Don’t Sleep on This, part trois
We’ve all heard the saying about waking up “on the wrong side of the bed,” but as it turns out, there’s quite a bit of truth behind this colloquialism. Americans in general are notoriously sleep deprived; lots of folks experience problems sleeping, not getting enough sleep, not feeling rested, and not sleeping well. This can lead to difficulties functioning during the daytime, and have very unpleasant effects on your work, relationships, and social and family life. Most people know firsthand that sleep affects their mental state, but do you know how closely connected sleep is to mental and emotional health? Sleep deprivation has major effects on your psychological state. The two- sleep and mental health- contribute greatly to one another, generally coexisting in a bidirectional relationship. People with mental health diagnoses are more likely to have insomnia and/ or other sleep disorders, and vice versa. Ultimately, mental health disorders tend to make it harder to sleep well, while at the same time, poor sleep and insomnia can be a contributing factor to the initiation and worsening of mental health issues.
Insomnia and other sleep issues have clearly demonstrated links to depression, anxiety, bipolar disorder, and other conditions like ADHD. In fact, chronic sleep problems affect 50% to 80% of psych patients, as compared to 10% to 18% of typical American adults. Both sleep and mental health are complex issues affected by a multitude of factors, but given their close association, there’s good reason to believe that improving sleep can have a hugely beneficial impact on mental health. In my opinion, helping to ensure a patient gets good sleep is an important component of treating most psych disorders.
Why is sleep so important? If you recall from last week, brain activity fluctuates during sleep, increasing and decreasing during different stages of the sleep cycle. In NREM- non-rapid eye movement- sleep, overall brain activity slows, but there are quick bursts of activity. In REM sleep, brain activity picks up very rapidly, which is why this stage is associated with more intense dreaming. Each stage plays a role in brain health, allowing activity in different parts of the brain to ramp up or down, and this enables better thinking, learning, and memory. Research has clearly demonstrated that all this brain activity while you’re sleeping has profound effects on emotional and mental health.
Sufficient sleep, especially REM sleep, facilitates the brain’s processing of emotional information. During sleep, the brain works to evaluate and remember thoughts and memories, and a lack of sleep is especially harmful to the consolidation of positive emotional content. This can influence mood and lead to emotional reactivity, and has been tied to various mental health issues and the severity thereof. It can even lead to suicidal ideation and behaviors. The old timers thought that sleep problems were strictly a symptom of mental health disorders, but after elucidating what goes on in the brain during sleep, science has made it clear that problems sleeping are not just a consequence of mental health issues, they can also be a cause of the same.
One of the major sleep disorders that people face is insomnia, which is basically an inability to get the amount of sleep needed to function efficiently during the daytime. It may be caused by difficulty falling asleep, difficulty staying asleep, or waking up too early in the morning. About 1 in 3 Americans report difficulty sleeping at least one night per week. Short-term insomnia is very common, and has a multitude of causes: stress, lifestyle, work schedule, travel, or other life events. It can generally be relieved by simple sleep hygiene interventions, things like exercise, a hot bath, warm milk, or changing your bedroom environment. On the other hand, long-term insomnia lasts for more than three weeks, and this should really be investigated by a physician, potentially with referral to a sleep disorder specialist.
Why? Because chronic insomnia is rarely an isolated issue, it’s usually a symptom of another illness, be it medical or psych, that requires investigation. Sometimes insomnia can be caused by obstructive sleep apnea, or OSA, which has also clearly been linked to mental health issues. OSA is a disorder that affects your breathing while sleeping. With OSA, your throat muscles intermittently relax and block your airway, causing you to repeatedly stop and start breathing while you sleep. This leads to a drop in the body’s oxygen levels, creating fragmented and disturbed sleep. In fact, OSA can cause as many as 30 sleep disruptions per hour. Yikes. There are serious repercussions for that. The human body likes oxygen, and it can get a little pissy when it doesn’t get enough of it. People with OSA experience these abrupt awakenings, accompanied by gasping or choking, along with morning headache, daytime drowsiness, difficulty concentrating during the day, forgetfulness, mood changes, high blood pressure, and decreased libido. It’s not good. Unfortunately, OSA occurs more frequently in people with psych disorders, and it’s a serious issue, as it detracts from physical health while simultaneously heightening mental distress. A 2017 study found that people with sleep apnea, when compared to those without, were 3.68 times more likely to have anxiety, 2.88 times more likely to experience severe psychological distress, and 3.11 times more likely to have depression. In addition, it found that their odds of suicidal ideation were 2.75 times higher. Sadly, the same study also found these patients with OSA reported a greater lack of mental health care and support.
Multiple studies recognize the correlation between OSA and poor mood, post traumatic stress disorder, and higher prevalence of psychosis and schizophrenia. The presence of OSA in the schizophrenic population has been found to be as high as 48 percent! Smoking and alcohol consumption further complicate this link between schizophrenia and OSA, as both are very common habits in people with schizophrenia, and both confer an increased risk of sleep apnea. And OSA isn’t just linked to schizophrenia. Existing studies note the prevalence of OSA in bipolar patients to be similar to that of schizophrenia.
