found that both men and women had a stronger emotional response when the emotional model used was female rather than male. Still another study found that gender differences came into play when the expressive model was displaying a threatening emotion, such as anger. They found that women responded to the angry faces with more expression, whereas men suppressed their emotional expression, and some even displayed a tendency to smile in response. The scientists hypothesised that this was due to the effect of socialization in the expression of emotion, with women being more likely to attempt to communicate their distress and men more likely to mask or suppress it. This is consistent with the concept of hegemonic masculinity, which is shrink speak for having stereotypically male dominant traits. Yet another study examined moods, before and after pairs of friends talked about multiple predetermined topics. It found that, after talking with a troubled friend, women’s moods were more likely to deteriorate in general, on both sides of the contagion equation (hey, maybe I am a poet) but men’s moods were far less changed, regardless of whether the troubled friend’s mood improved or not.
Regardless, all of the differences in these studies can only be interpreted as confirmation of the fact that cultural and behavioral “rules” are actually responsible for the mixed results and ensuing confusion when it comes to attempting to define how gender affects the expression of EC. And that’s pretty much what we figured, right? So now you know for sure.
Emotional Contagion: Practical Applications
Captain Obvious says that if you’re unhappy, being able to adopt the emotions of a happy person may allow you to feel better and more motivated. And clearly, a positive mindset helps you feel less stressed, which has a positive impact on emotional and physical health. By now you know that this phenomenon helps people connect on a basic emotional level, but EC also has some less obvious practical applications and implications as well, and some of these are an argument for how it can be developed as an intentional tool. In fact, some people subscribe to a broader definition of the phenomenon of EC as “a process in which a person or group influences the emotions or behavior of another person or group through the conscious or unconscious induction of emotional states.” I can appreciate the value of applying EC as a tool to motivate others, but I don’t appreciate it when it’s used as a tool to manipulate others into serving personal interests. First I’ll talk about the positive applications and implications of EC, then I’ll address the less than positive.
Humans generally want to be accepted and understood. To that end, it’s beneficial to know what other people are thinking, if they agree or disagree with you, if they’re understanding what you’re attempting to convey, and whether or not you’re connecting with them on a very basic emotional level. In a way, EC is sort of like a very primitive form of mind reading, as it gives you an idea of what another person is thinking, and therefore feeling.
EC is important to personal relationships because it fosters emotional synchronization. If you want to connect with a person on a deeper level, you want to be “in sync” with them, the euphemism derived from the term, and awareness of the phenomenon can give you an idea of whether your attitudes and beliefs are sympatico with another person’s.
EC can be developed as a skill for use as a tool for effective communication, and therefore one that would be especially important for public speakers and trial attorneys, and people in motivational type positions like sports coaches, among others. Think about listening to a lecture where the presenter is dynamic and expressive, and clearly believes what they’re saying; then contrast that with a presenter who is monotone, slumped over the podium, not moving, and clearly disinterested. Same idea goes for the coach or captain of any team. If one is animated and motivated and obviously believes and expresses that you’re a valuable and capable player, and that your team will win, will that be more effective than one that is totally unmotivated and seems unconvinced that the team is up to the task? Who would you be more inclined to listen to and believe in either of these situations? Even Captain Obvious says that the answers are so clear that they don’t even require responses.
EC has survival value as well. It has been conserved, developed, and reinforced throughout human evolution, which doesn’t tend to keep unnecessary processes. In fact, evolutionarily speaking, EC has evolved, in part, to ensure survival. The brain is hard-wired to keep you safe, and that’s one of the reasons it’s especially attuned to pay more attention to negative emotions like fear and pain. Speaking of which, let’s talk about a real world example of EC’s survival value. Imagine that you were on a plane, and (heaven forbid, but just go with it people) there was some emergency; you may not know how serious the situation is or how concerned and prepared you should be, but by paying attention to the emotions expressed on the faces and in the voices of flight attendants and the pilot(s), you can infer signals that may be critical to your survival. Like when to assume the crash position. I say early… very, very early. Like maybe immediately after boarding. Jk, people.
EC can also be useful in work settings, but only when the moods swing the right way. Numerous researchers have found that when business leaders are in a good mood, members of their work group not only experienced more positive moods, they also experienced fewer negative moods. Studies have also demonstrated that groups with leaders in an upbeat mood were more coordinated and actually expended less effort on tasks than groups with more downbeat leaders, which made them more efficient. But keep in mind that this is a double-edged sword, and a co-worker’s or boss’ bad attitude can spread quickly through a company and create a toxic environment for everyone.
Emotional Contagion: Conscious Strategy
We’ve just discussed how EC can be used as a positive tool, but as I mentioned, EC can also be used as a strategy for… let’s say, potentially less altruistic means.
Emotional Contagion in Marketing
Because it influences thoughts and feelings, EC results in changes to mood, emotions, and behaviors; and studies confirm that this includes consumer behaviors. This was verified by setting up experiments that videotaped participants’ facial expressions before and after exposure to specific photographs. After analyzing the changes in the expressions, these studies concluded the following:
-Participants who saw a smiling model in an advertisement mimicked the picture, smiling back, therefore confirming the process of CE.
-The positive emotion conveyed by the facial expression was also associated with a positive evaluation of the product displayed in the advertisement.
Therefore, as expected, the advertisement with a positive expression of a smiling model elicited a more positive attitude, sympathy, and increased perceptions of reliability and intentions to purchase, as compared to the neutral condition before the photograph was shown. In other words, if an advertisement can make you smile, laugh, or stimulate EC through any positive means, you will feel more positive about the product that the advertisement features. It will make you believe that you need that product, it is the best, better in every way when compared to similar products; and it will do that as if you thought these points yourself, thanks to the monkey-see, monkey-do mirror neurons.
Advertising and marketing execs know this and use it. I’m not saying that this is good, bad, right, or wrong; I’m just saying that EC is purposely used as a tool by employing advertisements that feature cute and cuddly babies, beautiful women in bikinis, hunky men in uniforms, and whatever imagery execs think will elicit a positive response, to sell you a product that you may or may not need, and that may or may not actually be as awesome as you might (literally) be led to believe. So be aware.
Emotional Contagion in Dating
Remember how I used the words “less altruistic” to describe some of the ways EC can be used as a strategy? Well, for this particular application, I’m going to replace those words with “morally reprehensible.” And I suspect many of you will agree. There’s a guy that developed what he calls a “method,” (I use quotation marks because it isn’t actually a method) for men to study and apply EC in an effort to manipulate women into “dating” them (which is actually just a euphemism for having sex with them), and all for the “low, low price of” (my best announcer’s voice) of whatever over-inflated amount he charges for it.
There are so many faults in this that I almost don’t know where to start. First, given my profession, I find it especially deplorable that a person would intentionally manipulate someone else’s feelings just because they can’t manage to get a date, i.e. have sex, with someone any other way. That said, my views on this would remain the same if I were a garbage man. And, it does bother me that this guy is so sexist that he clearly can’t even envision, much less appreciate, the fact that he developed a program “for men to get women,” and clearly doesn’t recognize that men can love men and women can love women; not that any program like this should exist, regardless. Also, not for nothing, but the light that this casts the users of this “method” in isn’t flattering at all. Helll-ooo, desperation. And that has to be considered, because I can almost guarantee you that eventually, your target will find out that you’re using psychology to manipulate them- which won’t make them very happy- because this program is fake.
Speaking of fake, who wants to be fake enough, in order to manipulate people long enough, to get them to sleep with you? And people with even an average amount of awareness can usually sniff out fake like two week old fish, because that’s what fake- and this program- smell like. And if your potential target didn’t have enough awareness before reading this blog, they certainly will after. So the solution to this problem is to share this blog and spread the awareness, people.
Unfortunately, I’m sure that this may cause some of you to want to try to look it up, even though I haven’t given you the name of this program. I say unfortunately, because I don’t want this guy to get any more credit than he already has; and because regardless, you’d be wasting your money. I can save you that, plus a lot of time and fake energy, and tell you that it won’t work, for any number of reasons. I can even make an alternate suggestion if you’re lonely enough to consider paying for something like this “method” which isn’t a method. Why don’t you use that money and make an investment in yourself, see a psychiatrist or psychologist and try to find out why you might not be attracting whatever person you want to be with, because I can say with some authority that attraction really starts with you, so you have to know yourself to attract other people.
I’ll even help you out here and now and tell you that, of the six factors that influence attraction, the most important psychological factor is reciprocity, which basically means that you are more likely to like someone who likes you. Some of the other factors that influence attraction are things like familiarity and similarity, which- guess what- also depend on you knowing yourself. So I suggest you get to know more about you. The very worst that could come of it is that you gain some perspective and some self esteem, and that’s half the battle won.
I apologize if my opinion is too clear, or offends anyone, but everyone has people they care about- friends and family- and most people wouldn’t want them to be manipulated and conned in this way, just to serve someone else’s purposes. That perspective is empathy at work, by the way, and hopefully it’s contagious. Maybe this guy and his “method” upset me so much because I expend such a huge amount of time and energy undoing the damage caused by manipulation. Just a theory. Anyway, moving on to slightly less manipulative applications of EC as a strategy.
Emotional Contagion in Digital Interactions
Emotions can even spread through all of our digital interactions, because EC doesn’t rely solely on visualizing facial expressions; it can also be influenced by emotions that are implied via language and word choice. All digital interactions are subject to EC, including text messages, emails, instant messages, and most importantly, social networks. It’s the most important because the moods are propagated i.e. spread to, and influenced by, the mood of your friends, that of your friends’ friends, and their friends’ friends, and so on. This has been demonstrated by one study that looked at online social justice movements, and which found a demonstrable “amplification effect,” wherein people more frequently liked replies that were actually more emotional than the original message posted. This would be a very effective method for propagation, because again, language and word choice play a role in the contagiousness of EC. But that’s another double-edged sword.
And speaking of social network studies, one dominant social media site, whose name rhymes with placelook, conducted a particularly controversial study that came to light in 2014, when scientists published a paper revealing that, in 2012, researchers (who were also employed by the same social media site by the way) conducted a study into EC. In the study, they surreptitiously altered the news feeds- the main page that users land on for a stream of updates from friends- of nearly 700,000 users. Feeds were changed to reflect more “positive” or “negative” content, in order to determine if seeing more sad messages makes a person sadder. My response: duh.
After analyzing more than 3 million posts, the team found that people exposed to fewer positive words made fewer positive posts themselves, whereas those exposed to fewer negative words made fewer negative posts. In other words, you are what you feed, not what you eat, on placelook. The experiment also demonstrated that personal interaction and verbal clues weren’t necessary for emotional contagion. It’s worth noting that both of those things had already been discovered from separate studies, designed and conducted by different researchers, one of which found that the very existence of feeds was making some users sadder. So basically, now we are absolutely sure, as if we didn’t know before, that placelook can manipulate your mood, which does affect your perspective, what you buy, why you buy it, whether you vote, how you vote, and pretty much everything else in your life. It certainly has the biggest effects on how you interact with your social media friends, especially after your news feeds are altered… helll-ooo!!
If you’re wondering about permission, here’s the scoop on how news feeds were surreptitiously tweaked without warning: placelook users agree to the social giant’s general terms of data use when they create a profile, and researchers tracked emotional responses of test subjects by judging any subsequent changes in their use of language, which is covered in those terms. It’s unclear if you, or I, were tested, and it will remain that way. Ultimately, as users, the check-box agreement gave permission for this kind of psychological experimentation.
I should add something. One reporter that had been aggressively following this story for Forbes got a response from placelook, which stipulated that, “…the research was conducted for a single week and none of the data used were associated with any specific user.” They further explained that they do research to make the content “…as relevant and engaging as possible” and that, “a big part of this is understanding how people respond to different types of content, whether it’s positive or negative in tone, news from friends, or information from pages they follow. We carefully consider what research we do and have a strong internal review process. There is no unnecessary collection of people’s data in connection with these research initiatives and all data is stored securely.”
One last note on this topic: another reporter had apparently spoken with the editor of the placelook study, who is also employed by them, and she reported that even they thought the mood study was creepy. I agree, and I also think that, when it comes to studies, placelook may not know exactly what they’re doing, but they definitely know what they have the power to do, and what a platform with access to the personal interactions of more than a billion users can do. And now I’ve said all I’ll say about the placelook study controversy.
When it comes to the ways emotional contagion can be used as an external tool, potentially on- or against- you, the take home message is be aware and beware.
Emotional Contagion: Final Thoughts
With any luck, people catch all the positive emotions, a colleague’s enthusiasm for a promotion at work, or a friend’s excitement over an engagement, and miss the negative ones. But what goes up must come down. Research suggests that just being around someone who’s stressed can increase your own stress levels. Other studies have found the same to be true for depression. Negative emotions, like sadness, fear, pain, and anger, are more contagious; and on top of that, they can be damaging to your overall health, as they can lead to sadness, depression, fatigue, decreased energy, and stress. Ultimately, negative states of mind may increase the risk for heart disease and other serious health issues over time. You’d think that with such negative impacts, people would always stay away from those who emit negativity. But it’s not that simple.
While the idea of making yourself impervious to other people’s emotions may be appealing, putting up an emotional barrier isn’t the answer. This is because the cost of it is the loss of empathy. You have to consider that shutting out other people’s dark moods precludes you from catching their good ones as well. So how should you respond to negativity?
First, consider this: research indicates that people can catch something that isn’t actually there to begin with, for the same reasons why EC confers survival value. Because we are wired to pick up on threats in the environment, we are susceptible to interpreting situations negatively. In addition, humans tend to create our realities in accordance with our beliefs, so if we go into an ambiguous interaction believing the worst of someone, we tend to act in a way that makes the other person more defensive, or worse, antagonistic; and this confirms our original view. The lesson is that reality is what you make it, so try to make it positive, even if it seems negative.
Since you can’t- and shouldn’t- shut out all negativity, what can you do to regulate it, while still ensuring that the positivity comes through loud and clear? There is some strategy involved in managing this, and like EC, it’s a skill you can work on. Take some time and reflect on your own emotional state.
Now we know how easily so many things can affect our mood, and then affect the moods of others, without us even realizing it. Below are some tips to manage EC if you think your moods “infect” others negatively, or vice versa, and some ways to do yourself a favor when they do.
Awareness is Key
When you become aware of the emotions you exude toward others, it helps you recognize when you’re picking up on the negative or positive emotions of others; this will allow you to create change if needed and protect your own emotional well-being, as well as that of the people around you. Take care of yourself when you need to. If you feel exceptionally stressed, first remember the possibility that you may be feeling something that’s not actually there. If you find it is actually there, then proceed with management.
Seek Professional Guidance
If you find that you’re more aware or sensitive to the moods of others, you can always evaluate those relationships and those triggers. Talking with a trained professional can help you in thought pattern recognition and guide you into healthy coping skills to ward off EC.
Create Your Happy Place
Surround yourself with things that make you happy. You’re less likely to succumb to someone else’s bad mood if you keep your surrounding environment full of things that bring you joy. So create your own personal happy place, at home and at work, that can help you if you start feeling like you’re coming down with a bad case of negativity. Bring in plants, put up photos of your pet, partner, children, and friends, and listen to your favorite music.
Accentuate the Positive
Incite radical acts of positive contagion: play upbeat songs on your way home if you’re stressed, like on the way home from work. Find proactive ways to boost your moods, and those of loved ones will increase as well. If you don’t want another person’s negativity to affect you, try turning the tables by smiling and trying to keep your voice cheerful. This not only helps you feel more positive, but the other person might also mimic your body language and catch your mood, making it a win-win situation.
When you feel negativity creeping in, share a funny video, tell a good joke, or enjoy your favorite sitcom or movie for a boost of positivity. Just like offering positivity, laughing can help improve your mood and relieve stress, and it can also spread to people around you.
One of the best ways of avoiding contagion with people who are down is actually to engage with them. Do things with them that will lift both their mood and yours, like taking a walk, sharing a meal, working out together, or just being generally supportive and talking through things.
It’s Not Personal
People have their own issues and they have nothing to do with you. Don’t encourage or even engage with bad behavior, or anything else that doesn’t feel right, and that includes online. Bad behavior breeds bad behavior. If you send out calm, positive signals, you are more likely to attract the same, and less likely to attract the opposite.
Remember that changing the behavior of an adult who thrives on negativity is typically very unlikely to happen, and the attempt can wear you out, especially because you’ll find you’re doing it over and over. If you’re dealing with an angry boss or an anxious father, always remember to take time for yourself to think the situation through before engaging and trying to convince people to change their bad behavior.
When you’re in a bad mood, there are also ways to avoid infecting other people with your negative emotions. They all boil down to one central theme: control. Realize that you have the power to “infect” a room via contagion, especially in your own home, and use that as an incentive to keep emotions in check and safeguard your colleagues, neighbors, and loved ones from your negativity.
We know what inoculation means, so try to do that first to make yourself less susceptible to bad moods that you can easily pass on to others. This includes the basics, like getting adequate sleep, eating well, exercising, and cultivating a sense of purpose.
Compartmentalizing can be useful in managing the effects of EC. You might think you have every right to be cranky, but if you consider how it can infringe on other people’s rights to exist in a content state, you might find it easier to set aside your negative thoughts and emotions. So shelve the bad mood when you know you’ll be interacting with other people. You can always choose to wallow in your negativity later, in private.
Show some emotional awareness by asking a long-term partner, or someone else you trust implicitly, for input on whether you’re giving off negative vibes too often. If so, work to regulate your sadness, anger, and anxiety through therapy or mindfulness, or by modifying your expectations or looking at the situation from a different perspective.
If you’re particularly irritable, consider isolating yourself. We’re all familiar with this one. You might be better served by watching happy movies or going to bed early.
Ask yourself some questions:
-What types of emotion do I give off and how does that affect the people I interact with, my family, roommates, spouse, colleagues, etc?
-How easily do I let others affect my emotions? Am I even aware when it’s happening?
-Are the people in my social networks the type of people I really want to surround myself with?
-Whom do I feel my best around?
-Who reinforces my strengths and best qualities?
-With whom am I the best version of myself?
-Are there actions or changes I need to make?
Keep in Mind:
-You aren’t responsible for the feelings of others, only your own.
-You may not be able to help other people, but you’ll never be of much help if you’re not feeling well, either. You can always take the time to help yourself, and you’re absolutely worth it.
-People usually share their experiences in the only way they know, and this is especially important to remember when they’re depressed.
-Check out the Emotional Contagion Scale to see how vulnerable you are to catching and adopting the feelings of others.
The Emotional Contagion Scale
This examines a person’s tendency to mimic five basic emotions: sadness, fear, anger, happiness, and love.
If you want to take it, forget everything you’ve just read- temporarily, mind you- and remember that there are no right or wrong answers. Read each question and choose the answer that best applies to you using the key below. Scoring interpretation instructions are at the end.
4 = Always; 3 = Often; 2 = Rarely; 1 = Never
1. If someone I’m talking with begins to cry, I get teary-eyed.
2. Being with a happy person picks me up when I’m feeling down.
3. When someone smiles warmly at me, I smile back and feel warm inside.
4. I get filled with sorrow when people talk about the death of their loved ones.
5. I clench my jaws and my shoulders get tight when I see the angry faces on the news.
6. When I look into the eyes of the one I love, my mind is filled with thoughts of romance.
7. It irritates me to be around angry people.
8. Watching the fearful faces of victims on the news makes me try to imagine how they might be feeling.
9. I melt when the one I love holds me close.
10. I tense up when I overhear an angry quarrel.
11. Being around happy people fills my mind with happy thoughts.
12. I sense my body responding when the one I love touches me.
13. I notice myself getting tense when I’m around people who are stressed out.
14. I cry at sad movies.
15. Listening to the shrill screams of a terrified child in a dentist’s waiting room makes me feel nervous.
The highest possible score is 60, and the higher the score, the more susceptible you are to emotional contagion.
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Thank you and be well people!
Personality and Behavior: DISC Model
Wikipedia defines personality as the “characteristic set of behaviors, cognitions, and emotional patterns that evolve from biological and environmental factors.” I’m sure they probably go on to list those factors in the third through fifth paragraphs, so this short definition seems neat and tidy without really committing to much. But as we all know, when you’re dealing with humans, things aren’t ever simple. In reality, there’s no formal or universal definition, but that’s okay, because it gives psych nerds something to argue about. Because there’s no universally accepted meaning, all definitions are essentially theories, most of which center somewhere around an individual’s psychological motivations and resulting interactions with their environment. Alternatively, people can refer to it as character, temperament, or disposition, but in my opinion, no matter what you call it, the bottom line is that each person has a unique combination of characteristics or qualities that form a distinctive set, and these govern their perspectives, motivations, and behaviors.
Now, before I really get into this week’s topic, this is a good place for me to add a disclaimer: When addressing concepts like personalities and behaviors with a large group of people, I have to simplify and generalize, because these are nuanced subjects with far too many influential and individual factors than I could ever address in a blog. So if there are any psych police out there on patrol, please don’t write me a ticket for simplifications and generalizations.
Now that that’s out of the way, I’ll start with a question: have you ever noticed at times how different the judgement and behaviors of your family and friends can be from your own? My profession means that I literally spend the majority of my life examining what someone does, their behavior(s), and why they do it, their motivation(s). I’m sure you’ve been in many situations where you’ve asked yourself, “Why did he/ she dothat?” or “What were they thinking?” While sometimes it can be frustrating to have a difference of opinion with people, the truth is that life would be boring if we all thought and acted the same way.
So how do you understand and reconcile these differences? Believe it or not, the starting point of understanding people is actually pretty simple; accept just one fact: that while I’m sure you’re fabulous, everyone is not like you. In point of fact, everyone is not like everyone else, either. If you search for a definition of the word personality, you’ll invariably find the words “characteristic” and “unique” included, along with other synonyms. These are all evidence of, and pretty words to convey, one fact: that we’re all different. We all carry our life experiences and opinions with us, and we filter everything we see, hear, and experience through them, so they color our perceptions and motivations; and these in turn influence our behaviors. I believe the saying goes something like “different isn’t bad, it’s just different,” and I can roll with that. Each of us is unique; we think differently, and therefore behave differently. It’s really a good thing; far, far better than the alternative.
But behavior and personality can be easily misunderstood, and if that becomes chronic, these repeated misunderstandings tend to become areas of stress that affect a person’s happiness, which in turn affects motivation and productivity in every aspect of life. If you’ve ever been in a situation where you felt like you couldn’t “get along” with someone, on some fundamental level, you probably just don’t understand them. A lack of understanding and acceptance of differences can lead to tension, disappointment, and miscommunication. When issues like these go unresolved, they tend to build, and ultimately, can lead to resentment. Resentments can be notoriously difficult to untangle, so in the end, it’s far better to avoid the original problem if you can. Admittedly, that’s often easier said than done, especially if you don’t have a clue what on earth is going on inside the mind of another person. I’ll shed some light on that, so that hopefully by the end of this blog, you’ll have more insight on what that may be.
If the problem is associated with misunderstanding(s), then it only follows that the solution to that problem probably has a lot to do with understanding. When I say that, I’m not talking about holding hands and singing kumbaya with everybody… I’m saying that accepting that people have different opinions from yours, and then making reasonable attempts at understanding where they’re coming from, will serve you better than being obstinate and absolutely refusing to do so. That said, the success of nearly every solution is in its application, so how exactly do we better understand people? There is a relatively simple visual model that can serve as a key to understanding the basics on how people behave. It’s called The DISC Model of Human Behavior, aka DISC model. It can be applied to loosely categorize a person’s personality traits and extrapolate their motivating factors and behavioral styles. More on that later.
Before I get into the DISC model, time for another disclaimer: Because personality and behavior are such diverse and nuanced human attributes, and since the DISC model is a theoretical one, it isn’t used for diagnostic or clinical applications. In other words, when you come into my office and tell me your life story, I’m not running through it in my head looking to categorize you as one of four types. People are complex and DISC is by nature more simple and general; and rarely, if ever, does anyone fall perfectly into any one type. That said, I’m covering this model today in blog form because I think it’s an interesting and practical way for everyday non-clinical people to better understand themselves and others, and to apply that in an effort to communicate more effectively with people who have differing perspectives… which is basically everyone!
Why Personality Traits and Behavior Matter
Why should you care to learn about behavior and personality or the DISC model? Believe it or not, personality and people skills are important aspects of life: personal, social, and workplace. If you can’t work in cooperation with other people, it can be really tough to make it in this world. It can affect your ability to keep a job or advance your position, to make friends, and to keep peace with partners, family, and friends. We’re all familiar with IQ, our intelligence quotient, and we spend years in school developing and learning how to effectively use our minds. But developing your personality to effectively use behavior is also vital to successful living. Studies have shown that technical skill, beginning with intelligence and developed through education and experience, accounts for only 15% of success in the workplace; the other 85% has been shown to actually come from people skills. These skills are developed through learning better ways to behave, communicate, and interact with others. The DISC model is commonly applied as a tool to increase your ability to understand yourself and others, and communicate more effectively with everyone.
History of the DISC Model
Even if it sounds like one, this isn’t a new age, hippy-dippy-trippy idea. Au contraire. Let’s get in the waaay-back-machineand go to Greece, around about 300 B.C.-ish. Why? To see Hippocrates. Whenever I hear his name I can’t help but smile despite myself, because it always makes me think of Bill & Ted’s Excellent Adventure. When they met Hippocrates, they mispronounced his name like the murderous mammal + crates, pronounced like it rhymed with plates, and in their characteristic burner dude affectations. And now the memory of that movie quote is inextricably linked to his name in my mind.. I hear them say it every time. Anyway, back to the topic at hand. Hippocrates was a physician, but also a rebel! And thankfully so. At a time when most of his fellow Greeks were attributing sickness to The Fates, superstition, and the wrath of the gods, Hippocrates espoused the firm belief that all forms of illness had a natural cause. Which, believe me, is a far better alternative than worrying about appeasing The Fates, the witches, and the gods. At any rate, perhaps in pondering the natural basis of illness, or maybe ways to prove his theory to his colleagues, Hippocrates began to recognize that the behaviors of individuals seemed to follow distinct patterns, and he began to loosely categorize the differences in these behaviors.
While Hippocrates had the original notions on behavioral patterns, many psychologists and scientists continued to explore and expand on his theory. In 1928, Dr. William Marston wrote The Emotions of Normal People, in which he theorized that people are motivated by four intrinsic characteristics or factors that direct predictable behavioral patterns, and described these four factors as personality types. He then created a visual model that utilized a circle divided into quadrants to represent these four personality types. In his original work, he labelled them as D, I, S, C: Dominance, Inducement, Submission, and Compliance. And poof… the DISC model was born.
From what I’ve read, Marston was kind of a freaky guy, and the slightly(?) deviant undertones of his word choices “dominance, inducement, submission, and compliance” seem to confirm this. Even though he was a well respected psychologist by day, he was also a surprisingly successful comic book author by night, and is in fact credited for creating the comic book character “Wonder Woman.” She’s an Amazonian, a race of female warriors from an island where men were not allowed. This actually isn’t too much of a stretch, because Marston was also a champion of women’s rights. Despite this, he seemed to have had more than his fair share of female-centric scandal in his life. I found several references that said that he invented the first lie detector test, but also found some that credit someone else with this feat. Regardless, apparently he wasn’t exactly always on a first name basis with the truth, because he lied to the public about being a bigamist. Evidently, after he married his second wife (who was also a former student) and she moved in with him and his first wife, he told the public she was just a relative staying with them… and they fell for it. So during his bigamist marriage, they all lived together in a ménage à trois, and he actually fathered children with both women. But in spite of the scandal he caused with his colorful private life, Marston’s theories of human behavior are still widely accepted today.
What is DISC Used For?
The DISC model is applied as a personal assessment tool designed to ascertain a person’s personality traits and behavioral styles. It’s essentially a series of questions that evaluate human behavior in various situations. For example, it looks at how you respond to challenges, rules, and procedures, how you influence others, and what your preferred pace is.
While Marston’s theories and DISC model were generally well received, some organizations later modified it and created a negative tool used by organizations and employers to weed out undesirables. But in later years, to reflect a change in attitudes, it has since seen several iterations. Now all existing forms of it are used exclusively as positive tools of inclusion rather than being negative and judgemental. DISC assessments are used to foster understanding and respect, improve people skills, build better teams, increase productivity, reduce conflict, and relate and communicate with others more effectively; all of this is meant to translate to increased cooperation and the creation of better working relationships. In fact, the DISC model is widely accepted in the business community; so much so that many organizations and employers incorporate it into all associate training programs, but it is especially used in fields and positions related to sales, marketing, customer service, and management.
I was surprised to learn that DISC assessments have confirmed use in 70% of the Fortune 500 companies, including Exxon/Mobile, General Electric, Chevron, and Walmart. Pretty impressive, as these are strong companies with good management; and according to what I read, that’s where most of them focus their DISC utilization.
But you can also apply the model to your personal life, to learn more about yourself and grow as a person, increase people skills, illuminate your own motivations, and uncover your strengths and blind spots, some of which you may not even be aware of. As a bonus, you’ll then be better prepared to answer certain questions that may come up in life; for example, when a prospective employer asks “What would you say your strengths are?” or even better, when your spouse or partner looks at you exasperatedly and asks, “Why the *bleep* do you do that?” Wouldn’t it be nice to have a handy answer to that one?!
In the end, despite its generalizations, the model is sort of like “personalities for dummies”- not that I’m saying you’re dummies- I’m just saying it’s a simple and useful way for non-clinical people to better understand themselves and their own motivations, and apply that knowledge to relationships and everyday interactions, both in and out of the workplace.
DISC Terminology: Four Behavioral Patterns
Since Marston’s time, while the general concept surrounding the DISC model has remained the same, some of the terminology has changed several times. Some publishers and reference models use a lowercase i in DISC as a way of distinguishing between different models and for trademarking assessments and reports (read: as a way of making money). DISC with a capital I can’t be trademarked, so I’ve used that form for our purposes. The terms used to convey the DISC personality/ behavioral types have also changed for several reasons: to reflect a change in attitudes and more positivity, as a way of distinguishing between different models, and for trademarking purposes; so now there are a few different versions that vary slightly. Different companies and publishers determine and apply their various terms, and I’ve listed the most popular ones, in an order with the ones that I find most applicable first and Marston’s being last.
D: Dominant / Dominance
I: Inspiring / Interactive / Inducement
S: Supportive / Steadiness / Submission
C: Cautious/ Conscientious / Compliance
No matter what term is used, the basic traits and behavioral styles are essentially the same; I’ll cover those later.
I should note that now some publishers have apparently modified assessments to further extrapolate personality traits and behavioral styles; I’ve seen some that will describe up to twelve types, and even an article that referenced exactly 41 personality types. I didn’t fact-check or verify that, but just wanted to mention it as kind of an outlier.
This model is based on two fundamental observations about what drives people to behave the way they do, which are essentially their motivators. I want to emphasize something to keep in mind: as you look at fundamental behaviors, you’re looking at tendencies, not absolutes. Most people will tend to behave more one way than the other, but will behave both ways, to greater and lesser degrees, depending on the situation they find themselves in. Also, behaviors are fluid; they can and do change over time and vary by situation.
DISC: Two Fundamental Observations
(Internal) Motor and (External) Focus
-Some people are more outgoing, while others are more reserved. This is each person’s “pace,” or “internal motor.” It is sometimes simply referred to as the “motor” drive. Some people engage quickly and always seem ready to go, and these are considered outgoing types. Others engage more slowly or more cautiously, and these are considered reserved types.
-Some people are more task-oriented, while others are more people-oriented. This is each person’s “external focus” or “priority” that guides them; sometimes simply referred to as “focus.” Some people are more focused on getting things done, and these are considered task-oriented types. Others are more attuned to the people around them and their feelings, and these are considered to be people-oriented types.
Visualizing the DISC Model
As I mentioned, DISC is a visual model, and it utilizes a circle to represent the range of “normal” human behaviors. You can imagine it as a clock face.
To illustrate the application of the first fundamental observation, aka motor drive, imagine you divide a circle in half horizontally, as from 9 o’clock to 3 o’clock on a clock face. The upper half then represents Outgoing (or fast-paced) people, while the lower half represents Reserved (or slower-paced) people.
To illustrate the application of the second fundamental observation, aka focus drive, imagine you divide a circle in half vertically, as from 12 o’clock to 6 o’clock on a clock face. The left half then represents Task-Oriented people, while the right half represents those who are more People-Oriented.
When the two motor and focus circles are superimposed to combine them, you end up with four behavioral tendencies to help characterize people: Outgoing, Reserved, Task-Oriented, and People-Oriented. The balance of these four tendencies shapes the way each person sees life and those around them.
To illustrate the incorporation of the two drives (motor and focus) you can imagine one clock face with two divisions (horizontal and vertical) and therefore in four quadrants. Starting at 12 o’ clock and moving clockwise, you would then see Outgoing at 12 o’clock, People-Oriented at 3 o’clock, Reserved at 6 o’clock, and Task-Oriented at 9 o’clock.
By combining the two drives, you now have four total behavioral tendencies: from the upper left quadrant, moving clockwise, those tendencies are then:
Outgoing and Task-Oriented (upper left quadrant)
Outgoing and People-Oriented (upper right quadrant)
Reserved and People-Oriented (lower right quadrant)
Reserved and Task-Oriented (lower left quadrant).
Then to further define and describe these four behavioral tendencies, the DISC terms are added, one letter per quadrant: Dominant, Inspiring, Supportive, and Cautious.
Illustratively, these are added to each of the four corners of the diagram, again starting with the upper left quadrant and moving in a clockwise direction: Dominant in upper left quadrant, Inspiring in upper right quadrant, Supportive in lower right quadrant, and Cautious in lower left quadrant.
Once added, starting with the upper left quadrant and moving in a clockwise direction, each DISC term correlates with the four behavioral tendencies such that:
Dominant types are Outgoing and Task-Oriented (upper left quadrant)
Inspiring types are Outgoing and People-Oriented (upper right quadrant)
Supportive types are Reserved and People-Oriented (lower right quadrant)
Cautious types are Reserved and Task-Oriented (lower left quadrant).
What emerges is the full graphical description of the complete DISC model.
To make the quadrants easier to discuss, we typically call each quadrant a behavioral style or type, though some people use the phrase personality type. I’ll spare you the specifics as to why, but technically speaking, it’s not really accurate to use the word “personality” type or style with the DISC model, because it’s actually a behavioral model. While I tend to refer to it as a behavioral style, either term- personality or behavior- is generally acceptable for a colloquial discussion or a blog.
DISCussion: Four Primary Behavioral Styles
While DISC refers to placement within four primary behavioral styles, always keep in mind that each individual person can, and usually will, display some of all four behavioral styles depending on the situation. The resultant blending of behavioral tendencies is often called a style blend, and each individual’s style blend will have more of some traits and less of others.
The Dominant “D” Style
An outgoing, task-oriented individual will be focused on getting things done, solving problems, making things happen, and getting to the bottom line, usually as quickly as possible. They can sometimes be blunt, outspoken, and somewhat demanding. The key insights in understanding and developing a relationship with this type of person are respect and results.
The Inspiring “I” Style
An outgoing, people-oriented individual is generally enthusiastic, optimistic, open, and trusting. They thrive on interaction and love to socialize and have fun. This person places emphasis on persuading others and is usually focused more on what others may think of them. The key insights in understanding and developing a relationship with this type of person are admiration and recognition.
The Supportive “S” Style
A reserved, people-oriented individual will place an emphasis on cooperation, sincerity, loyalty, and dependability. They enjoy working together as a team and thrive on helping or supporting others. They usually focus on creating and/ or preserving relationships and on maintaining peace and harmony. The key insights in understanding and developing a relationship with this type of person are friendliness and sincere appreciation.
The Cautious “C” Style
A reserved, task-oriented individual enjoys independence, and often fears being wrong. They will seek value, consistency, and quality information, and will usually focus on details, facts, rules, accuracy, and being correct. The key insights in understanding and developing a relationship with this type of person are trust and integrity.
I should also note that some organizations use a shortcut in discussing the different behavioral types, where the dominant type is also known as High D, the inspiring type is also known as High I, the supportive type is also known as High S, and the cautious type is also known as High C.
Behavioral Styles: Elevator Test
As you’ll see, this is a pun meant to give you an idea of your own behavioral style and to help you identify others. Captain Obvious says it’s not meant to be scientifically or clinically valid, people, it’s just to illustrate the four behavioral styles in a relatable, “everyday situation” kind of way.
The doors are about to close on a person who is eager to get on an elevator, which already has four people inside. One of the four people already inside glances at their watch, because they’re in a hurry and would prefer not to wait. But also inside is the bubbly, smiling, energetic second passenger who actually holds the door open while encouraging the newcomer to climb aboard. The third rider doesn’t mind if the new person gets on, and they simply step back to make room while patiently waiting for them to do so. The fourth passenger barely looks at the new guy, as they’re busily calculating the sum of everyone’s weight in their head while also looking around to estimate the age of the elevator.
Did you see yourself in this scenario? Did you recognize the behavioral styles of the other elevator passengers? Read on to find out if you’ve got it.
This scenario demonstrates behavior of the Dominant (outgoing / task-oriented) person who wouldn’t really mind if the elevator door closes before the new guy can get on, because they’re just focused on getting where they need to be as quickly as possible. But that possibility is dashed by the Inspiring (outgoing / people-oriented) person who feels energized by the addition of yet another positive interaction to their day. The Supportive (reserved / people-oriented) person just calmly steps back to make room for the new guy because they empathize with him and are willing to be accommodating. All of this while the Cautious (reserved / task-oriented) person almost can’t help but make sure the added person doesn’t exceed the weight limit of the old elevator and potentially cause them all to get stuck… or worse.
Notice that there were four different people who responded to the same exact event in very different ways? People are motivated differently, and therefore think differently, so they behave differently.
Every individual person has a unique combination of characteristics and qualities that form a distinctive set, and these govern their perspectives, motivations, and behaviors.
The DISC model developed by Marston is used as the basis for varying assessments of personality traits and behavioral styles.
While it is simplified and generalized, it can be an effective and empowering tool to examine motivating factors, to uncover and address blind spots, and to identify, highlight, and articulate strengths.
It can be used by people to better understand themselves and others, and to apply that understanding in an effort to improve people skills and to communicate more effectively with people who have differing perspectives.
It is commonly used in the professional arena, especially in Fortune 500 companies. Employers often use it for determining placement of new employees, to build better teams, increase productivity and communication, reduce and resolve conflict, and foster acceptance and understanding.
Each person has a unique blend of all of the major personality traits and behavioral styles to a greater or lesser extent.
Behavioral patterns are fluid and dynamic, and can change over time or as a person adapts to his or her environment.
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Thank you and be well people!
The Skinny on Psychostimulants, Part 3: Modafinil
Over the past two weeks, we’ve been discussing the psychostimulants amphetamines and methylphenidate, which stimulate the central nervous system by increasing synaptic concentrations of the neurotransmitters dopamine and norepinephrine to varying degrees, and are used in pharmaceutical preparations primarily for treating ADHD, narcolepsy, obesity, and binge eating disorders. They are also used off label to treat cognitive dysfunction and depression in cancer patients and as part of a regimen in chronic pain patients, as well as being used recreationally to get high, study, take tests, improve focus, and/ or stay awake for extended periods of time. In this last installment on psychostimulants today, I’ll discuss a popular drug called modafinil.
While modafinil isn’t technically a psychostimulant, it acts “stimulant-ish,” and ultimately elicits similar effects as its stimulant brethren. It actually belongs to a class of drugs called eugeroics, which are wakefulness-promoting agents, and is also considered a nootropic. Nootropics are “smart drugs,” substances that can enhance brain performance or focus. Strictly speaking, the term nootropic is generally reserved for prescription and over the counter (OTC) pharmaceuticals and supplements that are not taken therapeutically to treat a particular illness, but rather to enhance cognitive function in healthy individuals beyond what is usually considered “normal” in humans. Nootropics or smart drugs can alternatively be referred to as performance enhancers or pharmacological cognitive enhancers (PCE’s). To cover all the bases and avoid ticking off the biohackers, I suppose you could call modafinil a nootropic eugeroic. Whatever!