There’s also a causal relationship between OSA and depression. Decreased oxygen levels overnight, called nocturnal hypoxia, cause chronic stress, which then increases the production of corticosteroids in response. Higher levels of corticosteroids, in turn, cause mood changes and impaired cognitive function, as well as increased inflammation in the body, all of which contribute to the development of depression. Conversely, patients with depression exhibit lower levels of serotonin, a neurotransmitter that’s also linked to muscle tone of the upper airways. Decreased serotonin levels in the body increase the likelihood that the upper throat will collapse, causing even more episodes of apnea. It can create the perfect sleep storm.
Because OSA and depression share several symptoms, it can be difficult to discern the impact of one disease over the other. Both result in disturbed sleep, fatigue and lethargy, restlessness, and loss of concentration. Given those facts, it should come as no surprise that both OSA and depression are associated with increased vehicle and workplace accidents due to increased fatigue and poor concentration.
Insomnia: Cause and Effect
How well you sleep tells a physician like me a lot. About half of insomnia cases are related to depression, anxiety, or general psychological stress. Very often, the qualities of a person’s insomnia, along with their other symptoms, can be helpful in determining the role of mental illness in their inability to sleep. This is why I always ask patients to tell me about how they’re not sleeping… just knowing you can’t isn’t enough. For instance, early morning wakefulness can be a sign of depression, especially if it comes along with low energy, an inability to concentrate, sadness, and a change in appetite or weight. On the other hand, a sudden dramatic decrease in sleep which is accompanied by an increase in energy- or the lack of need for sleep- can be a sign of mania. Many anxiety disorders are associated with difficulties sleeping, and obsessive compulsive disorder is frequently associated with poor sleep as well. Panic attacks during sleep may suggest a panic disorder, while poor sleep resulting from nightmares may be associated with post traumatic stress disorder.
Sleep and Specific Mental Health Diagnoses
The way that sleep and mental health are intertwined becomes even more apparent when you look at how sleep is tied to a number of specific mental health conditions.
It is estimated that over 300 million people worldwide have depression, a mood disorder marked by feelings of sadness or hopelessness. Around 75 percent of depressed people show symptoms of insomnia, and many people with depression also suffer from excessive daytime sleepiness and hypersomnia, which is sleeping too much. Historically, sleeping problems were seen as a consequence of depression, but in reality, poor sleep may also induce or exacerbate depression, and sleep problems and depressive symptoms are mutually reinforcing. It’s essentially a negative feedback loop, where poor sleep worsens depression that then further interrupts sleep. But on the bright side of that, a focus on improving sleep may also have a corollary benefit of reducing the symptoms of depression.
Seasonal Affective Disorder
You may remember from a few months ago that SAD is a subtype of depression that most often affects people during times of the year with reduced daylight hours, typically fall and winter. It’s closely tied to the disruption of a person’s internal biological clock, or circadian rhythm, that helps control multiple bodily processes, including sleep. It shouldn’t surprise you then that people with SAD experience changes to their sleep cycles, and tend to sleep either too much or too little.
Every year, anxiety disorders affect an estimated 20 percent of American adults and 25 percent of teenagers, creating excess fear or worry that can affect everyday life and create risks for other health issues, including heart disease and diabetes. Anxiety disorders- including social anxiety disorder, panic disorder, specific phobias, OCD, and PTSD- have a strong association with sleeping problems. In these disorders, worry and fear contribute to a state of hyperarousal, when the mind is constantly racing, which is a central contributor to insomnia. Sleep problems may then become an added source of worry, creating anticipatory anxiety at bedtime, which makes it that much harder to fall asleep. It can become a vicious cycle. Research has found an especially strong connection between PTSD and sleep. People with PTSD frequently replay negative events in their mind, suffer from nightmares, and experience a constant state of being on alert, all of which can interfere with sleep. PTSD affects many veterans; at least 90 percent of U.S. veterans with combat-related PTSD have symptoms of insomnia. But sleep problems aren’t just a result of anxiety. Research indicates that poor sleep can actually activate anxiety in people who are at high risk for it, and chronic insomnia appears to be a predisposing trait among people who later go on to develop anxiety disorders.
Bipolar disorder involves episodes of extreme moods that can be both high, with mania, and low, with depression. A person’s feelings and symptoms are quite different depending on the type of episode, but both manic and depressive periods can cause major impairment in everyday life. In people with bipolar disorder, sleep patterns change considerably depending on their emotional state. During manic periods, they usually feel less need to sleep, but during depressed periods, they often sleep excessively. Very often, sleep disruptions continue when a person is between episodes. Research has found that many people with bipolar disorder experience changes in their sleep patterns just before the onset of an episode. There is clear evidence that sleeping problems induce or worsen manic and depressive periods, but that because of the bidirectional relationship between bipolar disorder and sleep, treatment for insomnia can reduce the impact of a person’s bipolar disorder.
Schizophrenia is a mental health disorder characterized by a difficulty in differentiating between what is and is not real. People with schizophrenia are more likely to experience insomnia and circadian rhythm disorders, and these issues can actually be exacerbated by medications that are used to treat schizophrenia. But once again, poor sleep and symptoms of schizophrenia may be mutually reinforcing, so there are potential benefits to stabilizing and normalizing sleep patterns.