Originally synthesized in France in the 1970’s, modafinil was approved by the FDA in 1998 and is used primarily to treat sleep disorders, including narcolepsy, shift-work sleep disorder, and residual/ excessive sleepiness in obstructive sleep apnea despite continuous positive airway pressure (CPAP).
It is used recreationally to increase focus and learning, for cognitive and physical performance enhancement, and to stay awake for extended periods of time. Modafinil is taken by mouth, usually once a day. Most people who work during the day take it in the morning on either a full or empty stomach, but shift workers who take it to promote wakefulness do so before their shifts begin. Modafinil is marketed under the trade name Provigil, while its R-enantiomer armodafinil is marketed under the name Nuvigil. If you recall, enantiomers are mirror image molecules, like left and right hands, that generally induce similar pharmacological effects. Indeed, the two are used to treat the same disorders, but armodafinil is a newer compound and has a slightly different side effect profile than its older sibling modafinil. More on that in a moment.
Both forms are Schedule IV drugs, which defines them as having a low potential for abuse and low risk of dependence. Some other examples of Schedule IV drugs are benzodiazepines like diazepam and alprazolam. That said, while I concur that (ar)modafinil has a low risk of abuse and dependence, I beg to differ on the risk of abuse and dependence being comparable to benzos. In my experience, benzos are far more commonly abused, and the incidence of dependence on benzos far exceeds that of modafinil. However, while studies have not shown any significant withdrawal effects from discontinuation of modafinil, any drug that provides stimulant effects to the brain can enforce drug taking to some extent, and thus carry the potential for dependency, which could lead to withdrawal symptoms upon cessation. Anecdotally, people have reported reduced energy, lack of motivation, and depression following discontinuation of modafinil; therefore, modafinil should always be tapered when discontinued if it has been used for a long period of time.
I’ve found that modafinil carries a very low risk of side effects, and a very mild profile when present, one that may be comparable to having an extra cup of coffee. The most common side effects are potentially occasional minor headaches, possibly some jitters, and sometimes trouble sleeping, which is usually related to the time of dosing being too late. But the official list of side effects also includes: dizziness, upper respiratory tract infection, nausea, diarrhea, nervousness, anxiety, agitation, and dry mouth. For armodafinil, you can add upset stomach to the list and take away upper respiratory tract infection. Something you have to be aware of when taking modafinil are the synergistic effects of other stimulants. If you consume coffee, energy drinks, or anything with caffeine, you’re likely to have much stronger stimulating effects, and these may include jitters or anxiety. It is wise to avoid anything else meant to make you or keep you awake when taking modafinil, at least until you are aware of its effects on your system, and even then you should still use great caution. As with any medication, if you take other prescription or OTC medications, be sure to disclose them with your prescribing physician to discuss potential interactions. Modafinil has a half-life of 12 hours, meaning that after 12 hours, the effects will start to wear off, but half of the drug will still remain in your system.
Modafinil’s off label and “lifestyle” use in healthy individuals to stay awake for extended periods of time and increase cognitive alertness and physical performance is well documented and likely exceeds its therapeutic utility as far as numbers go. In some professional groups such as pilots, academics, and scientists, modafinil use is reported in the ballpark of 20 to 30 percent; but I’d like to note that that is the reported use, not actual use, which I think is significantly higher, given how available it is on the internet. Modafinil’s popularity among college students, athletes, and the Silicon Valley techie set isn’t exactly a state secret, but its use among the military literally was until confirmed relatively recently. The US Armed Forces tested modafinil in improving performance despite sleep deprivation and in combating pilot fatigue; in fact, at one point, we led the world in military research on modafinil. I happened to catch part of a television show over the holidays that mentioned modafinil studies in Air Force fighter pilots. The show stated that it induced vigilance (aka kept them awake) for 40 hours, which, the show mentioned, is apparently a desired effect during times that necessitate flying to Iraq quickly. Now, I’ve never flown to Iraq, much less in a fighter jet, but I can’t imagine that it takes 40 hours to get there… but you get the point. If you were exhausted, but needed to get to Iraq all quick like, modafinil may be the compound of choice.
Of course, I had to look into these studies. Captain Obvious says that Uncle Sam has been “officially” dosing our Armed Forces for years, so modafinil is just another in a long line of compounds. I’ve had many patients that were/ are members of the US military, and I’ve been told of the sanctioned use of various drug combinations in all branches of it: hypnotics to induce them to sleep before a mission, followed by stimulants (in the form of dextroamphetamine) “go pills” to switch them back on just before, at “go time.” As far as modafinil is concerned, the experiments relating to sleep deprivation seem pretty ambitious, testing for 40, 60, or even 90 hours without sleep. In some journal articles, scientists speculated that with modafinil, troops might function for weeks(!) on as little as four hours of sleep a night.
Back to fighter pilots: in the study I looked at, Air Force scientists looked at the effects of being awake for 37 hours on pilot alertness and flight performance; this was evaluated through simulator tests repeated every five hours to track the pilots’ level of fatigue. The same experiment was conducted with and without modafinil, and also in a rested state without modafinil for comparison. What did they find? While on modafinil, the pilots’ performance significantly improved, especially at time points after 25 hours without sleep, and the pilots sustained brain activity at almost normal levels despite their sleep deprivation. Further, while under the influence of modafinil, flight performance degraded by 15 to 30 percent. Now that doesn’t sound great, until you consider that performance by pilots without modafinil (and without sleep) degraded by 60 to 100 percent (hell-ooo!!) as compared to rested levels. All of the findings led researchers to conclude that modafinil “significantly” reduced the effects and impacts of fatigue during flight maneuvers, even though sleep deprived pilots on modafinil were unable to maintain the same performance as they exhibited during a rested state off of modafinil. I’ll say… Degraded by 60 to 100 percent?! Bottom line: clearly, if a pilot can’t get sleep, they should get modafinil. Ultimately, they stated that until more research is done, a 100 mg dose of modafinil is viewed as an option to, but not a replacement for, a 10 mg dose of dextroamphetamine.
All of that said, most of us are not fighter pilots, much less operating a complicated machine at mach speed and 50,000 feet, under stress, and sleep deprived… and thankfully so. Most of the people that ask me about modafinil are everyday people looking to focus better at work, get excellent scores on SAT’s to get into a great school, win a medal or a pro poker tournament (pro poker players love modafinil) or maybe beat out somebody at work for a promotion. In my experience, for all of those things and more, modafinil is a safe and effective tool, and lots of folks want it in their tool box. It’s been around long enough to have some significant studies done; all findings echo my experience, and one another: it works well and nobody’s dropping dead at their desks.
The University of Oxford and Harvard Medical School conducted a formal review of all research papers on cognitive enhancement with modafinil in non-sleep-deprived individuals, dated from January 1990 to December 2014. They found and evaluated 24 studies, which included more than 700 participants total, dealing with different benefits associated with taking modafinil, including planning and decision making, flexibility, creativity, and learning and memory. They also surveyed overall performance enhancing capabilities and side effect reporting. Findings were as follows:
Modafinil made no apparent difference to working memory or flexibility of thought, but did improve executive function, the ability to sift through new information and make plans based on it.
As to side effects: (70 percent the of 24 studies looked at the effects of modafinil on mood and the side effects of modafinil) In those where side effects were studied, there were very few side effects overall, although a very small number reported insomnia, headache, stomach ache, or nausea, but these were also reported in the placebo group, meaning those who were unwittingly given a “sugar pill” with no biological action.
As to overall performance enhancing capacity of modafinil: this was found to vary according to the task; the longer and more complex the task tested, the more consistently modafinil conferred cognitive benefits.
Modafinil clearly and reliably enhanced cognition, especially in higher brain functions that rely on contribution from multiple simple cognitive processes.
Some snippets of findings from other studies:
“It has been shown to increase resistance to fatigue and improve mood.”
In healthy adults, modafinil improves “fatigue levels, motivation, reaction time and vigilance.”
Modafinil is effective at reducing “impulse response,” meaning it reduced the incidence of poor decision making.
Modafinil “…improved brain function in sleep deprived doctors.”
Modafinil “enhanced the ability to pay attention, learn, and remember.”
There is some evidence that modafinil only helps people with lower IQ, but I read validated accounts of years of use associated with validated corresponding increases in IQ, though this could theoretically be due to other unrelated factors.
How Does Modafinil Work?
Scientists haven’t gotten it all figured out quite yet, but like the psychostimulants we’ve already discussed, modafinil increases the production of norepinephrine and dopamine in the CNS, the neurotransmitters linked to emotional well being, motivation, memory, and focus. At the same time, modafinil may also reduce the production of neurotransmitters that are known for blocking communication between neurons. It also increases the production of histamine, which increases the oxygen concentrations travelling to the brain, making you more awake, or so it’s theorized. Just as the anti-histamine Benadryl dampens histamine and puts some people to sleep, modafinil boosts histamine levels, which has a tendency to wake you up and increase alertness. If you’ve ever had an acute allergy, especially an anaphylactic reaction, and experienced the typical increase in heart rate and blood pressure associated with it (which is also associated with wakefulness and alertness) then you’ve felt the acute effects of excess histamine production. Obviously, modafinil doesn’t cause this level of histamine release, that’s just an explanation of how the release of histamines from taking modafinil are thought to cause a feeling of wakefulness or alertness: from the increase in heart rate and blood pressure associated with their release. Though scientists aren’t exactly sure how it works, they have elucidated that modafinil also enhances several other CNS neurotransmitters, including serotonin, glutamate, and GABA.
The Ethics of Modafinil Use
Pharmacological cognitive enhancers (PCE’s) like modafinil may be used to treat cognitive impairments in patients, but they are more commonly used by healthy individuals in an effort to improve focus, stay awake and alert for extended periods of time, and boost mental and physical performance. This lifestyle use of modafinil by healthy people is increasing, and in fact, it appears that it far exceeds the therapeutic use of modafinil for cognitive impairment and sleep abnormalities. As it enhances cognition and has effects on attention, learning, memory, planning, and problem solving, this lifestyle use raises a number of ethical issues.
In societies and populations that foster or encourage academic and professional competition, access to knowledge about how to gain a competitive edge and how to perform better in the workplace is a valuable commodity, but not one that tends to be equally distributed across all social groups. As modafinil rises in popularity, will we soon be locked in a productivity arms race, pounding out after-hours spreadsheets with one hand while Googling “latest nootropic advancements” with the other? Some sports organizations already ban the use of prescription psychostimulant drugs- including methylphenidate- without an official ADHD diagnosis, for the same reasons they ban steroids and other performance enhancing drugs. Will employer drug screens soon test for off label modafinil use in an effort to avoid its presence in the workplace? Or will the opposite be the case; will CEOs welcome super sharp workers who never need sleep? Think about the Bezos’ and the Musk’s of the world… will they be adding modafinil to the water coolers?
Considering modafinil’s popularity, you can be sure that more cognitive enhancing drugs are right around the corner. Will everyone be able to compete? What if you can’t get access to a cognitive enhancer, can’t afford it, or can’t take it due to negative interactions or side effects… are you destined to be stuck in a dead end job or hit an impenetrable corporate ceiling while you watch your friends and co-workers climb the corporate ladder? How about your kids? If you think things are competitive now… just wait ten years. Will they be able to get into a good pre-school without putting modafinil or some other enhancer in their kool-aid, or juice, or whatever you’ll put in their sippy cups? Seriously, will they be able to compete… to get into a good school without cognitive enhancement? In a cognitively enhanced society, what happens to the benefits and self-satisfaction of earning something by the sweat of the brow… especially when that’s just. not. good. enough? Could this lead to a devaluation of hard work and generate less engagement with the world? And if so, what happens to a society where few people see the value of civic work or doing something for the greater good rather than getting ahead? These won’t be hypothetical questions for very long. How about things less under our direct control? Will the FDA save us by prioritizing drugs that preserve lives, or will they bow to pressures from big pharma to prioritize drugs that will undoubtedly be more popular among healthy individuals, have a far larger market, and make more money?
Hey people… these are things to think about. Don’t shoot the messenger.
In situations where there is a deficit in performance due to sleep deprivation or fatigue, a medical diagnosis, or learning disorder, there’s no doubt that modafinil can even the playing field. But what about in “normal” healthy individuals? Proponents of modafinil use in healthy individuals argue that it reduces fatigue-related and work-related accidents and improves learning outcomes; in other words, it’s a good thing, so use it. But when it comes to “enhancement” or “optimization” of performance, do the ends always justify the means? To use a sports analogy, does enhancement corrupt the “rules of the game”? If so, does it make the game pointless? Or is enhancement or optimization a slippery slope that leads to the desire to “perfect” human beings? The increase in medical options available to affect human characteristics and abilities over recent decades certainly offers more options to do so, but the desire to want to do so is hardly novel. The difference is that now we’re getting much closer to being able to actually do it. The door is open, and people are walking through it. Some people are running through it. But can we ever turn around to get back to where we were if/ when we find we don’t like what’s on the other side? What happens when average abilities become less the norm, and more of a negative exception… would average people feel fundamentally inadequate?
The ethical implications of the use of modafinil in particular, and smart drugs in general, has become one of the biggest issues in neuroethics and bioethics; it’s got ethics nerds everywhere red faced and arguing, and it’s certainly a favorite topic in the popular media as well, with tons of hype. What about the ethics of biohacking, using any and all, drug and non-drug technologies to improve cognition; ie training and nutrition to boost brainpower, and/ or the application of transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), or brain-computer interfaces (BCI)? There are plenty of biohackers out there- do they have an unfair competitive advantage, or is it mostly acceptable, because a lot of it requires at least more effort and dedication than just swallowing a pill? If most people biohack themselves in order to become cognitively superior, when is superior… superior enough? There could be serious ramifications concerning attitudes towards conventional human abilities in the long term.
I certainly don’t suppose that I have the answers to these questions, but I know that I’m not the only one asking them. The last question I’ll pose that is still unanswered is: when will we be forced to confront all of the above questions… and then some? Because that day is coming. Of that, I have no doubt.
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The Skinny on Psychostimulants, Part 2: Methylphenidate Stimulants
Last week I introduced a class of drugs called psychostimulants, or central nervous system (CNS) stimulants. As the name states, psychostimulants are “uppers” that stimulate the central nervous system when consumed in varying ways. This class includes the illicit drugs cocaine, ecstasy, and crystal meth, nicotine found in tobacco, and the most commonly consumed drug in the world, caffeine, which is a highly addictive compound that occurs naturally in more than 60 plant species, including the various beans brewed to make the most widely consumed beverage in the world, coffee. Other recognizable sources of caffeine include cocoa beans, tea leaves, and kola nuts. Caffeine is also chemically synthesized for handy inclusion in energy drinks, sodas, and various medications. This class also includes two types of stimulant medications, amphetamines and methylphenidate, which can be found as the bases in a myriad of pharmaceutical products.
In last week’s blog I introduced amphetamines; this week I’ll discuss methylphenidate stimulants. Like amphetamines, methylphenidate stimulants are tightly controlled Schedule II central nervous system (CNS) stimulants that work by stimulating the chemical messengers dopamine and norepinephrine, the neurotransmitters associated with control, attention, fight or flight response, and the pleasure/ reward system in the brain.
While these two types of drugs induce similar effects when taken, the way that they induce those responses, their mechanisms of action, are actually different. Both work to increase levels of dopamine and norepinephrine in the synapses between neurons, which helps messages move from one neuron to the next. Recall from last week that amphetamines have three mechanisms for increasing these levels: 1) they reverse the direction of the transporter pumps that would normally divert dopamine and norepinephrine away from the synaptic cleft, 2) they disrupt cellular vesicles, thereby preventing the storage of excess dopamine and norepinephrine, which frees them up for use in the cleft, and 3) they also promote the release of dopamine and norepinephrine at nerve cell terminals, making them more readily available in the synaptic cleft. Amphetamines’ three mechanisms combined ensure that there are very high concentrations of dopamine and norepinephrine in the synapses of the central nervous system and result in the very strong psychostimulant effects that amphetamines produce.
In contrast, methylphenidate affects the levels of dopamine and norepinephrine in the synaptic cleft through a single mechanism: by shutting down the transporter pumps that would usually take up excess neurotransmitters. It does not reverse these pumps to cause a flood of neurotransmitters to be released, and does not work to increase neurotransmitter levels through any other actions the way that amphetamines do. As a result, amphetamines are slightly more stimulating than methylphenidate-based stimulants. For this reason, I typically use methylphenidate-based stimulants for children and adolescents and generally reserve amphetamines for use in adults.
Both amphetamines and methylphenidate are used to treat and control symptoms of narcolepsy, obesity, binge eating disorders, and most commonly, attention deficit hyperactivity disorder (ADHD). Off-label indications, meaning potential uses that are not strictly approved by the FDA, include using either to treat major depressive disorder and in cancer patients to treat weakness, fatigue, and depression. There are also some relatively recent studies that indicate success in using psychostimulants off-label to decrease pain levels as part of a regimen in treating chronic pain patients.
All stimulants can be prone to misuse, and may be used recreationally in certain populations via oral route, smoking, injecting, or snorting, to get high and/ or to stay awake for long periods of time. And their ability to improve concentration means some people use them to boost cognitive ability, to improve focus, and to study for and/ or take exams. This is a relatively common practice among some college students.
The two types of medications are available as short-acting medications and in longer acting preparations. Both are essentially equally effective, and have the same benefits, risk(s), and side effect profiles, only varying mainly in their severity, with the profiles associated with amphetamines sometimes being slightly stronger than with methylphenidate. And while I’ve found that most patients respond equally well to either medication, adults to amphetamines and children to methylphenidate, some may respond better to one versus the other. But that’s certainly not a unique feature; that’s always the case with medications, as different bodies respond differently to varying formulations.
Methylphenidate is most commonly used for treating ADHD, and is FDA approved first line therapy for ADHD patients age 6 and up. While it may seem counterintuitive to treat hyperactivity with a stimulant, this class of drugs have been shown to be the most effective treatment for reducing the symptoms of ADHD. This is because CNS neurotransmitter concentrations are lower in the ADHD brain, sometimes markedly so, and the addition of a stimulant raises the neurotransmitter levels to equal those comparable to the “normal” levels found in the non-ADHD brain.
Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, and is associated with impaired functioning and negative developmental outcomes. Children with ADHD find it unusually difficult to concentrate on tasks, to pay attention, to sit still, and to control impulsive behavior. They generally have more difficulty focusing, controlling actions, and remaining still or quiet, as compared to classmates or other people the same age. The American Academy of Pediatrics (AAP) recommends behavior therapy and medication for children 6 years of age and older, preferably both together. The end result in up to 90 percent of cases is that methylphenidate-based stimulant medication helps children with ADHD become more focused, improve their approach to schoolwork, get better organized, think before acting, get along better with others, conform better to societal norms, and break fewer rules. They do better socially, academically, and in terms of self esteem. As a result, they, and their other family members, are happier. In my experience, as the chaos in the patient’s mind is decreased, the chaos that usually follows and surrounds them is also decreased, and that makes for better harmony in the home as well. To put the success of methylphenidate in treating ADHD into perspective, there is no other medication for a psychiatric condition that has such a high response rate.
In contrast, children with untreated ADHD don’t do as well comparatively speaking. Generally, if the symptoms of ADHD are negatively impacting any area of their life, they are impacting every area of their life, because ADHD is not just an academic problem, it’s a neurobehavioral problem that permeates every aspect of life and affects them academically, emotionally, and socially. Studies have shown that unchecked ADHD symptoms hinder childhood progress, causing a tendency to suffer in school and in social relationships. This negatively affects self-esteem, which causes feelings of anxiety and depression, not only at the time, but as lifelong consequences. The long term implications of low self esteem are well documented and extensive, and nearly always include fairly pervasive anxiety and depression. Low self esteem and all of its many consequences is common in adults with undiagnosed childhood ADHD, as well as from other sources, and it’s a common source of issues that I treat on a daily basis.
So the lesson is that when weighing risks of treating ADHD with methylphenidate stimulants, recognize that making the decision not to medicate a child with notable ADHD symptoms has its own risks that must be considered. When you take into account that childhood is meant to be a building block and a time to learn, not just math and grammar, but how to make friends and function in the world, what the decision encompasses is a whole person and a whole life, and all that entails. As a psychiatrist, my opinion might be biased, but I might never understand why the decision to treat disorders affecting mental health are made so differently from ones that affect physical health, as if good mental health isn’t as important, or as necessary, as good physical health. I wonder, if a child had diabetes that was negatively impacting their life, would you suggest that child be treated for it, or would you withhold medication from them? Why is mental health treated so differently?
While it has been used safely and effectively for decades, there’s still a great deal of angst and controversy surrounding using stimulants in children with ADHD, one that begs further discussion. I’ll start with some fast facts on ADHD.
ADHD: By the Numbers
Incidence and prevalence statistics always vary according to sources and sampling methods, but the following are the 2020 numbers quoted by the Centers for Disease Control and Prevention.
The number of children ever diagnosed with ADHD is 6.1 million, or 9.4 percent.
388,000 (2.4 percent) young children, aged 2 to 5
2.4 million (9.6 percent) of school-age children, aged 6 to 11
3.3 million (13.6 percent) of adolescents, aged 12 to 17
Symptoms of ADHD typically first appear between the ages of 3 and 6.
The average age of ADHD diagnosis is 7 years old.
Males are more than twice as likely to be diagnosed with ADHD than females (12.9% compared to 5.6%).
Despite that fact, the incidence of ADHD diagnosis in girls has increased in recent years. Historically, diagnosis and incidence reporting had been low in girls, but new research indicates how ADHD symptoms manifest differently in boys and girls, leading to better recognition in girls.
ADHD isn’t just a childhood disorder. About 60 percent of children with ADHD in the United States become adults with ADHD, which is about 4 percent of the adult population.
ADHD severity is generally based on the age at diagnosis:
Mild: Average age of diagnosis is 8
Moderate: Average age of diagnosis is 7
Severe: Average age of diagnosis is 5
Roughly two-thirds of children with ADHD diagnosis have/ have had/ will have at least one other mental, emotional, or learning disorder: most common are depression and/ or anxiety and other behavioral or conduct disorders, but other conditions such as autism spectrum disorder and Tourette syndrome/ tic disorder may also affect children with ADHD.
ADHD On the Rise
Cases and diagnoses of ADHD have been increasing dramatically in the past few years. The American Psychiatric Association (APA) says that roughly 8.4 percent of American children have ADHD, which differs significantly from the statistic quoted by the Centers for Disease Control and Prevention. The numbers vary depending on sampling methods and reference, but they all do indicate one thing: that ADHD diagnoses are on the rise.
To account for the differences in statistics, there may be an implication that ADHD is being commonly mis-diagnosed, that children are being diagnosed with ADHD when they don’t actually have it. In reality, while ADHD isn’t a fast, easy diagnosis to make, there are strict and clear cut guidelines for diagnosis that make mis-diagnosis fairly rare. There must be a comprehensive evaluation using multiple collaborative sources (including interviews with the child, the parent(s), and typically the teacher), established symptom rating scales, observation by a physician, and cognitive and/ or academic assessments. A valid diagnostic appraisal takes time, so while mis-diagnosis certainly occurs in a very small percentage, it is certainly not responsible for the rise in numbers.
What is responsible? The answer is multi-faceted, and includes: the increase in research and development in making the diagnosis, the decrease in the stigma associated with seeking help and/ or being evaluated for and/ or potentially having the diagnosis, and the increase in public awareness of ADHD. Many of today’s ADHD patients would have been yesterday’s “problem children.” In other words, we simply know better now, so we do better. Physicians are better trained in how ADHD manifests itself, especially in girls, since it’s stereotypically been a “boy disorder,” and everyone involved, including physicians, parents, and teachers, are more alert and pay closer attention to the disruption that behavioral issues cause in the classroom to everyone, not just the student with ADHD.
The question then may be asked if more kids are actually experiencing ADHD today than they were before, and if so, why? We now know that ADHD is caused by a mix of genetic and environmental factors, and current best estimates indicate that about 70 to 80 percent of the risk for ADHD is genetic. But it’s not very clear cut or simple, where you either have an “ADHD gene” or you don’t, and there’s no single marker to look for or confirm a diagnosis. Instead, each gene involved in the condition contributes a certain amount of risk for developing it. The genetic component is complicated, but we really know even less about the environmental component, which makes up the other 20 to 30 percent of the risk of developing ADHD. The environmental risk factors we are fairly sure of- the ones we have the strongest and clearest evidence for- appear to be preterm birth and low birth weight. We also know that it is likely that if in fact we are seeing a true rise in ADHD cases over the last 20 years or so, as we believe we are, environmental factors must play an important role in it, simply because genetics don’t change that quickly. Some studies have suggested that exposure to toxins (ie lead exposure, smoking during pregnancy) may play a role, and that traumatic brain injuries may also play a role in increasing risk of developing ADHD. In the end, the rise in the number of cases is most likely to be a combination or interaction of all of the above factors, and that some environmental factors interact with certain genetics to increase a child’s risk of developing ADHD. What else do we know about increasing numbers of ADHD cases? That we always need and want to know more.
There are several methylphenidate product formulations, including oral tablets and capsules in immediate release/ short-acting, extended release/ long acting, chewables, liquid, and patches to be applied to the skin. There’s even a formulation called Jornay PM, which is taken at night, but only becomes active in the morning. All are derived from essentially the same basic methylphenidate compound. Immediate release or short-acting formulations typically begin to work about 30-45 minutes after ingestion and last about 3-4 hours, while extended release generally last about 6-8 hours, though there are of course exceptions that may release even more slowly and last longer.
Ritalin is a short-acting formulation of methylphenidate that lasts about 3-4 hours. Focalin is another form of methylphenidate that also lasts about 4 hours. Both of these medications begin to work about 30-45 minutes after taking them. For children who have trouble swallowing pills, this medication can be crushed and mixed with foods. There is also a liquid and a chewable tablet form of the short-acting methylphenidate.
Other preparations of methylphenidate have been created to release the medication over a greater period of time, extending the duration of the effect of the medication. This is of great benefit when trying to provide a response that lasts through a school day, typically 6-8 hours. Some of these compounds take effect as quickly as the short-acting forms of these medications.
Concerta is one of the longest-acting methylphenidate medications on the market, lasting 8-12 hours. Concerta can’t be chewed or opened. It has to be swallowed whole in order for it to work the way it was designed. This can be a problem for some kids.
Ritalin-LA and Metadate CD are capsules that are filled with medication. These medications are very similar in that they both last about 6-8 hours. These are better for kids who can’t swallow pills, because you can open up the capsule and sprinkle it on foods like yogurt, applesauce, peanut butter, etc.
Aptensio XR and Focalin XR are also capsules filled with medication that can be opened and mixed with food. They typically work longer than Ritalin LA or Metadate CD.
Quillivant XR is a long-acting formulation of methylphenidate in liquid form, which makes it a good alternative for kids who have trouble swallowing capsules and can’t tolerate beads on food items either.
Quillichew ER is a chewable long–acting formulation of methylphenidate that can last up to 8 hours.
Daytrana is a methylphenidate patch. It’s another good option for kids who can’t swallow pills. You can wear the patch for up to 9 hours, and often get another hour’s worth of response after the patch is removed. But if using the patch, understand that it can often take 1-2 hours from application to the skin to start working.
Potential Benefits of Methylphenidate
In truth, the benefits of treating ADHD with stimulants are too vast to really list when you consider long term implications, but for our purposes, I’m only dealing with direct observed benefits when treating ADHD with methylphenidate stimulants here.
Methylphenidate based medications have been proven to reduce the disruptive and troublesome symptoms of ADHD, making kids less hyperactive, less impulsive, more focused, and less distractible, with few side effects, if any, when the medications work properly. However, it’s important to note that these medications cannot treat or correct learned behaviors or other types of learning disorders.
The Benefits of Methylphenidate on ADHD Brains: What Science Says
Much of the controversy that surrounds treating childhood ADHD with methylphenidate stimulants has to do with concerns about long term implications, mainly regarding brain development. Recent research on the neurobiological and anatomical underpinnings of ADHD has shed some light on this subject.
Several years ago, neuroimaging work confirmed that there are neuroanatomic, or structural differences, in the brains of people with ADHD versus those without ADHD, especially in the frontal cortex, which is involved with attention, organization, abstract thinking, and keeping track of things. It was also confirmed that total brain volume, made up of gray and white matter, also differs.
Regarding anatomical brain differences, specifically, children with ADHD had overall smaller brain volumes, by about 3 percent, than children without ADHD, though it is important to note that intelligence is not linked to or affected by brain size. In addition, five of the regional areas in the deep brain that pertain to regulating emotion, motivation, and emotional problems- the caudate nucleus, putamen, nucleus accumbens, amygdala, and hippocampus- were smaller in people with ADHD; and some showed structural deformations as well. The brains of children with ADHD showed decreased cortical thickness in the prefrontal cortex, and less white and gray matter.
White matter affects learning and brain functions, and acts as a relay to coordinate communication between different brain regions. White matter consists of axons, or nerve fibers, which have a myelin sheath whose color gives the area its name. Think of these myelinated nerve fibers of the white matter as the wiring of the brain- where information is carried from one point to the next- and these are insulated, so that the information is conserved, ie doesn’t “leak out” as it’s carried. Grey matter is the more outward layer of the brain that serves to process information in the brain and directs sensory stimuli to nerve cells in the central nervous system where the synapses induce the response to that stimuli. The grey matter has more connections than white matter, but isn’t as insulated as myelinated white matter; so this area relates more to memories and facts which are used every day to help a person function optimally.
In fact, further studies have shown that the structural differences in ADHD brains tended to be most observed in the brains of children with ADHD and not as much in ADHD adult brains. This is likely an indication that childhood is an important time to treat ADHD, which seems to be confirmed by further research. All in all, the findings led researchers to state that ADHD is a function of atypical brain structure and atypical chemical development. A few years ago, a research group took these findings a step further. Given the success of methylphenidate in treating the symptoms of ADHD, which is basically correcting the atypical chemical differences in neurotransmitter levels, they looked at the effects of methylphenidate on brain structure.
The study found that childhood psychostimulant medication (methylphenidate) led to volume normalizations in several areas where volume levels were known to be reduced in the ADHD brain. Normalization means that where they were previously reduced prior to treatment with methylphenidate psychostimulant medication, they were increased to the point of reaching levels found in “normal” non-ADHD brains after being treated with the psychostimulant methylphenidate.
These studies found that specifically, overall white matter volume and grey matter volume normalized, or “resolved” after childhood treatment with psychostimulant, as did anterior cingulate cortex (ACC) volume, which is implicated in several complex cognitive functions, such as empathy, impulse control, emotion, and decision-making. When they looked at the largest part of the brain, the cerebral cortex, which is the ultimate control and information processing center, responsible for higher-order brain functions of sensation, perception, memory, association, thought, and voluntary physical action, they found that the ADHD-related thinning that had been present, was moderated by childhood psychostimulant treatment. The ADHD-related size reduction of the deep brain structures, which are key to learning, memory, reward, motivation, and emotion, normalized after psychostimulant treatment, as did deformations of the caudate nuclei, when present.
One hypothesis that they had looked to prove or disprove was that methylphenidate treatment of ADHD during childhood and adolescence, but not during adulthood, would stimulate white matter, striatal, and frontal cortical development, resulting in more adult-like values. And in fact, their findings did prove this. This is important, because it is an age-related treatment response. It essentially means that when you treat childhood ADHD with methylphenidate in childhood, the methylphenidate stimulates a response that normalizes most of the abnormalities found in the brain of the child with ADHD such that they are comparable to normal adult values later. That’s a good thing.
Another study looked at behavioral changes associated with using methylphenidate, and found that, relative to periods off medication, ADHD patients on medication have fewer motor vehicle accidents, have a lower risk of traumatic brain injury, are less likely to engage in criminal activity, have lower rates of suicidal behavior, and have lower rates of substance abuse. Why? Because it seems that when neurotransmitter levels are normalized, behavior is normalized as well, which makes behavior when on medication safer, more risk averse, ie less risky. The authors end the report of their findings with this: “Thus the answer to the question ‘Is there long-term benefit from stimulant treatment for ADHD” is a definite “Yes!'”
Potential Negative Side Effects of ADHD Stimulant Medications/ Methylphenidate
Most side effects associated with methylphenidate are very mild and temporary, but if they exist, are likely to be dose or formulation related, as it can take some time to find the appropriate medication and dose. If you find that any side effects are intolerable or persist, it’s important that you inform the prescribing physician. In addition, the dose should be re-evaluated each year, even if there are no issues, as the medication needs can change over time, especially in growing children.
This is the most common side effect of stimulant medications. The loss of appetite may happen just while the medication is effective, and then wear off, as the benefits of the medication do. Children may be very hungry once the medication wears off, and if they haven’t eaten, they may also be irritable, aka hangry. This is typically a manageable problem, but the issue should be discussed with the physician who prescribes the medication if it persists or is intolerable.
Insomnia/ Sleep Problems
There may be issues with falling asleep associated with methylphenidate. This is usually fairly mild, and it tends to occur more in younger children who might have already had issues with falling asleep before they started the medication. There are many things that can interfere with falling asleep or manifest as sleep issues, so it’s important to determine if any external causes (other than medication) may be present. These can include poor or irregular sleep schedule, excess screen time/ blue light exposure right before bed, academic concerns/ worrying about school tests, or social issues with friends. Again, problems falling asleep are likely to improve over time, but may also be overcome by changing either the time or type of the medication that is given. For example, if a second or third dose of a short-acting formula is taken too late in the day, it may not have worn off by bedtime, which could cause the issue. This can be addressed by the physician with formula or dosing changes.
There is a small subset of children with ADHD who may seem moody and irritable when they take stimulant medications, even if they are taking the best possible dose. If this is going to happen, it usually happens right away, as soon as they start taking the medication, and goes away immediately when they stop taking it. If this happens, it may help to switch to a different formulation or dose, so inform the prescribing physician right away to discuss potential alterations. Sometimes when a stimulant dose is too high, especially in children, they may begin to look tired or experience irritation. If this happens, the prescribing physician may opt to adjust the dose until the right dose is found: one in which the child gets the most benefit from the medication with the least possible side effects.
While this isn’t technically a side effect, a very small minority of children experience behavioral changes as their ADHD medication wears off, which typically occurs at the end of the school day. Some parents call it “rebound” but that term can be a bit misleading. They can seem more irritable or emotional, but it is usually a mild transient finding. Sometimes it’s related to being hangry or overtired, but it can be connected to the medication level dropping, and strategies that create a more gradual decrease in the medication level may help relieve it. Obviously, discuss with the prescribing physician if you notice it and believe it’s due to the medication levels.
About 10% of kids with ADHD will have concomitant tics, whether or not they take methylphenidate, so that translates to a fair number of children. Tics usually start between 6 and 8 years of age, which is often when kids also first start taking a medication for ADHD. Tics may also be transient, and may come and go over time. The best we know from a series of studies, is that stimulants don’t cause tics, but if tics are present, sometimes methylphenidate can aggravate them. Despite this, methylphenidate may possibly still be used, but treatment should be more closely monitored if this is the case. If tics increase significantly during treatment, there may be an option to use a non-stimulant medication that affects the brain in a different way.
Non-Stimulant Medications for ADHD
There are two types of non-stimulant medications that can help to alleviate some symptoms of ADHD. While they don’t have the efficacy that stimulants do, and they have very different side effect profiles, they may be an option worth trying if stimulants aren’t a viable option due to concomitant disorders like tics. Just as with stimulants, it may take several attempts to find the right medication and dosage, with the least side effects.
Clonidine (Catapres, Kapvay) and guanfacine (Tenex, Intuniv) are called alpha-adrenergic agonists, and these medications were developed to lower high blood pressure in patients with hypertension. But they are also prescribed in adjusted doses for children with ADHD who don’t tolerate stimulants well, and are sometimes also used to treat tics. These medications can cause fatigue related to low blood pressure, so blood pressure and heart rate must be regularly monitored while taking these medications. These are typically short-acting medications that require several doses each day, but they come in longer acting versions, Kapvay and Intuniv.
Atomoxetine (Strattera) is in a class of drugs called norepinephrine reuptake inhibitors. Norepinephrine is one of the CNS neurotransmitters needed to control behavior.
Unlike stimulants, Atomoxetine can take 4-6 weeks to take effect and has to be taken daily.
There’s a great deal of false information out there on ADHD and stimulants.
Does using stimulants stunt growth?
In spite of concerns that have been voiced regarding growth and stimulants, a recent well-validated clinical study showed that neither ADHD, nor treatment with stimulants, was associated with a decrease in growth rate during the maximum growth period in childhood, or a change in final adult height. Combined with other studies, it is clear that treatment with stimulants has no impact on growth rate or final adult height.
Are psychostimulants addicting?
Provided they are taken via the prescribed route, at the level they are prescribed for ADHD, methylphenidate medications do not raise the dopamine level high enough to produce euphoria, and they are not considered addictive.
Does using stimulants make children prone to addiction later in life?
Observational studies conclude that stimulant medication to treat young children with ADHD does not affect- neither in an increasing nor decreasing way- the risk for substance abuse in adulthood.
Does using stimulants change a child’s personality?
ADHD medications should not change a child’s personality. If a child taking a stimulant seems sedated or zombie-like, or tearful and irritable, it usually means that the dose is too high and the clinician needs to adjust the prescription to find the right dose.
Does using stimulants have negative long term effects?
In over 50 years of using stimulant medications to counteract the symptoms of ADHD, and hundreds of studies, no negative effects of taking the medication over a period of years have been observed. On the contrary, using methylphenidate to treat childhood ADHD especially, is associated with the positive effects and benefits of normalization of neurotransmitter levels and structural brain differences.
Using Methylphenidate for ADHD in Children:
As a parent, making a decision to place a child on a stimulant for ADHD isn’t to be taken lightly. As a physician, it’s certainly one I take very seriously. The following are things to keep in mind when weighing the decision.
All research studies indicate that stimulants are the most effective treatment for symptom reduction in ADHD.
Methylphenidate has been used for decades, and is considered safe and generally well tolerated by most people, including children and adolescents, with low side effect profiles.
Do a risk/ benefit analysis. You have to weigh the risks associated with treating ADHD with a safe and effective stimulant with a good track record versus not treating the ADHD, and all of the areas of the person’s life that decision impacts, including the well documented academic and social implications. In the total analysis, the risks associated with living with untreated ADHD are generally greater than treating with a methylphenidate stimulant that has an excellent safety profile and actually has the benefits of normalization of neurobiological and structural brain anomalies associated with ADHD.
When the symptoms of ADHD are negatively affecting every aspect of a child’s life, medication is a better and safer alternative than allowing that negative impact to persist throughout school age years and beyond.
Methylphenidate, like all medications, may cause some side effects, but most are mild, temporary, and/ or can be relieved by a change in formulation or dosing. It may take some trial and error to find the prescription and dosage that works well with the least side effects. While this may take time and patience, it’s time well spent.
Deficiencies in neurotransmitters such as those in ADHD also underlie many common disorders, including anxiety, mood disorders, anger-control problems, and OCD, obsessive-compulsive disorder. As a result, ADHD often occurs concomitantly with other disorders. In other words, ADHD may not be the only thing going on with an ADHD brain. At least two-thirds of people diagnosed with ADHD are also diagnosed with at least one other mental health or learning disorder in their lifetime, according to the American Academy of Child and Adolescent Psychiatry. Some of the more common accompaniments, especially in children, include anxiety disorders, depression, and learning and language disorders. As a parent, you may find you’re looking for the right mix of medications or treatments for multiple issues.