ADHD is a neurodevelopmental disorder that involves reduced attention span and increased impulsiveness. While usually diagnosed in children, it may last into adulthood, and is sometimes only formally diagnosed when someone is already an adult. Sleeping problems are common in people with ADHD. They may have difficulty falling asleep, frequent awakenings, and excessive daytime sleepiness. Rates of other sleep disturbances, such as obstructive sleep apnea and restless leg syndrome (RLS) also appear to be higher in people with ADHD. Once again, there is clear evidence of a bidirectional relationship between sleep and ADHD; in addition to being a consequence of ADHD, sleep problems may aggravate symptoms, especially in reduced attention span or behavior problems.
Substance use disorders can also cause problems with sleep. While alcohol is sedating in limited quantities, alcohol intoxication disturbs your sleep patterns and can make you wake up numerous times in the night. Some sedative medications may cause sleepiness during intoxication, but it’s far too easy to develop a dependency on them, and ultimately they’ll disturb sleep and cause serious problems sleeping in people who are misusing or withdrawing from them. Illicit drugs like LSD and ecstasy are also associated with interruptions in sleep.
Keep in mind that many mental health conditions don’t arise in isolation, and that coexisting conditions can influence one another, as well as a person’s sleep. For example, it’s not uncommon for people to experience both depression and anxiety, and people with both conditions have been found to have worse sleep than people with “just” depression or anxiety.
As you can see, poor sleep has clearly been shown to significantly worsen the symptoms of many mental health issues. This is down to the bottom line, that lack of sleep will change your brain, at the very least making it harder to get through the day. At the same time, severe sleep problems can decrease the effectiveness of certain psych treatments. Treatment of sleep disorders has been studied in relationship to schizophrenia, ADHD and other psych issues, and all of the scientific data shows the connection between them. Good sleep is necessary for recovery- or prevention- in both conditions. It’s a multifaceted, bidirectional relationship. Sleep has a very important restorative function in ‘recharging’ the brain at the end of each day, just like we need to charge a mobile phone. You know what happens if you don’t plug that in, right? It dies. Enough said. Poor quality of sleep may seem like a minor symptom, but if it’s chronic, it can be a sign of something much bigger. Good sleep can enhance quality of life and positively contribute to managing any concurrent mental illness. In fact, the relationship between mental health and sleep is so strong that steps to improve sleep may even form part of a preventive mental health strategy.
Next week, we’ll talk about what you can do to help ensure good, restorative sleep. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Hello, people! Welcome back to a brand new blog for a brand new year! It’s been a tough one for moi thus far, as I got the gift no one wants… covid. It’s been gnarly, but thankfully, I’m starting to feel more like myself again. This week, we’re starting a new series on a very important topic that I hear a lot of complaints about: sleep. Sleep is a vital part of life; we spend up to one-third of our lives doing it, and can’t live without it. It’s a lot like sex… everyone wants it, and some people get more of it than others.
Don’t Sleep on this…
Lots of go getters and workaholics will say “I’ll sleep when I’m dead.” But the problem is that that might be sooner than you want it to be if that’s your point of view. Why is this? Why is sleep so important? What happens in our bodies and brains during sleep? Why is it so hard for some people to fall asleep, while others are out cold before their heads hit their pillows? How can we get better sleep? How does sleep- or lack thereof- affect mental health? One of my patients recently told me about her latest sleepwalking escapades. What’s that all about? These are just some of the questions I’ll be addressing in this series.
We’ll start with the first question: why do we sleep? At the most basic level, it makes us feel better. A sleepless night usually leads to a dull, lethargic day, but a good night of sleep makes us feel more alert, more energetic, happier, and better able to function. It is as necessary as food, and one way to think about the function of sleep is to compare it to that life-sustaining activity, eating. Hunger is a mechanism that has evolved to ensure that we consume the nutrients our bodies need to grow, repair tissues, and function properly, and feeling tired essentially serves the same purpose. Eating and sleeping are not very different, and both are regulated by powerful internal drives. Going without food produces the uncomfortable sensation of hunger, while going without sleep makes us feel overwhelmingly sleepy. And just as eating relieves hunger and ensures that we obtain the nutrients we need, sleeping relieves sleepiness and ensures that we obtain the sleep we need. But the question remains: why is it necessary? What is the function of sleep?
Despite decades of research and many discoveries about other aspects of sleep, the question of exactly why we sleep has been difficult to answer. Scientists have developed several theories, but as is the case with so many human processes, it’s unlikely that a single theory will ever be proven correct, as sleep is necessary for many biological functions.
Inactivity Theory, aka Adaptive Theory
One of the earliest theories of sleep, sometimes called the adaptive or evolutionary theory, suggests that inactivity at night is an adaptation that served as a survival mechanism by keeping organisms out of harm’s way at times when they would be particularly vulnerable. The theory suggests that animals that were able to stay still and quiet during these periods of vulnerability had an advantage over other animals that remained active. For example, they weren’t killed by nocturnal predators and didn’t have accidents during activities in the dark. Through natural selection, this behavioral strategy of inactivity presumably evolved to become what we now recognize as sleep. But for every yin there’s a yang, and a simple counter argument to this theory is that it may be safer to remain conscious in a dangerous environment, in order to be able to react to an emergency. So there doesn’t seem to be any major advantage to being unconscious and asleep if safety is paramount. I mean, yeah, you’re less likely to be run over by a car, but it’s easier to be eaten if you’re just laying there, conveniently waiting for the predator to get you.
Energy Conservation Theory
The energy conservation theory of sleep suggests that a main purpose of sleep is to reduce a person’s energy use during certain periods when it’s inconvenient and less efficient to hunt for food. This is backed up in our biology, as research has shown that our metabolic rate is significantly reduced during sleep, by as much as 10 percent in humans, and even more in other species. According to this theory, sleeping allows us to reduce our overall caloric requirements by spending part of our time functioning at a lower metabolism. Although it may be less apparent to people living in societies in which food sources are plentiful, one of the strongest factors in natural selection is competition for, and effective utilization of, energy resources. The theory supports the proposition that sleep is a process of natural selection; we’ve evolved to sleep to expend less energy for a certain amount of time each day. And in fact, research suggests that humans getting 8 hours of sleep can produce a daily energy savings of 35 percent over complete wakefulness.
Another explanation for why we sleep is based on the long held belief that sleep serves to “restore” what is lost in the body while awake. The bottom line is that sleep provides an opportunity for the body to repair and rejuvenate itself, and many important processes happen during sleep. In fact, many of the major restorative functions in the body- like muscle growth, tissue repair, protein synthesis, and growth hormone release- occur mostly, or in some cases only, during sleep. There is a great deal of empirical evidence collected in human and animal studies to support the restorative theory. For example, studies have demonstrated that animals deprived of sleep entirely lose all immune function and die in just a matter of weeks. All of the “sleep when you die” folks should probably read that.
Other rejuvenating aspects of sleep are specific to the brain and cognitive function. For example, while we are awake, neurons in the brain produce adenosine, which is a by product of cellular activity. As long as we are awake, adenosine accumulates and remains in high concentrations. During sleep, the body has a chance to clear adenosine from the system, and, as a result, we feel more alert when we wake. In fact, the accumulation of adenosine in the brain is thought to be one factor that leads to our perception of being tired; scientists think that this build-up during wakefulness may promote the drive to sleep.
Brain Plasticity Theory
One of the most recent and compelling explanations for why we sleep is based on findings that sleep is correlated to changes in the structure and organization of the brain. This phenomenon is known as brain plasticity, and its connection to sleep has several critical implications. Simply put, this theory says sleep is required for brain function. Specifically, sleep allows your neurons, or nerve cells, time to reorganize. Sleep affects many aspects of brain function, including learning, memory, problem-solving skills, creativity, focus, concentration, and decision making. Ever have trouble remembering today something you did or said yesterday if you didn’t sleep the night before? That’s because sleep contributes to memory function. While you sleep, short-term memories are converted into long-term memories, and information that is not needed is erased, so as not to clutter the nervous system. In addition, when you sleep, your brain’s glymphatic system clears out waste and removes toxic byproducts from your brain which build up throughout the day, and this allows your brain to work well when you wake up. If you don’t sleep, these things don’t happen, so if it seems like your brain doesn’t work properly when you’ve pulled an all-nighter, it’s because it doesn’t… it’s full of waste and useless info!
What else is sleep essential for?
Not only is sleep needed for physical health, sleep is also necessary for emotional health. Sleep and mental health are intertwined: on one hand, sleep disturbances can contribute to the onset and progression of mental health issues, but on the other hand, mental health issues can also contribute to sleep disturbances. I will cover this in more detail in another blog, but during sleep, brain activity increases in areas that regulate emotion, and this helps support emotional stability. One example of how sleep helps regulate emotions occurs in the amygdala. This part of the brain, located in the temporal lobe, is in charge of the fear response- it’s what controls your reaction when you face a perceived threat, like a stressful situation. When you get enough sleep, the amygdala can respond in a more adaptive way, but if you’re sleep-deprived, the amygdala is more likely to overreact.
Sleep affects your weight by controlling the hunger hormones ghrelin, which increases appetite, and leptin, which increases the feeling of being full after eating. During sleep, ghrelin decreases because you’re using less energy than when you’re awake. But lack of sleep elevates ghrelin and suppresses leptin, and this imbalance makes you hungrier, which increases the risk of eating more calories and gaining weight. Research shows that chronic sleep deprivation, even as few as five consecutive nights of short sleep, may be associated with increased risk of obesity, type 2 diabetes, and other metabolic syndromes. In addition, sleep is necessary for proper insulin function and may protect against insulin resistance. Insulin is a hormone that helps your cells use glucose, or sugar, for energy. But in insulin resistance, your cells don’t respond properly to insulin, and this can lead to high blood glucose levels and eventually, type 2 diabetes. Basically, sleep helps keep your cells healthy so they can properly take up glucose.
A healthy and strong immune system depends on sleep, period. Research shows that sleep deprivation lowers immunity and can inhibit immune response, which obvi makes the body much more susceptible to germs. When you sleep, your body makes cytokines, which are proteins that fight infection and inflammation. It also produces certain antibodies and various immune cells during this “down” time, and together, these prevent sickness by destroying harmful germs. This is why sleep is so important when you’re sick or stressed, as during these times, the body needs even more immune cells. Having had covid recently, I can vouch for that.