Granted, there are a lot of issues to consider, but hopefully I’ve managed to cover most of them here. My opinion is clear, and it is that overall, given the high efficacy, the track record, the safety, and the many well proven benefits of its use, methylphenidate treatment for ADHD far outweigh the risks associated with not treating it.
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The Skinny on Psychostimulants
Happy 2021 people! Are you as happy as I am that 2020 is finally in the rearview?! Weirdest. Longest. Year. Ever.
That actually makes me think of a new and hilarious commercial I just saw for a big online dating site. It starts out with Satan bored out of his mind in hell, and then he gets a text message from the site saying he’s been matched with a girl, and he’s very intrigued. When they meet, it’s obvious that they’re both instantly smitten. Then the starry-eyed girl introduces herself as 2020. They fall in love. And they live happily (?) ever after… apparently in hell. Unless they stay at her place I guess. Anyway, 2020 is over, even though unfortunately, we’re still schlepping some of its covid baggage, but hopefully not for much longer.
Considering the euphoria surrounding the new year and the stimulation of resolutions, I thought it very fitting that I start with a three part blog series on pharmacological central nervous system stimulants, aka psychostimulants. One of the main compounds in this class of drugs are the amphetamines, and that will be today’s blog topic.
As psychostimulants go, amphetamines are very strong ones; they are a group of very tightly controlled and well monitored schedule II drugs. Add a little carbon atom, bind some hydrogens to it, and you’ve got a methyl group; and that makes it methamphetamine, which everyone’s heard of. When prescription methamphetamine is (very) illegally altered…tah-dah…you’ve got crystal meth, aka speed, ice, crank, etc. Other examples of psychostimulants include caffeine, nicotine, cocaine, and other prescription compounds that I’ll cover next week.
Because of their stimulant activity within the central nervous system, prescription amphetamines are used in the treatment of several disorders, including narcolepsy, obesity, binge eating disorders, and very commonly, ADHD, or attention deficit hyperactivity disorder. They can also be used recreationally in certain populations to get high, to stay awake for long periods of time, and/ or to improve focus and study for exams. In fact, it’s those last two that make amphetamines very popular party favors among college students.
Structurally speaking, amphetamines are drugs that are related to catecholamines, which are chemical messengers that help transmit a message or signal across neural synapses in the central nervous system, from the terminal end of a transmitting nerve cell to the receiving end of a target nerve cell. In an over-simplified explanation, when a signal gets to the end of one neuron, catecholamines help the signal jump to the beginning of the next neuron, hence the name “neurotransmitter.” That message is repeated billions upon billions of times, as there are billions upon billions of neurons in the central nervous system. These neural signals activate emotional responses in the amygdala of the brain, such as fear in a “fight or flight” situation. At the same time, catecholamines also have effects on attention and other cognitive brain functions. Examples of catecholamines include the neurotransmitters dopamine, epinephrine, and norepinephrine. Pharmacologically speaking, amphetamines increase levels of the specific neurotransmitters dopamine and norepinephrine in the neural synapses, which helps the message to make the jump from one neuron to the next. In a way of thinking, amphetamines “speed” the transmission of the message by increasing the levels of these neurotransmitters. Amphetamines increase these dopamine and norepinephrine levels through three different mechanisms of action, at least that we know of: 1) they reverse the direction of the transporter pumps that would normally divert dopamine and norepinephrine away, 2) they disrupt cellular vesicles, thereby preventing the storage of excess dopamine and norepinephrine, which frees them up, and 3) they also promote the release of dopamine and norepinephrine at nerve cell terminals, making them readily available in the synaptic cleft. These three mechanisms combined ensure that there are very high concentrations of dopamine and norepinephrine in the synapses of the central nervous system. The “catecholaminergic” (try that one next time you play scrabble) actions of increasing the levels of dopamine and norepinephrine result in the very strong psychostimulant effects that amphetamines produce.
You’ll notice that I keep saying amphetamines, plural. Why? Because like the neurotransmitters dopamine and norepinephrine it effects, amphetamines are chiral molecules; this is a fancy way of saying that in their three dimensional world, they can exist in different forms called enantomers (more scrabble points!) that are mirror images of each other. I know this sounds complicated, but it’s really not. Think of it as “handedness.” Your left and right hands are mirror images of one another: they look similar, except the placement of the fingers and thumbs are mirror images, and they can do pretty much the same things, like hold a fork or a pencil, but the way they do so differs slightly. The same is true of amphetamines. The two enantiomers of amphetamines are usually referred to as dextroamphetamine (also denoted as d-amphetamine) and levoamphetamine (also denoted as l-amphetamine). All prescription amphetamines boil down to four variations of the amphetamine molecule, which have markedly similar, but potentially slightly variable effects: dextroamphetamine, aka dexadrine; lisdexamphetamine, which is a precursor or pro-drug of dextroamphetamine; methamphetamine, aka methamphetamine HCL, which has that methyl group I mentioned before; and mixed amphetamine, which is essentially a mixture of dextroamphetamine and levoamphetamine at a specific ratio.
Of those four active forms of amphetamines, there are several brand name drugs on the market, some of which have generic forms available. They are all oral formulations that may be immediate-release, which are typically taken twice a day, or extended-release, which are obviously released more slowly and taken once a day.
Adderall XR (generic available)
Dexedrine (generic available)
ProCentra (generic available)
The desired effects of amphetamines include: stimulation (thank you Captain Obvious), increased alertness, cognitive enhancement, euphoria, and mood lift. Amphetamines have been around for a long time and when taken as prescribed, they’re fairly safe, but there are potential negative side effects. These can include insomnia, hyperfocus, GI irritation, headache, anxiety, slight increase in heart rate and blood pressure, and anorexia. There is addiction potential associated with amphetamines, and there is a short and fairly mild associated withdrawal period where one might feel some fatigue, sleep a lot, and experience strange dreams.
When taken as directed, and by mouth, usually 20mg – 40mg per day, amphetamines are fairly safe. However, when smoked, injected, or snorted, they are decidedly UNsafe; especially in large doses. I’ve seen people take up to 1000mg per day… though not for long. Why? Because they usually end up dead of overdose. What happens if you choose to use amphetamines in large quantities and/ or via routes other than oral? Hallucinations, delusions, psychosis, seizures, cardiovascular collapse/ arrest, stroke… the bottom line is it ain’t pretty, people, so don’t do it.
Because amphetamines have multiple mechanisms of action and thereby are very strong psychostimulants, I generally restrict their use to adults only, and choose to use another type of psychostimulant in children called methylphenidate. And that will be the topic next week in psychostimulants part 2 of 3.
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Kratom: Panacea or Poison?
What is Kratom?
Kratom (scientific name: Mitragyna speciosa) is a tropical evergreen tree in the coffee family that is native to the jungles of Southeast Asia; specifically found in Thailand, Myanmar, and Malaysia. It is also found in Papua New Guinea. Other names for kratom include thang, kakuam, thom, ketum, and biak. Whatever it’s called and wherever it may be found, this tree, or at least the leaves on it, has been causing quite a commotion in recent years.
The Scientific Scoop
Mitragyna speciosa leaves contain multiple active components, referred to as alkaloids, with properties ranging from stimulant-like energizing and uplifting to opiate-like drowsiness and euphoria, so this makes it difficult to characterize kratom as one particular type of drug, i.e. as “stimulant” or “opiate.” Kratom’s two main alkaloids are mitragynine and its active metabolite, 7-hydroxymitragynine, which has strong activity at the µ-opioid receptors (where µ is pronounced like ‘you’ but with an m: mu). This is the main opioid receptor, the same one that is the primary binding target of opioids like heroin and oxycodone. Why is this so important? Why do we need to know exactly where kratom binds and what effect that has? Well, so we know how it may be used. Here in America, the government isn’t so good with just accepting that this ancient Asian secret does xyz just because they said so. Because kratom binds to µ-opioid receptors just like heroin etc, opponents say that it must be categorized as a narcotic and therefore, it must be addictive just like heroin etc. But Narcan/ naloxone is also categorized the same way, and obviously it’s not addictive; in fact, it’s used to save people in cases of opioid overdose.
There is a great deal of supportive scientific evidence from many independent laboratory studies using mouse models and multiple human cell lines that confirms that kratom’s alkaloid metabolite 7-Hydroxymitragynine is in fact a key mediator of the analgesic effects of kratom, through its agonistic binding to the µ-opioid receptor. This has also been confirmed by the finding that in the presence of the opioid receptor antagonist naloxone, the pharmacological blockade of the analgesic effect will occur. In plain language: they’ve clearly shown that kratom binds specifically to the µ-opioid receptor in human cell lines, and demonstrated that this binding produces analgesic effects by giving it to a specific type of live mouse that essentially models the human system. So after the mice were given kratom, they exhibited analgesic effects from it– through previously established and accepted behaviors that I’m totally not going into here– just trust people. And then, as if that’s not enough, to further prove that this analgesic effect the mice were having was definitely the result of kratom’s binding to the µ-opioid receptor, they then gave the kratom-dosed mice Narcan, aka naloxone, which is a µ-opioid receptor antagonist. What does that mean? Think of it this way: the Narcan “antagonizes” the µ-opioid receptor; it basically bullies anything already bound to that µ-opioid receptor, pushes it off, and then it binds to it and blocks it so that as long as it’s parked there, nothing’s getting by it to bind to those µ-opioid receptors. That’s how and why Narcan saves people from overdose: it pushes all the opioids off all of the µ-opioid receptors and then sits on them, and hopefully that happens soon enough that the person survives the overdose. If they do, and if they then ingest more opioids for several hours after being given the Narcan, they won’t feel the effects of the drugs for as long as the Narcan is present there on those receptors, because the drug’s opioids won’t be able to bind to the µ-opioid receptors, as the Narcan will be sitting there. So there’s been a lot of work done in various labs all over the globe to elucidate kratom’s form and function. But despite all of this work, there’s much more to be done! I’ll talk more about that later.
None of kratom’s uses are clinically proven, as it has not been studied in the human clinical trials that the FDA requires to allow a drug compound to be legally available on the open market. Clinical studies are very important for the development of new drugs, as they help to identify consistently harmful effects, harmful interactions with other drugs, and dosages that are effective, yet not dangerous. That said, there have been many legitimate published laboratory studies with clear demonstrable findings in mouse models and human cell lines that do allow us to at least extrapolate the effects of kratom in humans with some accuracy and relative safety. Most findings have been positive, and there is a large vocal community of kratom supporters with numerous anecdotal testimonials of kratom’s effectiveness in treating various conditions. But despite this, because treatment practices using kratom have not been rigorously studied as either safe or effective, the DEA staunchly maintains that it has no valid medical uses or benefits. In fact, several years ago, the FDA threatened to make kratom a Schedule 1 narcotic, meaning it would be grouped with marijuana, LSD, and ecstasy, among others, and this elicited a huge backlash… tens of thousands of kratom proponents complained vociferously, signed endless petitions and all that yada yada, and the FDA caved, dropping the issue, at least for the time being. But that’s not going to be the end of that story people… not when the government’s involved. So for now, kratom’s status should be listed as “to be continued.”
What is Kratom Used For?
In its native regions of Southeast Asia, kratom has been known to be used as a traditional medicine for more than a century, but has likely been used for multiple centuries. There in Southeast Asia, the leaves of the kratom tree are typically chewed directly from the tree or consumed as a tea, and they induce stimulant and opioid-like analgesic effects, depending on the amount used. This is because the effects felt from ingesting kratom have been found to be dose-dependent: at low doses, which is generally considered 1 to 5 grams, kratom has been reported to work like a stimulant, imparting feelings of being more energetic, more alert, and more sociable. At higher doses, considered to be 10 to 15 grams, kratom has been reported as being more sedating, dulling emotions and sensations while producing euphoric effects. Anything over 15 grams is considered risky.
The stimulant type effects have traditionally made kratom popular among Southeast Asian agricultural workers especially, who use it to aid them in their long hours of hard labor. But for generations there, kratom has also been used successfully in its native regions for several other purposes: as an aphrodisiac to increase sexual desire, as an energy booster, to ameliorate withdrawal symptoms following cessation of opioid use, and for treating cough, diarrhea, and chronic pain. More recently, here in the US, there has been an uptick in the use of kratom by people who are self-treating chronic pain and managing acute withdrawal from opiates, while seeking alternatives to prescription medications. While some people claim to have success using kratom to treat depression and anxiety, and others say that kratom can also be used to treat muscle aches, fatigue, high blood pressure, diarrhea, and post-traumatic stress disorder (PTSD). Some studies report that kratom possesses anti-inflammatory, immunity-enhancing, and appetite-suppressing properties, but obviously more research is needed to confirm these benefits.
Kratom: Processing and Forms
The psychoactive compound referred to as kratom is found in the leaves of Mitragyna speciosa, and the processing seems pretty straightforward: after the plant’s large dark green leaves are harvested, they can be prepared in several ways: fresh leaf, dried leaf that is pulverized and powdered, dried leaf that is simply crushed, and concentrated liquid leaf extract. Kratom can typically be purchased in multiple forms, including paste, capsule, tablet, gum, tincture, and extract. In certain forms it is often combined with added sweetener to overcome its harsh bitterness. Kratom can be brewed into a tea as well, a form that is offered in kratom tea houses present in a few US states. Kratom can also be smoked or vaporized, though this is not very common.
While the use of Mitragyna speciosa is certainly not new, the alkaloid extraction and refinement methods to turn the alkaloids from the plant into kratom has certainly evolved, and now purity is said to be higher. I’ve read that now there are also fortified kratom powders available, and these contain extracts from other plants in a nod to the nutraceutical angle. In the United States, kratom is usually marketed as an alternative medicine, and often found in stores that sell supplements. Kratom can also be found in gas stations and paraphernalia shops in most parts of the US, except in the handful of states and cities that have banned it. Many people purchase kratom over the Internet, where it may be sold for “soap-making and aromatherapy,” a lot like what happened with synthetic marijuana or spice; that’s in an effort to circumvent the FDA’s 2014 ruling that made it illegal to import or manufacture kratom as a dietary supplement in the US.
Is Kratom Legal?
Although kratom is technically legal at the federal level, some US states and municipalities have chosen to ban it, making it illegal to sell, possess, grow, or use it. Other states have imposed age restrictions. In the states of Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin, kratom is illegal to buy, sell, possess or use. There are special cases in some states: while kratom is legal in California, it is banned in San Diego. While it’s legal in Colorado, in Denver it’s considered illegal for human consumption. Kratom is legal in Florida, except for Sarasota Country, where it’s banned. Kratom is legal in Illinois for those over the age of 18, except in the city of Jerseyville, where it is banned. Kratom is legal to use in Mississippi, except in Union County, where it’s banned. In New Hampshire, kratom is only legal for those over the age of 18. Please don’t quote me on these people- make sure to double check if you’re wanting to purchase- not that I’m encouraging that or even saying it’s acceptable btw.
As far as countries around the globe go, kratom is illegal in: Australia, Denmark, Finland, Israel, Japan, Latvia, Lithuania, Myanmar, Malaysia, New Zealand (unless prescribed by a doctor), Poland, Romania, Russia, Singapore, South Korea, Sweden, Thailand, and Vietnam. Note that most places where native Mitragyna speciosa grows, it’s illegal… funny! Speaking of that, the country of Thailand has recently reconsidered the status of some illegal substances, so kratom might not remain illegal there.
In countries like Ireland, Italy, and the United Kingdom, the rules may vary from one city to the next. It’s also important to note that the status of kratom legality isn’t widely known for some countries. For example, it isn’t clear whether it is legal in China, or in many of the African nations. However, as the drug kratom becomes more widely known, countries, counties, and cities that don’t currently ban kratom may choose to do so at any point.
Is Kratom Safe?
Proponents say kratom is an amazing compound, a game-changer and lifesaver. Opponents, like the FDA, say it has no viable medicinal properties. How the US DEA, medical professionals, and millions of regular kratom users can have such divergent views of the same plant is hard to fathom. The overarching “company line” seems to answer this question “No!!” They state that kratom is considered addictive, that people can develop a physical dependence on it, and that in and of itself indicates that it’s not safe. There are some anecdotal reports of people becoming dependent on kratom, but there are more reports of people successfully using it to recover from opioid addiction; not to mention successfully treating chronic pain, fibromyalgia, anxiety, depression, on and on. So in my book, the jury’s out people.
The question of kratom’s safety comes down to two factors: the lack of regulation and the interactions with other drugs or substances, whether endogenous or exogenous.
Lack of Regulation
Any time a substance, including herbal supplements, isn’t regulated by the FDA, there are potential safety hazards. This is because there is no standardization when a substance isn’t regulated. That means that companies, particularly if they’re operating online, can market the product however they want. There are no official drug warning labels for kratom, and people may take it without knowing what other substances it contains. A buyer never knows what level of potency a kratom product could have or whether it’s pure. In addition, the active ingredient in kratom varies widely by plant species. As with marijuana strains, different kratom strains have slightly different effects; there are multiple species of the tree, so this makes kratom’s effects unpredictable. This unpredictable nature leads to a risk of overdose and other serious side-effects, including seizures, hallucinations, chills, vomiting, liver damage, or even death.
Because there is little research currently available on how kratom interacts with other substances, the breadth and severity of effects are yet unknown. This unpredictability adds to the dangers of using kratom in combination with something else, because you’ll have little idea what it could do to you. Potentially negative effects can be even more severe when kratom is combined with other drugs and prescription medicines. Some of the kratom chemicals have been shown to interact with how the liver metabolizes other drugs, which can lead to dangerous interactions. Another risk is presented when people buy commercial versions of kratom that have been combined with other drugs or substances, especially if they too work on the same opioid receptors. The potential consequences of many drug interactions can range from seizures to liver damage.
Various Points on the Kratom Controversy
Depending on what you read and who you believe, kratom is a dangerous, addictive drug with no medical utility and severely deleterious side effects that include overdose and death, or it is an accessible pathway out of undertreated chronic pain and opiate withdrawal, as well as being useful in treating many other health issues. There are great physicians and impressive institutions with interesting facts on both sides of this issue.
Recent increased kratom use in the United States, combined with concerns that kratom represents an uncontrolled drug with abuse potential, has highlighted the need for more careful study of its pharmacological activity. The major active alkaloid found in kratom, mitragynine, has been reported to have opioid agonist and analgesic activity in vitro and in animal models that are consistent with the purported effects of kratom leaf in humans. However, preliminary research has provided some evidence that mitragynine and related compounds may act as atypical opioid agonists, meaning they induce their therapeutic effects like analgesia, while also limiting the negative side effects that often accompany classical opioids. One such side effect that is absent in kratom is constipation. A chronic pain medication like kratom that doesn’t cause constipation like current opioids all do sounds like a good thing, but as I said before, it’s a long way from here to there, especially considering the FDA’s current opinion. And something tells me they won’t be changing their collective mind any time soon.
As it stands now, there is little to no control or reliable information on growth, processing, packaging, and/ or labeling of the kratom currently sold in the US; and all of this adds to the already considerable uncertainty of its health risks. In 2018, the FDA instituted a mandatory recall of all kratom containing compounds over concerns about Salmonella contamination in these products. More recently, the DEA placed kratom on its “Drugs and Chemicals of Concern” list, but as I mentioned before, it has not yet labeled it as a controlled substance, though not for lack of trying. Time will tell how long that lasts.
Kratom can be addictive due to its opiate-like qualities, and a small minority of users may end up requiring addiction treatment. The CDC claims that between 2016 and 2017, there were 91 deaths due to kratom; but this claim should be met with healthy skepticism, as all but seven of these casualties had other drugs in their system at the time of their deaths, and that makes it totally impossible to uniquely implicate kratom.
A patient wishing to use kratom to treat chronic pain or to mitigate opioid withdrawal symptoms could expect to encounter several problems with doing so, not all of which even have anything to do with the intrinsic properties of the kratom itself.