While the exact causes aren’t clear, scientists have established a link between heart disease and poor sleep. It is associated with risk factors for heart disease, including high blood pressure, increased sympathetic nervous system activity, elevated cortisol levels, increased inflammation, weight gain, and insulin resistance.
The Centers for Disease Control and Prevention says the average adult needs 7 hours of sleep a night. During that time, the body repairs cells and tissues, restores energy, and releases molecules like hormones and proteins, while the brain stores new information and gets rid of toxic waste, and the nerve cells communicate and reorganize. Without these processes, our bodies can’t function correctly. It’s a lot for a body to do, so give it the time it needs to do it!
Next time, we’ll talk about more what happens while you’re sleeping. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Scariest Psych Disorders, the finale
Hello, people… welcome back to the blog! Last week, we talked about more of the strangest and scariest psych disorders, and this week, we’ll finish that off before we take a break for the holidays. Let’s get right to it.
Ever had a food craving? Maybe you want a piping hot pepperoni and mushroom pizza, with extra cheese. Sounds good, right? How about you add some dryer lint? Yum! Or maybe a little shredded phone book? Still sound good? No? How about sex… ever had a craving for that? Of course, everyone has, right? How about sex with a truck? Not in a truck… WITH a truck. Hmmm…. Maybe not so much.
Well, imagine craving the taste of that phone book, or wanting to have sex with a car. It sounds unreal, but those things are reality for people with Kluver-Bucy Syndrome, a very scary neurological disorder associated with damage to the temporal lobes of the brain, resulting in the desire to eat inedible objects, sexual attraction to inanimate objects, and memory loss.
First described by neuropsychologist Heinrich Klüver and neurosurgeon Paul Bucy- hence the name- the story of Klüver-Bucy syndrome begins with a monkey and a cactus. Actually, it begins with mescaline, which is a chemical derived from a cactus, that causes vivid hallucinations. It was studied very thoroughly- and quite personally- by psychologist Heinrich Klüver, who noticed that monkeys that were given mescaline often smacked their lips, which reminded him of behaviors exhibited by patients with seizures arising from the temporal lobe of the brain. Unsure if this was due to mescaline or not, this made the two of them curious as to all of the functions of the temporal lobe, so they designed an experiment on a monkey named Aurora, who happened to be particularly aggressive. They removed a large part of Aurora’s left temporal lobe to investigate it under a microscope, and noted that when she woke, her previously aggressive demeanor had vanished, and she was instead placid and tame.
Apparently, this drew their interest more than the mescaline, so they focused solely on the temporal lobe, performing bilateral temporal lobe surgery on a series of 16 monkeys, and afterwards noted the following symptoms:
Psychic blindness- this indicates a lack of recognition or understanding of a person, place, or thing being viewed. After the surgery, the monkeys would look at the same object over and over again, unable to recognize the form or function of the object. Even things they should fear, like a hissing snake, they didn’t recognize, much less fear.
Oral tendencies- like a very small child, the monkeys evaluated everything around them by putting it all into their mouths, rather than using their hands, as they normally would. They would even attempt to push their heads through the bars of their cages in order to touch things with their mouths, instead of their hands.
Dietary changes- prior to the temporal lobe surgeries, these monkeys usually ate fruit, but afterwards, the monkeys began to accept and consume large quantities of meat.
Hypermetamorphosis- this meant that anything that crossed the monkeys’ field of vision required their full and immediate attention.
Altered sexual behavior- after the procedure, the monkeys become very sexually interested, both alone with themselves, and with others.
Emotional changes- the monkeys became very placid, with reduced or even absent fear. Facial expressions were also lost for several months, but those did return after a period of time.
Not surprisingly, people with Kluver-Bucy syndrome often have the same symptoms: trouble recognizing people and/ or objects that should be familiar to them, and excessive oral tendencies, with the urge to put all kinds of objects into the mouth, whether food items or not. Hypermetamorphosis is also common, the irresistible impulse or need to explore everything that comes into view. Other symptoms include memory loss, emotional changes, extreme sexual behavior, indifference, placidity, and visual agnosia, which is difficulty identifying and processing visual information. A nearly uncontrollable appetite for food is often noted, and there may be dementia type symptoms as well.
Klüver-Bucy syndrome is the result of damage to the temporal lobes of the brain. This can be the result of trauma to the brain itself, or the result of other degenerative brain diseases, tumors, or some brain infections, most commonly herpes simplex encephalitis.
Thankfully, this type of extreme damage is rare. The first full case report of Klüver-Bucy syndrome was reported by doctors Terzian and Ore in 1955, when a 19-year-old man had sudden seizures, behavioral changes, and psychotic features. First the left, and then the right, temporal lobes were removed. After the surgery, he seemed much less attached to other people, and was even quite cold to his family. At the same time, he was hypersexual, frequently soliciting people who happened by, whether they were men or women. He also wanted to eat constantly, regardless if the items were food or not.
Because it is so rare, like many classical neurological syndromes, Klüver-Bucy syndrome is really more important for historical and academic reasons, rather than for its immediate applications to patients. The reports of Klüver and Bucy got a lot of publicity at the time, mainly due to their demonstrating the temporal lobe’s involvement with interpreting vision, and their work added to the growing recognition that particular regions of the brain had unique functions which were lost if that region of the brain was damaged. Science is built on the work of others- the more we know, the more we learn- and while Klüver-Bucy syndrome isn’t very common, the work that went into describing it still has an impact felt in neurology to this day.
To be or not to be… that is the question. At least, that’s one of the many questions someone with aboulomania is likely to ask themselves. From the Greek a-, meaning without’, and boulē, meaning will, aboulomania is a psych disorder in which the patient displays pathological indecisiveness. While many people have a hard time making decisions, it is rarely to the extent of obsession, and that’s exactly the case in aboulomania.
In most people, the part of the brain that is tied to making rational choices, the prefrontal cortex, can hold several pieces of information at any given time. But people with aboulomania quickly become overwhelmed when trying to make choices or decisions, regardless of the importance of that decision. They come up with all the reasons how and why their decisions will turn out badly, causing them to overanalyze every situation critically. It’s a classic case of paralysis by analysis, where a lack of information, difficulty in valuation, and outcome uncertainty combine to become obsession. Often associated with anxiety, stress, and depression, as you can imagine, aboulomania can severely affect one’s ability to function socially.
As for etiology, it’s usually extremely authoritarian or overprotective parenting that leads to the development of aboulomania; when caretakers reward loyalty and punish independence. Sometimes there’s a history of neglect and avoidance of expressed emotion during childhood that contributes to it. If someone is a victim of humiliation or abandonment during childhood, the chances for aboulomania increase, as shame, insecurity, and lack of self-trust can all trigger it. It’s sad to see, when everyday tasks become deciding questions of peoples’ lives. Simple decisions… to see a movie or stay at home, and what movie? Do I want Mexican or Italian food? Should I call John or text him? These are questions that cannot be answered by people with aboulomania without an eternity of dilemmas.
It’s common for people with aboulomania to avoid being alone whenever they know a decision has to be made, or feel like a dilemma might come up. But this doesn’t come from a fear of being alone, it comes from the need to have someone there to make the decision for them, and assume the responsibility for said decision. Here, the fear of being alone isn’t the root of the problem, it’s just a symptom of a bigger issue. It’s important to mention that this dependency on people makes it easier for others to manipulate or lie to people with aboulomania. Some people will take advantage of their indecisiveness and use that, while others will simply leave them for not being able to make choices or ever express disagreement.
Many times, people with aboulomania don’t recognize it, or recognize it but try to play it off, but this is a pathological level of indecision, a mental illness, not just a self-esteem or insecurity issue, so diagnosis is important. Look, being indecisive when having to make an important decision is normal, but when it starts affecting your relationships, and it makes it impossible for you to live your life, it’s a problem, so it’s time for an evaluation. Once diagnosed, the process really consists of dealing with any of the underlying anxiety, depression, or stress that usually goes with it. The idea is to then help the person develop more autonomy, self esteem, and social skills, like assertiveness.
Ah Paris… the beautiful city of lights, croissants, funny mimes, the Champs-Elysées, macarons, the Eiffel Tower, and art at the Louvre. Sounds fabulous. That’s what most people think of, that view that I just described, so the reality can come as a shock… McDonald’s on every corner, crime, graffiti, and rude taxi drivers and waiters, irritated by tourists who don’t speak the lingo. I mean, every place has its pros and cons, but people seem to have romantic expectations of Paris, right? Hence Paris syndrome, an extremely odd, but thankfully temporary, mental disorder that causes one to become completely overwhelmed while visiting the city of Paris. And to be clear, not overwhelmed by the beauty, but rather by the reality of Paris.
Interestingly, Paris syndrome seems to be most common among Japanese travelers. The theory is that they’re used to a more polite and helpful society in which voices are rarely raised in anger, and the experience of their dream city turning into a nightmare can simply be too much. Of the approximately 6 million Japanese visitors to Paris each year, one to two dozen experience overwhelming anxiety, acute delusions, hallucinations, feelings of confusion and disorientation, nausea, paranoia, dizziness, sweating, and feelings of persecution that are Paris syndrome. Researchers really just speculate as to cause; because most people who experience this syndrome have no history of mental illness, the leading thought is that it’s triggered by the language barrier, physical and mental exhaustion, and the reality of Paris as compared to the idealized version.
So what can one do to prevent Paris syndrome? Simple: adjust your expectations. Ultimately, it’s like any modern metropolis- dirty, crowded, loud, and often indifferent… but beautifully so. Just don’t expect the furniture to spring to life and help you get ready for your dance with the Beast, and a trip to Paris will be exciting, and, most importantly, free of debilitating anxiety and hallucinations.
It seems like there have been so many iterations of The Walking Dead, and like every generation sees a new zombie trend, but this isn’t all movie magic. Imagine feeling IRL that you are dead already, that your body and all of your internal organs are rotting, and that you are ceasing to exist. Well, that’s how it is for people with this very strange- and incredibly frightening- neuropsych disorder also known as nihilistic delusion, as well as walking corpse syndrome. Boy, that last one pretty much says it all, right? Named for neurologist Jules Cotard, who first described it in 1880 as “The Delirium of Negation,” Cotard delusion typically occurs in conjunction with severe depression, some psychotic disorders, and other neurological conditions.