A patient that wants to use kratom to treat a legitimate illness or condition will likely face four problems for the foreseeable future:
-The first problem is that the DEA still occasionally threatens to make it a Schedule 1 controlled substance, along with drugs like heroin and ecstasy. This would make kratom very difficult to access, and would likely make the supply as a whole even more dangerous than it is now. Generally, it’s not a good idea to use something to treat chronic pain or addiction that may soon become less available and less safe: you want to know it’s going to be readily available, and that as a cure, it won’t cause more problems than the illness it’s being used to treat!
-The second problem is that the complete lack of oversight and quality control in the production and sale of kratom makes its use potentially dangerous.
-The third problem is that kratom has not been well studied for any of the uses its proponents claim it has an affinity in treating! Maybe the FDA hasn’t heard the saying that goes, “Absence of evidence of benefit isn’t evidence of absence of benefit.”
-The fourth and final problem is that kratom doesn’t show up on drug screens. I like kratom’s potential, but I can argue that adding another potentially addictive opiate-like substance while an opiate epidemic is already going on may not be the best course of action.
Is there a sensible path forward with kratom?
I’m not sure that anyone has the answer to that question, but at a bare minimum, the safety of kratom could be improved through:
-Regulation: it would be safer if people knew the exact dosage of kratom they were truly consuming, and that it was totally free of contamination.
-Education: educated consumers who know all of the potential benefits and dangers of the compound they are consuming are far less vulnerable to misleading claims.
-Research: if kratom does in fact have the benefits that have been demonstrated in the laboratory for treating either addiction or chronic pain, we should absolutely know it and make it known: accurately defining the risks of using kratom is critical, as is making all medical personnel and laypersons informed.
If all four of these points could somehow be accomplished by scientists and public health specialists, without: overdue distortion from corporate interests, anti-drug ideology, and romanticism by kratom enthusiasts, then we should have enough clarity to answer the basic questions about kratom, including the most important question of all…is it harmful or helpful?
Effects of Kratom: Good, Bad, Ugly
Recall that the expected effects from kratom are dose-dependent: that smaller doses will produce a stimulant-like effect, while larger doses will produce sedative or opioid-like effects.
A small dose of kratom to produce stimulant effects would be up to just a few grams, and these effects would be felt within 10 minutes after ingestion and can last up to 90 minutes. These expected stimulant effects include increased energy, alertness, and sociability, increased sex drive, decreased appetite, and giddiness.
A larger dose of kratom, between 10 and 25 grams, can have a sedative effect, imparting feelings of sedation, calmness, euphoria, pain reduction, and cough suppression, which last for much longer periods of time, potentially up to six hours.
Potential unsafe and negative effects of regular kratom use, even at low doses, can include: agitation, tachycardia, drowsiness, vomiting, confusion, anxiety, tremors, itching, sweating, insomnia, lack of appetite, tremor, coordination problems, and withdrawal symptoms.
There can also be negative effects of high dose kratom, including: addiction, nausea, itching, constipation, and withdrawal symptoms of tremor and sweating.
There can be negative side effects of taking any dose of kratom at irregular times or random intervals as well. Many users of kratom have reported something called “The Kratom Hangover” the day after taking it, the symptoms of which can include irritability, anxiety, nausea, and headaches.
Because kratom can cause problems with coordination and sleepiness, it’s dangerous to drive or operate machinery while using it. For this same reason, pregnant women are also advised never to use kratom.
There can be grave side effects from taking kratom, which can include seizures and respiratory and/ or cardiac arrest.
If a person takes a high dose of kratom and falls asleep, they may vomit and choke while asleep.
There are numerous calls into the CDC poison centers for kratom overdose every year.
The risk of overdose increases when kratom is taken with another substance, especially opioids.
Recent studies have found evidence of fatal kratom-only overdoses involving severe and negative side effects that can occur when someone takes too much. Some of the symptoms of taking too much kratom can include: impaired motor skills, lethargy, slurred speech, either shallow or very heavy breathing, tremors, listlessness, aggression, delusions, and hallucinations.
Long-term and heavy use of kratom can lead to liver problems, as kratom tends to make it more difficult for the liver and kidneys to process and filter toxins out, contributing to the potential for this type of organ damage.
Signs of liver damage include dark-colored urine and yellow skin and eyes.
Kratom: Necessary Evil or Just Plain Evil?
Kratom is currently considered a dietary supplement, as it is not approved nor regulated by the US FDA. That said, there are anecdotal reports of beneficial effects of kratom use, though there is no clinical evidence yet to support them. In the future, with the proper supporting research, kratom may indeed have proven potential.
But without this research, there are a lot of unknowns with kratom, such as effective and safe dosage, possible interactions, and possible harmful effects, including death. These are all things that you should weigh before taking any drug, but for kratom, they’re all question marks. In the final analysis, going by laboratory findings, kratom holds great potential. But if you’re thinking about using kratom to treat chronic pain or opioid addiction, or anything else… exercise extreme caution people.
I hope you enjoyed this blog and found it to be interesting and educational. Sharing means caring, so 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!
Since it’s pretty clear you people really like reading about all things tangential to sex, I don’t mind indulging your secret freaky sides every once in a while. Hey, far be it from me to deny you! So in that spirit, this week’s topic is….
wait for it….
The Oxford Dictionary has this to say:[sey-doh-mas-uh-kiz-uhm]
interaction, especially in sexual activity, in which a person enjoys or derives pleasure from inflicting or receiving physical or mental suffering upon or from another person.
Abbreviation: S&M, S and M
The shrinky dink version from the American Psychological Association Dictionary version:
1. sexual activity between consenting partners in which one partner enjoys inflicting pain (see sexual sadism) and the other enjoys experiencing pain (see sexual masochism).
2. a paraphilia in which a person is both sadistic and masochistic, deriving sexual arousal from both giving and receiving pain. —sadomasochist n. —sadomasochistic adj.
The Mark G. Agresti version:
deriving pleasure or gratification from inflicting or experiencing pain.
It’s important to note that both the pain and pleasure given and/ or received in sadomasochism can be physical, emotional, or both. In addition, when it exists in the strictest definition, it is considered a mental illness, but there are all sorts of conditions and considerations- and controversy- that go along with that. I’ll elaborate a little on that later. No matter who you listen to or what you believe, sadomasochism tends to be a rather delicate topic, and strictly speaking, not exactly one you’d discuss in “polite society.” Whatevs. I’m all about taking deep dives into that kind of stuff- it’s actually one of my missions in life- and in fact, my entire profession centers on helping people with delicate issues that aren’t talked about in “polite society.” Despite not being coffee talk, there’s a lot to be said about sadomasochism… including the fact that many people exhibit sadomasochistic tendencies, which is not to say they regularly wear black leather gear or want to tie their partners up and beat them btw. I’d even venture to say that most people, eapecially when in romantic love relationships, exhibit characteristics of sadomasochists. How does that grab you? If you’re thinking Ineed my head examined right about now, then keep reading about the psychology of sadomasochism.
But first, I have to get into where the term sadomasochism comes from, break it down (pun intended), look at its nominal derivation, and how it’s been viewed and analyzed throughout the ages. Let’s just say that shrinky dinks have had a lot to say on the subject.
Captain Obvious says that sadomasochism is the mashup of sadism and masochism, terms coined in the late 1800’s by an Austrian psychiatrist dude named Richard von Krafft-Ebing, who believed that the natural tendency of the male was toward sadism, while the natural tendency of the female bent toward masochism. What!Everrr! In reality, studies show that sadistic fantasies are just as likely to occur in females as they are males, though the masochistic bend definitely develop earlier in males. We now know that, like many things, sadomasochism knows no gender. When you break it down, sadism is defined as pleasure or gratification gained from the infliction of pain and suffering upon another person, while the counterpart, masochism, is the pleasure or gratification of having pain or suffering inflicted upon the self. At the simplest, most basic level, you could say that sadists get off on dishing it out and masochists on taking it. Now, how often are things that simple? Like never, people. And believe me, that’s the case here. But this generalization works just in terms of remembering which is which. That said, there are no clear lines dividing the two, and in practice, they’re often interchangeable and may even coexist in the same individual at different times.
Krafft-Ebing named sadism after the 18th century Marquis de Sade, a French nobleman, revolutionary politician, philosopher, and writer. He is most famous for his libertine sexuality, and he ‘graced the world’ with novels, short stories, plays, and dialogues, including Justine, which is basically about a woman with the same name who travels around the world getting the crap beaten out of her as she goes, and Les prospérités du vice, which roughly translates to something like the pleasures of vice, in which he said:
How delightful are the pleasures of the imagination! In those delectable moments, the whole world is ours; not a single creature resists us, we devastate the world, we repopulate it with new objects which, in turn, we immolate. The means to every crime is ours, and we employ them all, we multiply the horror a hundredfold.
Two of his most commonly annotated quotes:
“It is always by way of pain one arrives at pleasure.“
“I’ve already told you: the only way to a woman’s heart is along the path of torment. I know none other as sure.“
Sounds like a great guy, right? Evidently, his current day ancestors have been very busy trying to rehabilitate their great great great whatever’s image by creating a line of gourmand treats: wine, pâté, cheeses and such; and supposedly had pitched a Sade line of lingerie to Victoria’s Secret. Another fun fact, the film Quills, starring Geoffrey Rush, Kate Winslet, and Michael Caine, is inspired by the story of Sade.
Krafft-Ebing was a busy guy, naming masochism for a contemporary of his, 19th century Austrian nobleman, writer, and journalist Leopold von Sacher-Masoch, who gained renown for his romantic stories of Galician life. He also authored Venus in Furs, in which he wrote:
Man is the one who desires, woman the one who is desired. This is woman’s entire but decisive advantage. Through man’s passions, nature has given man into woman’s hands, and the woman who does not know how to make him her subject, her slave, her toy, and how to betray him with a smile in the end is not wise.
Interestingly, evidently Masoch did not approve of this use of his name. Bummer that somebody names something after you and you don’t approve of it. My suspicion is that it’s more likely that he didn’t approve what it was used for, as Krafft-Ebing essentially outed the guy as a masochist. Sadly, no word on a lingerie line for Sacher-Masoch, but I’ll keep you posted.
Sadomasochism as a mashup term was actually coined by none other than Freud, the mother-loving, father-hating Austrian neurologist and psychologist who is widely regarded as the father of psychoanalysis, a therapeutic process designed to make the subconscious conscious by releasing repressed emotions and experiences.
Even The Kama Sutra, which dates back to second century India, includes an entire chapter devoted to “blows and cries.” According to the Hindu text, “sexual relations can be conceived as a kind of combat… For successful intercourse, a show of cruelty is essential.” Seriously?
Now that you’re good to go for the daily double on historical literary references to sadomasochism…
Most of the time, for obvious reasons, we think of sadomasochism and it’s nominal components in terms of sexual behavior only, but they can have broader applications, and this is especially the case in sadism. The quality of being sadistic is most applicable to some notable autocrats of the past and present, and these are actually the first thing that comes to mind when I hear the word. When no other single word could possibly encompass the horror of their being, sadist just works. Think Stalin, Pol Pot, Hitler, Saddam Hussein, and the Kims. I was surprised to even see our 45th President’s name included while looking up a statistic. Hmmm… wonder who submitted that? (Dr. Mark Agresti is not making a statement about any person’s sexual inclination or mental status and is not claiming any political affiliation; this advertisement is brought to you by the equal opportunity offender party.)
Okay, I have no clue how that dude got in here, but you get the idea about sadism. On the other hand, masochists enjoy receiving pain, which, again, may or may not be sexual. Strangely (?) I couldn’t find much in terms of famous or known masochists. The best I could do was a British artist I actually remember from some required art “appreciation” class freshman year, a painter named Keith Vaughan. Evidently, he purpose built some kind of gizmo contraption to electrocute his own genitals. They definitely didn’t cover that part in my class though, I’m pretty sure I’d remember that.
Sexual sadism and masochism can actually be considered to be psychological disorders, as each are categorized by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) as paraphilias, which are sexual disorders that are characterized by socially unacceptable preoccupations or behaviors. Some other examples of paraphilias include voyeurism, exhibitionism, and fetishism, to name just a few. There’s a great deal of controversy on this topic, and at first glance, I generally think of sexual sadism and masochism as quasi-disorders at best. Proponents of the ‘disorder theory’ claim that because sadism involves causing physical or psychological pain or suffering to another human being, anyone who enjoys it is mentally ill. Opponents say that it doesn’t involve pain or suffering in the ‘classic sense,’ (say whaaat??) and that as long as it occurs with a consenting partner, it should be argued that it is not a psychological disorder.
I say that there are many factors to take into account, but that it should definitely be considered a psychological disorder in certain cases: if and/ or when it causes anxiety or depression to that individual, causes problems that interfere with work, social setting, or family, and obviously when it poses, or is likely to pose, a potential danger to another individual person or group. And in fact, more recent versions of the DSM back me up, asserting that it must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” in order for sexual sadism or masochism to be considered a disorder. I’ll spare you the markers that must be considered to establish that distinction. And you’re welcome for that.
When applied to sexual relationships, sadomasochism is generally termed BDSM, or Bondage and Discipline, Dominance and Submission, and Sadism and Masochism. BDSM is generally considered to be an “alternate” sexual preference that includes a variety of sexual identities and activities. Mainstream culture often represents it as reckless, dangerous, and unhealthy; a dark, non-normal kind of sexual preference which typically forces its players to retreat into carefully curated communities alienated from the majority of society. If you actually paid attention to Fifty Shades of Grey, you might have understood that Christian Grey’s reasons for enjoying kink stem from a childhood filled with abuse. Television crime dramas often portray fetishists as seedy, unethical lawbreakers, and that’s probably as a result of the psychological disorder theory more than anything else. Participants or “kinks” often make the argument that dominance and submission are more a power dynamic than a punisher-punishee relationship; and they usually identify themselves in one of three main ways: dominant, submissive, and switch, though the identities are fluid and continuous, and can change depending on the participants’ mood or partner. But if you consider the fact that the terms sadism, masochism, and sadomasochism were coined in the late 1800’s, pop culture wasn’t responsible for making kink the latest fad… it seems some humans have long had a penchant for adventurous sex. Even way back in 1956, when the Kinsey Institute was in its heyday, a study revealed that 50% of men and 55% of women enjoyed erotic biting, evidently as racy as they got when describing kinky sex. Considering all of the historical evidence taken together, I can only surmise that we’re not necessarily having more kinky sex than we always were, but we’re just talking about it- or admitting it- more than before.
Bondage: A form of restricting a sexual player’s movement, ie by ropes or handcuffs, to increase pleasure.
Discipline: A series of rules and punishments typically used by a dominant partner to exert control over their submissive partner.
Dominance: The act of dominating a sexual partner, during or outside of sex. This can include dictating sexual behavior, food habits, and even sleep patterns.
Submission: The act of a submissive partner following a dominant’s actions or dictates.
Consensual sadomasochism should not be confused with acts of sexual aggression. While sadomasochists do seek out pain in the context of love and sex, they do not do so in other situations, and typically abhor uninvited aggression or abuse as much as the next person. Generally speaking, sadomasochists are not psychopaths, and thankfully, the opposite is usually true as well. Also contrary to popular belief, evidently submissives have just as much control over deciding what happens to them as their dominant partner does, and sometimes even more so. Communication between the dominant and submissive is of utmost importance, as that’s where boundaries are set, desires are shared, and permission is given. Consent, in the form of a formal contract, a verbal agreement, or a casual conversation, is the key to healthy expression of BDSM and sadomasochism. There is typically an understanding between all partners that activity could stop at any moment should they be uncomfortable with the intensity of play; this can be done through the use of previously agreed upon safe words that signal others to stop when uttered. I’ve seen references to layers of safe words that are like a traffic light: green means good to go, yellow means proceed with caution, and red means get the hell away from me. That’s sure different than the “red light-green light” we played as kids.
Speaking of games….
Maybe you think that this sort of stuff only applies to a small number of “deviants,” but the truth is that many people, if not most, do actually harbor sadomasochistic tendencies. For example, many casual, “normal” behaviors, like infantilizing, tickling, and love-biting, could be considered as containing traces and elements of sadomasochism. In addition, sadomasochism can play out on a more psychological level- sadomasochism on the DL if you will. Consider the fact that in almost every relationship, one partner is more attached than the other. This phenomenon is just accepted as fact without much discourse, so commonly that it has even been the subject of poetry and philosophy, with the more attached partner being referred to as “the one who waits.”
In 1977, A Lover’s Discourse: Fragments philosopher Roland Barthes writes:
Am I in love? —yes, since I am waiting. The other one never waits. Sometimes I want to play the part of the one who doesn’t wait; I try to busy myself elsewhere, to arrive late; but I always lose at this game. Whatever I do, I find myself there, with nothing to do, punctual, even ahead of time. The lover’s fatal identity is precisely this: I am the one who waits.
When this asymmetry is examined, the less attached partner (A) grows dominant, while the more attached partner (B) becomes infantilized and submissive in a bid to please, coax, and seduce them. Sooner or later, (A) feels stifled and distances themselves, but if he or she moves too far away, (B) feels threatened and may go cold or give up. That in turn prompts (A) to flip and, for a while, to become the more enthusiastic of the two. But the original dynamic soon re-establishes itself, until it is upset again, and so on, ad nauseum. Domination and submission are elements of every relationship (or nearly so) but that does not mean that they are not tedious, sterile, and immature, as Freud points out…endlessly I might add.
Rather than playing cat and mouse, couples need to have the confidence and the courage to rise above the game playing. True love is about trusting, respecting, nurturing, and (healthy) enabling, but not everyone has the capacity and maturity for this kind of love. I see this domination-submission phenoma nd game playing a lot…like a lot a lot, and it can be quite the mess to rectify, as people get comfortable in their roles, whetjer they’re conscious of them or not.
Sadomasochism, BDSM, kink…they aren’t really my thing. Then again, neither is sociopathy, but I can still effectively diagnose and treat patients with it. That said, sadomasochism as a practice is definitely harder to understand than just grasping it as a general concept. I classify it as one of those great mysteries of the human condition that give me a headache when I try to completely untangle them. I’ve of course had patients into all kinds of kink and BDSM, and then again, I’ve also had some who are more “classic” practicing sadomasochists, who can be more challenging to treat. Everybody’s got a backstory that I may or may not be privy to, so I don’t judge and I think I do a pretty good job of treating everybody fairly. I figure that understanding, or at least the most earnest attempt at it, is the best way to deal with anything we may not ascribe to, even as we wish to respect the person who does. Along that same vein, if you’re curious about BDSM and kink, there are websites galore with tips and tricks, even online “academies” where you can learn to be a dom or a sub, or BDSM groups for the over 50 set…you name it, it’s there for your perusal. If you do decide to partake, I can only suggest to communicate, communicate, communicate; be safe, establish a safe word and safe boundaries, and have fun people.
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Thank you and be well people!
Migraine: Strategies to Treat It and Beat It
Last week, I talked all about migraine. What do I hope were the takeaways? Well, there are roughly 10,000 known human diseases under the sun… of allll those diseases, I hope you learned that migraine is a very unique beast, thanks to a very unusual constellation of facts surrounding it: its striking capacity to debilitate (ranked first in neuro and sixth overall) and staggering prevalence (ranked third overall) despite a frighteningly high (60%-70%) rate of misdiagnosis really make it a beast of a neurological disease.
This week, the focus will be on how to manage and/ or prevent migraine. I’m going to cover some basic suggestions and nonprescription ways to avoid or prevent migraine, and I’m also going to discuss some prescription medications and procedures to treat migraine when it occurs. Spoiler alert: one of the very new migraine meds has been like a miracle in my life people. So read on to find out how you might be able to avoid getting a migraine as well as some ways to deal with it once it rears its ugly head.
First, a few more takeaways from part 1:
– Migraine is more than a bad headache.
– Proper and early diagnosis by a specialist physician with specific neuro symptoms is very important.
– Episodic migraine occurs once or twice a month while chronic daily migraine is minimum 15 days per month.
– There are several migraine types classified mainly by presence or absence of neurological aura.
– Migraineurs often have identified triggers that will cause attack.
– All migraines suck, but some more so than others (hello cluster, rebound, and status migrainosus) because of the extreme pain, but also because of the extreme neurological disturbances that come along for the ride.
– Exact cause of migraines still unknown, but thought related to a combination of genetics, neurotransmitters, and/ or hormones.
– There are medications to prevent, abort, and rescue from migraine.
Why isn’t there an obvious known way to prevent and treat migraine?
When people find out I have cluster headaches or when I’m asked by a fellow migraineur or a patient why we don’t already have a foolproof way to prevent and treat migraine, the answer is intensely unsatisfying, especially considering that migraine affects zillions of people, and has done so for a looong time. For the love of Pete, why haven’t we figured it all out by now? Well, even though it is the world’s most common cause of neurological disability, researchers are only just beginning to understand what really causes migraine. I say ‘really’ because unfortunately, the common and long accepted vascular explanation for migraine had to be thrown out relatively recently. The vascular theory was proposed in 1938 and claimed that pressure changes in the vascular system near the brain, and in the brain, caused migraine. More specifically, that vasospasm and vasoconstriction narrowed the blood vessels, slowing and restricting blood supply in and around the brain and causing visual aura and other neuro symptoms; then vasodilation occurred, and those vessels rebounded and widened, allowing too much blood to course through too quickly and causing pain. Eventually, the vessels came back to their normal size and state and the migraine ended…until the next time. This vascular explanation had considerable intuitive appeal because alteration in blood flow seemed to fit the pulsating pain quality that migraine headaches often possess. But now after extensive testing, this theory no longer has any validity. We now know for sure that migraine is a gene-related neurological disease, not a vascular one. So we lost a lot of valuable time looking at the wrong culprit and screwing around with the vascular theory.
Current research shows that a variety of genetic mutations are at least partly responsible for migraine, with the TRESK gene being identified as one such genetic mutation site. The TRESK gene provides the blueprints for a potassium ion pump channel that is believed to help nerve cells rest. When mutations occur in this gene, they may cause nerve cells to become overexcited, making them more responsive to a smaller pain stimulus or less pain. Personally, I would call that over-reactive rather than overexcited, but that’s just me. Either way you get the idea. Even though genetic mutations tell part of the story, migraine initiation is enormously complicated. It relies on several processes which either result in a visibly changed brain structure or are caused by these changes in structure. In fact, it seems that most scientists believe as I do, that there isn’t just a single cause. In my thinking, there can’t be- there are so many different systems and senses affected that there have to be multiple causes in play. Obviously, lots of research is still needed before we know the whole story.
Treating Migraine: Natural Remedies
When a migraine does strike, you’ll do almost anything to make it go away. There are ten natural remedies and at-home treatments that may help prevent migraines, or at least help reduce their severity and duration.
1. Know and avoid triggers, esp in diet
Diet plays a vital role in preventing migraines. Many foods and beverages are known migraine triggers, such as:
-Foods with nitrates, including hot
dogs, deli meats, bacon, and sausage
-Naturally-occurring tyramine compound, such as blue, feta, cheddar, Parmesan,
and Swiss cheese
-Alcohol, especially red wine
-Foods that contain the flavor enhancer monosodium glutamate (MSG)
-Foods that are very cold such as ice
cream or iced drinks
-Cultured dairy products such as
-Buttermilk, sour cream, and yogurt
-Caffeine: a small amount of caffeine may ease migraine pain in some people, and a small amount of caffeine is found in some migraine medications. But too much caffeine may also cause a migraine and/ or may also lead to a severe caffeine withdrawal headache.
**Track yourself! As Migraine Warriors, we tend to think of the occasions when attacks occur and the major symptoms that go along with them. Always keep a diary or list of things that act as warning signs or triggers of an oncoming migraine, including foods or environmental triggers, how much sleep have you had, what the weather is like, what you ate and when, etc. To figure out for the first time which foods or beverages may trigger your migraines, keep a daily food diary. Record everything you eat and note how you feel afterward. All information may be very important and will likely help you to avoid future attacks.
2. Apply lavender oil
Inhaling lavender essential oil may ease migraine pain. According to a 2012 study, people who inhaled lavender oil for 15 minutes during a migraine attack experienced faster relief than those who inhaled a placebo. Lavender oil may be inhaled directly or diluted and applied to the temples.
3. Try acupressure or acupuncture
Acupressure is the practice of applying pressure with the fingers and hands to specific points on the body to relieve pain and other symptoms. While there are no recent scientific studies, according to some sources, acupressure is a credible alternative therapy for people in pain from chronic migraine and other conditions, and may also help relieve migraine-associated nausea. And although there may not be any definitive scientific studies on acupuncture, some migraines may respond well to acupuncture, the Chinese method of inserting needles into specific body locations to reduce or stop pain. Because the results are so variable, some doctors do not recommend this treatment. But because some patients report headache relief, it is another treatment method to consider.
4. Look for feverfew
Feverfew is a flowering herb that looks like a daisy, and according to some, is a folk remedy for migraines. According to some sources, there’s not enough evidence that feverfew prevents migraines, but many people still claim it helps their migraine symptoms without side effects.
5. Apply peppermint oil
The menthol in peppermint oil may stop a migraine from coming on. A 2010 study found that applying a menthol solution to the forehead and temples was more effective than placebo for the pain, nausea, and light sensitivity associated with migraine.
6. Go for ginger
Ginger is known to ease nausea caused by many conditions, including migraines, and it may also have other migraine benefits. One study claimed that ginger powder decreased migraine severity and duration as well as the prescription drug sumatriptan, and with fewer side effects.
7. Sign up for yoga
Yoga uses breathing, meditation, and body postures to promote health and well-being and may relieve the frequency, duration, and intensity of migraines. It’s thought to improve anxiety, release tension in migraine-trigger areas, and improve vascular health. Although researchers conclude it’s too soon to recommend yoga as a primary treatment for migraines, they believe yoga supports overall health and may be beneficial as a complementary therapy.
8. Try biofeedback
Biofeedback is a relaxation method that teaches you to control autonomic reactions to stress. Biofeedback may be helpful for reducing migraine triggers like stress and early migraine symptoms such as muscle tension.
9. Take vitamins and supplements
Some vitamins and supplements (collectively known as nutraceuticals) may be useful therapies. One of the nutraceuticals that has shown some evidence of relief in preliminary testing is magnesium. Magnesium deficiency is known to be linked to headaches and migraines and studies show magnesium oxide supplementation helps prevent migraines with aura, and may also prevent menstrual-related migraines. Adding magnesium to your diet may be helpful. You get magnesium from foods like nuts and nut products, including almonds, sesame seeds, sunflower seeds, Brazil nuts, cashews, peanut butter, eggs, oatmeal, and milk.
10. Book a massage
A weekly massage may reduce migraine frequency and improve sleep quality, according to a 2006 study. The research suggests massage improves perceived stress and coping skills and also helps decrease heart rate, anxiety, and cortisol levels.
If you get migraines, you know the symptoms can be challenging to cope with. You might miss work or not be able to participate in activities you love. Try the above remedies to possibly find some relief… they can’t make it much worse!
It might also be helpful to talk to others who understand exactly what you’re going through. There are lots of websites, support groups, and apps to connect you with real people who also experience migraines. You can ask treatment-related questions and seek advice from other people who totally “get it.” So do some googling for migraine support.
Calculate your Headache Burden
Another good idea… Some doctors like to estimate how much migraine disrupts your normal activities before establishing a treatment regimen. A questionnaire may be given to the patient to estimate how often they miss various functions (school, work, family activities) because of their attacks. You can also commonly find other surveys and tools online meant to be filled out, printed, and brought to a primary care physician to broach the subject of headache and/ or to discuss migraine types with specialist physicians to help define headache/ migraine type and zero in on the best treatment regime.
Treating Migraine: Medications
There are many types of medications for people with migraine headaches. Some help to reduce symptoms of acute migraine as they occur, while others prevent episodes from occurring. Captain Obvious says that taking any drug can have side effects, and that some are safer than others.
Two primary ways that medications treat migraine headaches: Acute medications aim to treat symptoms of migraine headaches as they occur. Preventive medications aim to reduce the risk of migraine headaches occurring in the first place by reducing migraine frequency and severity.
Over-the-Counter (OTC) Medications
-Acute medication to treat migraine
-A range of migraine medications are available without a physician’s prescription.
-These include analgesic medications like aspirin, acetaminophen, naproxen, or ibuprofen, may help to reduce pain.
-Many of these analgesic medications are nonsteroidal anti-inflammatory drugs (NSAIDs). This means that similar to steroids, they reduce inflammation which may help with migraine symptoms.
-It is best to take these medications when the first signs of an episode occur. The medicines will take time to enter the bloodstream, and taking them too late means that the headache will likely last longer and possibly won’t be susceptible to the medication; in other words it may not help.
-The risks associated with using OTC analgesics are relatively low.
-May cause mild side effects in some people, such as rashes.
When over-the-counter (OTC) medications do not work, a doctor may recommend stronger prescription drugs. There are several different types of prescribed migraine medications.
Prescription Medications: Treat Migraine
As opposed to preventing migraine
Ergot Alkaloids: Treat Migraine
-Medication to treat acute migraine
-I want to point out that ergot drugs are really old school. The American Migraine Foundation wants to point out that doctors don’t commonly prescribe them any longer, but they may recommend them in severe cases if someone doesn’t respond to other analgesics.
-Two main types are dihydroergotamine (DHE) and ergotamine (Ergomar)
-Ergot alkaloids may cause blood vessels to narrow, which can have serious side effects for people with cardiovascular disease issues.
-Other potentially serious side effects: nausea, dizziness, muscle pain, unusual or bad taste in the mouth, vision problems, confusion, unconsciousness, in addition to many drug interactions.
-These side effects and the drug’s interactions are so problematic that physicians typically severely restrict use of ergotamines except in very rare cases.
-Fun fact: many scholars claim that the behavior of Salem’s “witches” was actually due to a fungal infection in the grain used at the time; ergotamines are essentially a mimic of this grain infection. So maybe don’t take it unless you look good in black and like the pointy hat look. Yikes people! Because of the side effect profiles and lack of efficacy, this class is definitely not as commonly used as newer and more effective triptans and more novel compounds.
Triptans: Treat Migraine
-Acute medication to treat migraine
-Approved to treat moderate to severe migraines: headaches where the symptoms interfere with the ability to perform daily tasks.
-Triptans act on the symptoms of a migraine headache in its early stages. -They will not stop the migraine headache, but they can help with some symptoms, such as nausea, pain, and light sensitivity.
-Several triptan medications exist:
-A person should take these drugs as soon as migraine symptoms start.
-They may not work if taken during a migraine aura.
-They are available in several forms: pill, orally disintegrating tablet, nasal spray, or injection.
-Triptans can cause side effects: dizziness, fatigue, nausea and vomiting, pain in the throat, chest, or head, numbness, dry mouth, burning or prickly feeling on the skin, indigestion, hot flashes, chills.
Antiemetics/Antinausea: Treat Migraine
-Acute medication for migraine symptoms
-Also known as antiemetic drugs, these can help people with migraine, even if they don’t feel nauseous.
-Don’t reduce pain, so some people take them alongside pain relief medication.
-Examples of antiemetic drugs:
CGRPReceptor Antagonist: Treat Migraine
-The FDA has recently approved several drugs that block calcitonin gene-related peptide (CGRP) receptors for the immediate treatment of migraine.
-CGRP is a molecule typically involved in migraine episodes.
-Examples of recently approved CGRP receptor antagonists include ubrogepant (Ubrelvy) and rimegepant (NURTEC).
Ubrogepant (Ubrelvy): Treat Migraine
-First drug in the class of oral CGRP (calcitonin gene-related peptide) receptor antagonists approved for the acute treatment of migraine with or without aura in adults
-Similar to Rimegepant (Nurtec ODT)
-Most common side effects that patients in the clinical trials reported were nausea, tiredness, and dry mouth.
-Contraindicated for co-administration with strong CYP3A4 inhibitors such as ketoconazole, clarithromycin, and itraconazole.
-Your doctor may change your treatment plan if you also use: nefazodone; an antibiotic – clarithromycin, telithromycin; antifungal medicine – itraconazole, ketoconazole; or antiviral medicine to treat HIV/AIDS – indinavir, nelfinavir, ritonavir, and saquinavir.
Rimegepant (Nurtec ODT): Treat Migraine
-CGRP receptor antagonist used for acute treatment of migraine with or without aura in adults.
-Similar to ubrogepant (Ubrelvy)
-Orally Disintegrating Tablets (ODT) for sublingual or oral use.
-Side effects include: nausea and
hypersensitivity, including shortness of breath and severe rash
-Important: like Ubrelvy, Nurtec will interact with other medicines such as: strong CYP3A4 inhibitors and moderate CYP3A4 inhibitors such as ketoconazole, clarithromycin, and itraconazole. Will also interact with inhibitors of P-gp or BCRP.
**This is the new medication for treating migraine that works like a miracle for moi people!
Lasmiditan (Reyvow): Treat Migraine
-First in a brand-new class of drugs (Ditans) that stimulate the serotonin 1F receptor found in different brain regions and believed involved in causing migraine
-Slows body’s pain pathways
-Used for acute treatment of migraine with or without aura in adults.
-Not useful for migraine prevention.
-Taken by mouth
-Common side effects: sleepiness, dizziness, tiredness, numbness
-Reduces inflammation that arises in the nervous system.
Prescription Medications: Preventing Migraine
-For people who get migraine headaches regularly, some medications can help to reduce the number and severity of episodes, ie prevent migraine.
-Most drugs for preventing migraine headaches are relatively low risk.
-May cause side effects such as constipation, muscle spasms, and cramps.
-Several categories of preventative medications:
-Antihypertensive drugs lower blood pressure, usually in people with high blood pressure.
-There are many different types of antihypertensive drugs that might help to prevent migraine headaches, such as: beta-blockers, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors
-Anticonvulsant drugs treat seizures in people with epilepsy by reducing activity in the brain- and this can also reduce the risk of a migraine headache.
-Examples of anticonvulsants for treating migraines include topiramate (Topamax) or valproic acid (Depakene).
-Antidepressants often work to increase the availability of serotonin in the brain. -Because of this mechanism, some of these drugs could also help to prevent migraine headaches, such as amitriptyline (Elavil).
-Calcitonin Gene-Related Peptide
-CGRP inhibitors are preventive migraine treatments that disrupt a protein called CGRP, which is particularly active in people with migraines.
-They block the flow of CGRP to the brain, disrupting signals that cause migraines.
-Unlike traditional migraine meds, such as sumatriptan (Imitrex), CGRP inhibitors don’t constrict blood vessels, so they’re safe for people who’ve had a stroke, heart attack, or vascular disease.
-Three new CGRP inhibitors are injected once a month to prevent migraines:
fremanezumab (Ajovy) galcanezumab-gnlm (Emgality)
-So new: may cause unknown side effects, and consequences of long-term use are still unknown.
-FDA 2020 approval, migraine prevention in adults
-First drug for migraine prevention via IV infusion.
-Treatment involves doctor administering this drug intravenously for 30 minutes every 3 months.
Devices: Treat/ Prevent Migraine
-There are three new noninvasive medical devices currently available:
-Placed on the forehead to stimulate a nerve that impedes migraine pathways.
-Used as prevention or for treating when a migraine strikes.
-Magnetic stimulator placed on the back of the head to disrupt migraine signals in the brain.
-Used as prevention or for treating when a migraine strikes.
-Used for treating when a migraine occurs, cannot prevent migraine
-Placed at front of the neck to stimulate the vagus nerve.
Procedures: Preventing Migraine
There are two profedures used in an attempt to prevent migraine by reducing frequency and severity.
SPG Nerve Block
The sphenopalatine ganglion (SPG) is a group of nerve cells linked to the trigeminal nerve.
-Applying local anesthetics to this group of nerve cells can reduce sensations of pain related to migraines.
-Doctors can apply medication to this area through the use of small tubes called catheters. They can place these tubes inside the person’s nose, then insert numbing medication through the tube using a syringe.
-OnabotulinumtoxinA (Botox) injections for people with chronic migraine headaches.
-Doctor might prescribe Botox if a person has experienced at least 15 headaches per month for 3 months, eight of which must have included migraine symptoms.
-Doctors tend to recommend two or three other types of medication before trying Botox injections.
-Comes as injection only, can have many side effects.
-Progress carefully monitored, treatment may be stopped if there is no response after 8–12 weeks or if migraine episodes fall to less than 10 per month for 3 months.
-Can also have many possible side effects, including numbness or mild nausea. -Some other side effects are more serious, such as gallbladder dysfunction, visual problems, and bleeding.
Your Migraine Treatment: Is it Working?
-Sometimes initial treatments for migraine either do not reduce the symptoms or only marginally reduce them.
-If, after trying prescribed treatment(s) about two or three times and getting little or no relief, you should ask your doctor to change the treatment.
-Patients are strongly urged to treat migraine attacks early: some references indicated to take it within about 2 hours of the start of headache to get full benefit of treatments.
-Taking it earlier is better: as early as possible.
Migraine Treatment: Medication Limits
-Some chronic headaches are due to overuse of medicine
-Avoid using migraine-prescribed medicines more than twice per week. -Using and tapering medicine for migraine should proceed under your doctor’s supervision.
-Narcotics are a bad idea except used only as a last resort for migraine because they are addictive and very easily cause rebound headache pain. For example, only in an emergent situation, an ER visit.
Migraine: When to Seek Emergent Care
Most people know the pattern of their attacks (triggers, auras, and headache pain intensity). However, new headaches, in people with or without a migraine history, that last two or more days should be checked by a doctor. However, if a headache develops with symptoms such as fever, stiff neck, confusion, or paralysis, the person should be examined emergently and should be taken to an Emergency Medicine Department for scans and thorough evaluation.
Okay people, now you know pretty much everything about migraine… I hope it’s information you don’t need for yourself, and that you can tuck it away in your brain for the who knows when future. If you learned something, great! If you’re interested in a blog about a specific topic, please feel free to leave that in this comments section and I’ll see what I can do. And don’t forget about the sex and orgasm survey people! We need people to agree to be contacted once we finish it, so leave that in the comments too if you’re willing to takw it. Please pass this blog on to friends and fam. And definitely check out my YouTube channel for all of my videos and please like, comment, and share those too. As always, my book Tales From the Couch is available on Amazon and in the office.
Migraines, Part I
This is a very personal topic for me, as I have had cluster headaches and migraines my entire life. While I was double checking a statistic for this blog, I came across a term that I’d never heard before: migraineur. Such a romantic sounding word to define a person with migraines. But when in Rome… As a migraineur, at times my headaches dictated my entire life, what I did and when I did it; or more accurately, if I did it. My cluster headaches are horribly disabling, like fireworks going off in one side of my head; bunches of them exploding at random intervals- in clusters- hence the name. Best medical intel indicates this barrage lasts 4 to 72 hours, though mine have always been a helluva lot closer to the latter than the former. And I swear that migraines and clusters somehow alter the spacetime continuum, tearing a hole in the fabric of time such that every minute lasts an hour. In any event, suffice it to say that every minute of a cluster or migraine is the Longest! Minute! Of! Your! Life! If you’re having difficulty imagining what that pain might feel like, consider yourself lucky. Most people (physicians included) don’t realize how consequential and life altering migraine can be. Migraine is the 3rd most prevalent illness on the planet and the 6th most debilitating illness on the planet, yet also the most misunderstood, underestimated, mis-/un-diagnosed, and mis-/under-treated neurological disorder, especially in relation to its symptoms and ability to incapacitate afflicted people, people. While most migraineurs have “attacks” or episodes once or twice a month, more than 4 million adults experience chronic daily migraine, which is defined as having at least 15 migraine days each month. Though it’s usually unintentional, medication overuse in treating episodic migraine is one of the most common reasons why episodic migraine becomes chronic daily migraine.
Migraine Fast Stats
-Affects 12% of the US population = 39 million people in US, 1 billion globally.
-Affects 18% of all American women, 6% of all men, and 10% of all children.
-Onset can occur at any time, but most commonly falls between ages 18 and 44.
-Approximately 90% of migraine sufferers have a family history of migraine.