One of the main symptoms of Cotard delusion is nihilism- the belief that nothing has any value or meaning- but can also include the belief that nothing really exists. And in fact, in some cases, people with Cotard delusion feel like they’ve never existed, never lived. But it does have a flip side, the feeling of being immortal. As for other symptoms, depression is numero uno, with anxiety a close second. Hello, I think I’d be depressed and anxious too if I thought I was rotting and my very soul didn’t exist. But depression is in fact very closely linked to Cotard delusion, with a review indicating that 89% of documented cases cited depression as a symptom. Aside from anxiety, other common symptoms include hallucinations, hypochondria, guilt, and a preoccupation with hurting oneself or with death.
Researchers aren’t sure what causes Cotard delusion, but there are a few potential risk factors. Being female is one, as women seem to be more likely to develop Cotard delusion. Age is a factor. Several studies indicate that the average age of people with Cotard delusion is about 50, but it can also occur in children and teenagers. Interestingly, people with Cotard delusion that are under the age of 25 tend to also have bipolar depression, so that’s a risk factor. In addition, Cotard delusion seems to occur more often in people who think that their personal characteristics, rather than their environment, cause their behavior. People who believe the opposite- that their environment causes their behavior- are more likely to have a related condition called Capgras syndrome. That should sound familiar from the first installment of this series, as the syndrome causes people to think their family and friends have been replaced by imposters. Notably, Cotard delusion and Capgras syndrome can also appear together. Imagine that… believing that your body is rotting away, you are ceasing to exist, and all of the people and places in your life have been replaced by imposters! Jump on the empathy train, people.
In addition to bipolar disorder, other mental health conditions that might increase one’s risk of developing Cotard delusion include postpartum depression, psychotic depression, schizophrenia, catatonia, and dissociative disorder. Cotard delusion also appears to be associated with certain neurological conditions, including dementia, brain infections, brain tumors, multiple sclerosis, epilepsy, migraines, stroke, traumatic brain injuries, and Parkinson’s disease.
As you can imagine, feeling like you’re ceasing to exist- or like you’ve already died- can lead to some gnarly complications. For example, some people stop bathing or taking care of themselves, which can lead to skin and dental issues. All of that can cause people around them to start distancing themselves, which then usually leads to additional feelings of isolation and depression for the patient. Others stop eating and drinking because they believe their body doesn’t need it, and in severe cases, this can lead to malnutrition and starvation, even death by starvation. Unfortunately, suicide attempts are very common in people with Cotard delusion. Some see it as a way to prove they’re already dead by showing they can’t die again, while others simply feel trapped in a body and life that feels hopeless and doesn’t seem real. They hope that their life will get better or that their condition will stop if they die again.
Fortunately, Cotard’s delusion is very rare, with about 200 cases known worldwide, and while the symptoms are extreme and it can be hard to get the right diagnosis, most people get better with treatment. That generally entails a mix of therapy and medication, often a combination of meds to find something that works. If nothing seems to work, ECT- electroconvulsive therapy- may be used as a last resort. Done under general anesthesia, ECT passes small electric currents through the brain; this induces a generalized seizure and causes changes in brain chemistry that may quickly reverse or resolve symptoms of certain mental health conditions. While it sounds horrifying, ECT is not the procedure depicted in old B movies, and it can be a real game changer for some people with refractory conditions… I’ve seen a single ECT session change a person’s life.
There are descriptions of several Cotard’s cases available on the interwebs. One of the earliest recorded cases occurred in 1788, when an elderly woman was preparing a meal and felt a sudden draft, and then became totally paralyzed on one side of her body. When feeling, movement, and the ability to speak eventually came back to her, she told her daughters to dress her in a shroud and place her in a coffin. For days, she continued to demand that her daughters, friends, and maid treat her like she was dead. They finally gave in, putting her in a shroud and laying her out so they could mourn her. Even at the “wake,” the lady continued to fuss with her shroud, and even complained about its color. When she finally fell asleep, her family undressed her and put her to bed. After she was treated with a “powder of precious stones and opium,” her delusions went away, only to return every few months.
Some 100 years later, Cotard himself saw a patient he called Mademoiselle X, and she had an unusual complaint. She claimed to have “no brain, no nerves, no chest, no stomach and no intestines,” yet despite this predicament, she also believed that she “was eternal and would live forever.” Since she was immortal, and didn’t have any innards, evidently she didn’t see a need to eat, and soon died of starvation. Cotard’s description of the woman’s condition spread widely and was very influential, and the disorder was eventually named after him.
But Cotard’s delusion isn’t strictly confined to the history books. In 2008, a New York psychiatrist reported on a 53-year-old patient who complained that she was dead and smelled like rotting flesh. She asked her family to take her to a morgue so that she could be with other dead people. Thankfully, they dialed 911 instead, and the patient was admitted to the psychiatric unit, where she accused paramedics of trying to burn her house down. After a month or so on a strict drug regimen, her symptoms were greatly improved, and she was well enough to be released to her loving family.
That seems like a good place to stop. We’ll be taking a break for the holidays, so the next blog will be in 2022! I hope you enjoyed this week’s blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Happy holidays! Be well people!