Migraine and Gender
-Migraine disproportionately affects women, as 85% of chronic migraine sufferers are female, affecting 28 million women in the US.
-Fluctuations in estrogen levels are often responsible for increased severity and frequency of migraines.
-Before puberty, boys are more affected by migraine than girls, but adolescence sees an increase in the risk and severity of migraine in girls such that by adulthood, three times more women suffer from migraine than men.
-Very often undiagnosed or misdiagnosed
-Evidence suggests association with infant colic, possibly an early form of migraine.
-Occurs in kids as young as 18 months.
-50% of first migraine attacks occur before age 12.
-Occurs in 10% of school-age children 7-14 and 28% of adolescents 15-19.
-Migraines are hereditary: studies have shown that a child with one parent who suffers from migraines has about a 50% risk of developing migraines, but if both parents have a migraine diagnosis, a child’s risk of developing migraines jumps to 75%. If just a distant, non-parent relative suffers from migraine headaches, the risk for any genetically related offspring to also develop migraine is 20%.
-Childhood aged boys suffer from migraine more often than girls, but as adolescence approaches, the incidence rate increases faster in girls than in boys, and by adulthood, females with migraine outnumber males by three to one.
Costs of Migraine
-Migraine is a public health issue with major social and economic consequences.
-More than 157 million workdays are lost each year in the US due to migraine.
-US industry loses $36 billion per year due to absenteeism, lost productivity, and medical expenses caused by migraine.
-US headache sufferers receive $1 billion worth of brain scans each year.
-Over 90% of sufferers are unable to work or function normally during migraine, claiming at least a 50% reduction in overall productivity.
-24% of people living with migraine disease report headaches so severe that they have sought emergency room care.
-Medical costs of treating chronic migraine itself equal approximately $6 billion annually, but sufferers spend nearly seven times that treating the conditions often associated with it including depression, anxiety, and sleep disturbances.
-Healthcare costs are 70% higher for a family with a migraine sufferer than a non-migraine affected family.
Headaches vs Migraines: Who’s Who?
Headache refers to any pain within the head, face, or neck. This pain may be centralized to one focus or area, or it may be diffuse and emanating throughout all areas. While many people consider all “bad” headaches to be migraines and/ or use the two terms interchangeably, this is inaccurate. As I’ll explain next, migraines are a type of primary headache, so that means that all migraines are headaches. But the reverse, that all headaches are (or can be) migraines, is not true.
Headaches: Three Main Categories
Category 1) Primary Headache
Category 2) Secondary Headache
Category 3) Painful cranial neuropathies and other (facial) pain
Primary Headache: Refers to a headache that occurs on its own. The three major types of primary headaches are migraine, tension, and cluster.
Secondary Headache: Refers to a headache that is caused by something else, such as ‘medication overuse headache’ which is caused by using migraine medication over a long period of time. This is also known as rebound headache, a very disabling headache that is basically the result of taking meds for frequent migraines over an extended time period, even when taken as directed. I have a chronic daily migraine patient that at one time had 22-plus migraine days per month, and she got locked into a gnarly rebound headache. They’re super painful and the only way to treat them is to discontinue the causal migraine med… and that’s a problem if that’s the only thing that’s ever helped. Thankfully, these days we have more options for both preventing migraine and treating it when it rears its ugly head. But I’ll tackle all of that next week. For now, continuing on with migraines.
Painful Cranial Neuropathies and Other Facial Pain: Refers to headaches/ pain arising from, or related to, nerve abnormalities in the upper part of the head and neck. For example: a whiplash injury or disk injury with nerve damage (ie neuropathy) leading to inflammation and pain.
As opposed to “bad” headache, migraine is a neurological disorder whose accurate diagnosis requires the presence of specific symptoms and certain qualities.
Requisite Migraine Symptoms
Migraine attacks are accompanied by one or more of the following disabling symptoms: visual disturbances, nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch, and smell, and/ or numbness/ tingling in extremities or face.
-(Mostly) occuring on one side of head
-Pulsating pain quality
-Moderate to severe pain intensity
-Made worse with physical activity
-Nausea and/ or vomiting
-Sensitivity to light (photophobia)
-Sensitivity to sound (phonophobia)
Migraine: Ancillary Symptoms
The presence of one or more disabling symptoms (listed above) are required for diagnosis of migraine, but many other ancillary symptoms can be (but aren’t required to be) associated with migraine. These can include abdominal pain, fever, dizziness, and fatigue.
Many things under the sun can trigger a migraine. Triggers are very individualized, they’re not the same for everyone; what’s more, what causes or triggers a migraine in one person could relieve it in another.
Migraines are commonly triggered by environmental factors, and these can be external factors like eating certain foods or taking certain medications, or internal factors like stress or blood sugar changes.
Triggers may be hormonal, behavioral, physical, emotional…they vary, but there are common themes. Below are some of the usual suspects, along with ways to avoid them.
Certain light patterns, loud sounds or strong smells
Alcohol: Red wine is a common and well recognized migraine trigger, but other alcoholic drinks can also cause migraine.
Weather changes: Even small changes in barometric pressure can cause migraine, especially those associated with storms and hurricanes. If weather is a trigger for you, ask your doctor about the possibility of taking medication at the first sign of atmospheric change.
Bright light: It’s believed that light “turns on” certain cells that can trigger pain. Wearing sunglasses indoors can increase your eyes’ sensitivity to light, so save your shades for outside. You can also try wearing FL-41 boysenberry-tinted lenses, which have been shown to minimize the triggering effect of light.
Caffeine: Caffeine is unusual in that both its presence, and its withdrawal, can trigger a migraine; and it is a common component of prescription and over the counter migraine remedies. If you have migraine, your best bet is to not vary your regular coffee/ tea routine and caffeine intake, even on weekends.
Processed meats and cheeses: Some people may be sensitive to tyramine, a substance found naturally in some foods: especially aged and fermented foods like some cheeses, kimchi, smoked fish, soy sauce, caviar, cured meats, and some types of beer.
Computers: Poor ergonomics and the screen’s bright light can combine to trigger a migraine. Practice good posture and take frequent stretch breaks.
Dehydration: Not consuming enough liquids causes blood volume to drop and decreases blood flow to the brain, which can trigger migraine. Low electrolyte levels and/ or the loss of electrolytes are also common culprits. Aim to drink at least eight 8-ounce glasses of water a day.
Hormonal changes: Migraines affect women disproportionately, which could be partly due to fluctuations in estrogen levels. Talk to your doctor about whether you should take NSAIDs a few days before menstruation.
Hotter temperatures: The risk of migraine jumps almost 8% for every 9-degree Fahrenheit increase in temperature. Stay hydrated and consider avoiding outdoor activities during the hottest seasons and/ or times of the day if you’re sensitive.
Anatomical Migraine Triggers
Rather than an environmental trigger, these are four distinct external sensory nerve regions in the neck and face that can act as anatomical migraine triggers. Patients who are subject to one or more of these triggers will feel as if migraines are emanating from these specific areas. The common trigger areas are 1) the area above the eye/ forehead, 2) the neck, 3) the nose (felt behind the eye), and 4) the temple(s).
Two long term treatment options act against these trigger points:
-Botox injections will relax all of these trigger sites except for the nose.
-Trigger point surgery will physically release these nerves.
More on these next week.
Nearly one in four American households includes someone with migraine. This exceptionately high incidence rate means that every American knows someone who suffers from migraine (whether they’re aware of it or not) or they themselves struggle with it. Despite this high incidence rate, migraine is misdiagnosed more frequently than it is accurately diagnosed, most often as tension headache or sinus headache. Seriously? Misdiagnosed as often as it’s accurately diagnosed?! Scary, no? Blows my mind… but check out this this cute little factlet: 60% of women and 70% of men with migraine are misdiagnosed… period, end of story. But getting an accurate diagnosis is critical for arranging the right treatment, as some medications indicated for specific migraine types can actually be dangerous to people with other migraine types.
The science behind migraines can get complex people… we are dealing with the brain after all. But understanding exactly what’s occuring during a migraine can help in receiving the proper diagnosis and treatment options, as when it comes to migraine, it’s always better to err on the side of caution. Why? Aside from the fact I mentioned above, about how certain type-specific medications can be dangerous if utilized incorrectly… Well, if a migraine is not properly diagnosed and treated, an individual will typically experience recurrent and increasingly severe symptoms, including extreme head pain, fatigue, nausea, vomiting, and increased sensitivity to light and sound. Not only do the symptoms of the migraine become more severe when left untreated, the migraine tends to become more difficult to treat as it becomes more prolonged. In addition, the neurological disorder as a whole tends toward the progressive, such that subsequent instances of migraine and associated symptoms generally become more severe with time. But even setting aside the health and medical implications, there’s simply no reason to suffer pain needlessly and allow your life to be totally disrupted in the (horrifyingly) special way that only migraines can. Primary care physicians are often responsible for a preliminary diagnosis of migraine headaches, but it is strongly suggested that patients suspected of having migraines see a neurologist for a full workup, including a neuro evaluation and imaging studies if/ when indicated. Knowing exactly which type of migraine you have is essential to finding the safest and most effective treatment for you.
What’s Up with the Migraine Brain?
What’s happening in the brain to create such an excruciating storm? A migraine typically starts with a trigger, which is often incoming sensory information that wouldn’t bother most people… maybe opening the door to a bright sunny day or walking into Starbucks with the intense smell of coffee beans roasting. But a migraine brain is essentially damaged, so it doesn’t respond to stimuli the way a “normal” non-migraine brain does. So during a migraine, these incoming stimuli feel like an all-out assault.
Simple mechanistic view of a migraine brain: upon presentation of a trigger, the migraine prone brain produces an oversize reaction to that trigger, and its electrical system immediately starts (mis)firing on all cylinders. All of this electrical activity causes a change in blood flow to the brain, which in turn affects the brain’s nerves, causing pain and other associated symptoms. About 25% of migraine sufferers have an associated visual disturbance called an aura, which usually lasts less than an hour. In 15-20% of migraine attacks, other disabling neurological symptoms occur before the actual head pain, while in some other cases of migraine, these neurological symptoms occur without any actual head pain. More on these specific phenomena to come.
Migraine: Progression of Stages
Migraine attacks can progress through four distinct stages: prodrome, aura, attack, and post-drome. It’s important to note that not everyone with migraine goes through any or all of these stages.1) Prodrome Stage
Beginning one to two days before a migraine, some subtle changes that may warn of an impending migraine include:
-Mood swings, depression to euphoria
-Increased thirst and urination
-Frequent yawning2) Aura Stage
Reversible symptoms or sensations of the nervous system that might occur before or during migraines or other neurological events. They’re usually visual symptoms, but they can also include other types of disturbances as well. Each symptom usually begins gradually, builds up over several minutes, and lasts for 20 to 60 minutes before fading away.
Examples of migraine aura include:
-Visual phenomena, ie bright spots, flashing lights, and zigzag lines
-Pins & needles sensations in extremities
-Weakness or numbness in face or single side of the body
-Auditory symptoms: noises/ music
-Uncontrollable movement,shakes/jerking3) Attack Stage
A migraine usually lasts from 4 to 72 hours, depending on its severity and if/ how it’s treated. Migraine frequency varies from person to person; may occur rarely or strike many times each month.
During a migraine, you will likely have:
-Pain on one side of your head, but can occur on both sides.
-Pain that throbs or pulses
-Sensitivity to light, sound, smell, touch to varying degrees.
-Nausea and vomiting4) Postdrome Stage
After a migraine attack, you might feel drained, confused, hung over, and moody for up to two days. Some people report mood swings from elation to despair. Sudden head movement may briefly bring on pain once again.
Traditional migraine treatment involves a combination of medications, lifestyle changes, and potentially, alternative therapies like acupuncture. Migraine medications are usually divided into three groups: preventative, abortive, and rescue.
Preventative medications: Captain Obvious says that preventative meds are generally taken daily in an effort to avoid getting (aka prevent) a migraine, as they are intended to reduce the frequency and severity of migraine attacks.
Abortive medications: Abortive meds are generally the first-line, acute medications meant to be taken when someone gets a migraine. Unlike pain medications that only mask the pain for a few hours, abortive medications work to stop the migrainous process itself and end the associated symptoms, and they are most effective when taken as early as possible in a migraine attack.
Rescue medications: Rescue meds are often pain medications, and are intended to be used if and when abortive meds fail, or when abortive meds might be contraindicated due to allergy, side effects, or pregnancy in some cases. Other types of rescue meds can be used to help people relax and get through a migraine by reducing nausea for example. Rescue meds don’t have the ability to abort a migraine, but the idea is they may mask the pain for a few hours while the migraine runs its course.
While most migraineurs experience “attacks” or episodes once or twice a month, more than 4 million adults experience chronic daily migraine, which is defined as having at least 15 migraine days each month. Though it’s usually unintentional, medication overuse in treating episodic migraine is the most common reason why episodic migraine becomes chronic daily migraine. About 25% of migraine sufferers have an associated visual disturbance called an aura, which usually lasts less than an hour. In 15-20% of migraine attacks, other disabling neurological symptoms occur before the actual head pain, while in some other cases of migraine, these neurological symptoms occur without any actual head pain. More on these specific phenomena to come.
Migraines are like ice cream… they come in a variety of different ‘flavors’ that ‘taste’ different to each of us. The basic ingredients may be the same, but the symptoms and severity vary widely by person, age at time of attack, and length of time they’ve been experienced. It’s always possible to have multiple migraine types, so talk to your doctor about your symptoms if you’re uncertain.
According to the ICHD-3 the International Classification of Headache Disorders, there are seven types of migraine, with diagnostic criteria based on scientific evidence. It should be clear by now that not everyone will have ‘typical’ migraine, so please view this information as a guide only, and not as a replacement for physician evaluation. Note that some references created different divisions.
ICHD-3 Seven Migraine Types:
1. Migraine without Aura
-Formerly called common migraine
-First & most widespread type of migraine
-Main symptoms: throbbing pain that starts on one side of your head (as opposed to starting behind the left eye where most migraines tend to start), moving around tends to make the pain worse, and it’s normal to feel nauseous, dizzy, and sensitive to light and sound.
-Duration 4 to 72 hours
-Prodrome brings: difficulty speaking or reading, increased urination, irritability and depression, food cravings, frequent yawning, muscle fatigue or tight or stiff muscles in the neck and shoulders, nausea, constipation, or diarrhea, poor concentration, sensitivity to light, sound, touch, and smell, and trouble sleeping.
-After the 4 to 72-hour headache attack, hits, postdrome with “migraine hangover” can make you: feel moody, feel sensitive to touch, especially in areas where the headache was focused, feel tired, have stomach issues
Here’s some more info about how the common migraine progresses.
2. Migraine with Aura
-Formerly called classic migraine, focal migraine, complicated migraine, aphasic migraine, migraine accompagnee.
-Main symptoms: visual disturbances before migraine begins, followed by common migraine symptoms
-Duration of visual disturbances: ranges from a few minutes to a full hour, usually before the actual migraine attack starts.
-Duration of migraine: 4 to 72 hours.
-25% of people with migraines also experience aura.
-Aura can cause visual disturbances, neurological symptoms, and unpleasant feelings like a numb face or tongue, or pins and needles that spread across body.
-ICHD3 breaks these down even further into four types: typical aura, brainstem aura, retinal aura, and hemiplegic aura.- ICHD-3 Subtype 1: Typical Aura
-Typical aura brings visual symptoms, inc temporary blind spots, geometric patterns, zigzag lines, stars or shimmering spots, and flashes of light. – ICHD-3 Subtype 2: Brainstem Aura
-Brainstem aura involves symptoms that seem to originate in the brainstem, like difficulty speaking, double vision, ringing ears, or vertigo.- ICHD-3 Subtype 3: Retinal Aura
-Retinal migraine (a.k.a. ocular migraine and optical migraine) differs from a typical migraine with aura in that you typically only have visual disturbances in one eye. Because they cause visual issues, they’re sometimes called “ocular migraines” or “optical migraines.”- ICHD-3 Subtype 4: Hemiplegic Aura
-Hemiplegic migraine involves symptoms like motor weakness or a loss in the strength of your muscles, usually on one side of your body; you may also struggle with language and feel confused or tired.
-Like with typical aura migraines, these symptoms usually last only minutes, and usually for no more than an hour, though may be longer for some; but memory loss and problems with your attention span can linger for weeks or even months. -Sometimes, hemiplegic migraines can cause more serious issues, like seizures, coma, and long-term problems with brain function and body movement.
-These facts might be frightening to read, but these types of migraines are rare and the extreme side effects are uncommon.
3. Menstrual Migraine
-Also called “hormonal migraines.”
-Pretty much as they sound: migraines in women triggered by hormonal changes.
-Duration: 4 to 72 hours
-ICHD-3 notes that menstrual migraines can happen with aura or without, and usually strike just before or at the beginning of your period.
-If you experience migraines during this time in two out of three periods, they are likely to be menstrual migraines.
-According to the US Office on Women’s Health, menstrual migraines might be triggered by the quick drop in the hormones estrogen and progesterone that happens before your period starts. -Affect about 7% to 19% of women
-Most women who usually get menstrual migraines also have other migraine types at other times.
-Frustrating but good-to-know: menstrual migraines tend to last longer than your average non-menstrual migraines, and might be more painful.
4. Vestibular Migraine
-Main symptoms: vertigo, dizziness, and trouble with balance
-Duration: ranges from a few seconds to a few days
-Surprisingly common, affecting 30%-50% of migraine sufferers.
-Vestibular migraines can give you sudden bouts of vertigo, where you see the world spinning or feel like you’re moving when you’re not.
-These bouts of vertigo might not always occur like aura symptoms, ie right before a headache sets in…
-These vertigo bouts may happen for just a few random seconds or may even happen intermittently for a few days.
-Sometimes this occurs when you move your head too quickly or when you see something particularly stimulating.
5. Migraine without Headache
-Main symptom: no actual headache pain, thank you Captain Obvious.
-Duration: each aura symptom can last 1 hour or less
-If you get aura symptoms but never get the telltale splitting pain in your head, you might have a migraine without a headache, sometimes known as a “silent migraine,” “painless migraine,” or “acephalgic migraine.”
-ICHD-3 simply calls them a “typical migraine with aura without a headache”
-An acelphagic migraine, or a migraine with no pain, can have all the same symptoms of migraines with aura, except the headache just never shows up!
-Interestingly, migraines without headaches become more likely as you get older. Something to look forward to!
6. Abdominal Migraine
-Main symptom: stomach pain instead of a headache
-Duration: 1 to 72 hours
-Migraine can cause extreme pain in your abdomen rather than your head; this is an abdominal migraine.
-Causes pain near the belly button, can make you feel nauseous, give you no appetite, cause vomiting, and make you look pale.
-This is more common in children than adults, but 2/3 of the children with a history of abdominal migraine actually end up developing migraine headaches as adolescents.
-Just like common migraines, abdominal migraines can be triggered by things like stress, bright lights, and food additives like monosodium glutamate (MSG). -Typically treated using the same medications as standard migraines with headaches.
7. Status Migrainosus
Main symptoms: a migraine that that lasts more than 72 hours
Duration: 72+ hours
-Basically a migraine (with or without aura) that lasts longer than the standard max of 72 hours.
-ICHD-3 recognizes status migrainosus, and points out that overusing migraine medications could be a likely cause
-Other triggers can bring on Status Migrainosus, like: changes in food and sleep habits, changes in medication, changes in weather, head and neck traumas, hormones, illnesses like the flu or a sinus infection, sinus, tooth, or jaw surgeries, and stress.
-Status migrainosus can be extremely frustrating; called a “trick candle on a birthday cake,” because the headache might briefly respond to medication, just to flood back randomly after a break.
Next week I’ll get into more specifics on these seven migraine types, along with the various medications used to treat the specific types and why they’re used. Also lots of intel on non-pharma methods of managing migraine, including devices.
That’s all for today folks. Please make sure to share my blogs and YouTube vids with friends and fam, and like, subscribe, and comment people! As always you can find my book Tales from the Couch on Amazon.com.
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Thanks and be well!