Hello, people! Welcome back to the blog. Hope everyone had a great weekend. I’ll tell you, anyone who doesn’t believe in global warming doesn’t live here in SoFla, because it was a warm one. It sure doesn’t feel like two weeks until Christmas. Anyway, I guess we should get to the shrinky stuff. Two weeks ago, I introduced you to some of the scariest mental disorders out there, and we talked about apotemnophilia, where people have the desire to amputate a healthy, functional limb, Capgras delusion, where people believe that the people in their lives have been replaced with duplicate imposters that are hell bent on harming them, Diogenes syndrome, better known as hoarding, and factitious disorder, where people go to great lengths to fake symptoms of real illness. This week, we’re going to continue the discussion, and things are going to get way weirder- and scarier- so buckle up, folks.
Alice in Wonderland Syndrome
Alice in Wonderland is total fantasy, but one of Alice’s more bizarre experiences shares its characteristics with a very scary and all too real neurological disorder. Also known as Todd Syndrome, Alice in Wonderland Syndrome (AIWS) is characterized by transient, episodic distortions of visual perception, phenomena known as metamorphopsias. There’s a scrabble word for you. Just as Alice grows too tall for the house in Wonderland, people with AIWS may see their body parts or other objects as larger or smaller than they really are, hear sounds louder or quieter than they actually are, and even lose their sense of time and velocity. They may also experience derealization and depersonalization, which are shrinky terms for mental states where you feel detached from your surroundings and where you lose your sense of self identity, respectively.
There are three main types of AIWS, which are divided according to how the person’s perception is distorted.
Type A involves sensory distortion of oneself, and in this type, the most common issue is people feeling as though their body parts are changing size.
Type B causes more visual distortions of the surrounding environment, and includes episodes of micropsia, where objects appear too small; macropsia, where objects appear too big; metamorphopsia, where height and width of objects appear inaccurate; pelopsia, where objects appear too close; and teleopsia, where objects appear farther away than they actually are.
Type C is a mix of types A and B. A person with Type C AIWS can perceive both the image of their own body, and that of other people or things around them, to be changing.
AIWS can affect perception of every sense: sight, hearing, touch, and time. As you can imagine, it’s a terrifying disorder, sort of like an LSD trip without the euphoria, but thankfully it’s considered fairly rare, with fewer than 200 “clinical” cases described in the literature, meaning cases requiring medical attention. That said, I also read that “non-clinical” AIWS- meaning fleeting, transient cases not requiring medical attention- have been described in up to 30 percent of the general population. That doesn’t sound so rare to me, right? And by the way, anytime I see my body parts changing size right before my very eyes, I think I’d require medical attention. Just sayin.
While the exact cause or etiology is still unknown, it’s most often associated with migraine, head trauma, brain tumor, fever, drug use, certain types of epilepsy, and certain infectious diseases, especially Epstein-Barr virus and varicella-zoster virus. It’s also theorized that it can be caused by abnormal amounts of electrical activity, resulting in abnormal blood flow to those parts of the brain that are responsible for visual perception and processing. Encephalitis, which is inflammation of the brain, often caused by infection or an allergic reaction, is the most common cause of AIWS in children, while in adults, migraine is the most common cause. Prognostically, AIWS in and of itself is generally considered relatively harmless, but clearly that depends on the underlying pathology.
Alien Hand Syndrome
Any South Park fans here? If so, you may recognize this syndrome… Cartman claimed he suffered from this in the episode with Pancake Head. But true alien hand syndrome is a frightening neurological disorder where a discrepancy develops between one’s intentions and actions of a hand or limb, causing that hand to seemingly act on its own free will. Sometimes one leg is affected, though this isn’t as common. During these episodes, the affected hand feels foreign to its owner, as it carries out its unintentional tasks. Sometimes referred to as Dr. Strangelove syndrome, Strangelovian hand, or anarchic hand, alien hand can affect children, but usually occurs in adults.
Alien hand syndrome can be caused by several factors. Some people develop this after a stroke, brain trauma, or tumor. It’s sometimes associated with cancer, neurodegenerative diseases like Alzheimer’s Disease and Creutzfeldt-Jakob Disease, and brain aneurysms as well. It’s often linked to anything that separates or affects communication between the two hemispheres of the brain, usually a division or an issue with the corpus callosum, which divides the brain hemispheres and allows for communication between the two sides. Surgeries to treat epilepsy sometimes affect the brain in this way. Lesions have also been found in the anterior cingulate cortex, posterior parietal cortex, and supplementary motor cortex areas of the brain in people with alien hand, which would affect intentional planning systems and could cause spontaneous movements.
Alien hand can be like a bad B movie… sufferers have reported their alien hand attempting to choke either themselves or others, ripping clothing, and scratching to the point of drawing blood. Yikes. Unfortunately, no cure exists for alien hand syndrome, and it’s best that those affected by it keep their hands constantly occupied, and use their other hand to control the alien hand. It’s used in some terrifying plot twists, but alien hand syndrome is hardly limited to the fictional world.
Boanthropy is a rare and serious psychological disorder in which a human being experiences a mental metamorphosis, believing they are a cow, and go so far as to behave as such. Sometimes people with boanthropy are found in fields with “other” cows, walking on all fours and chewing grass as if they were a member of the herd. This is actually how they’re identified, as a result of their behavior. But people with boanthropy not only walk like a cow, they often “talk” like a cow… they stop talking like human beings, using language, and instead prefer mooing. They often stop eating people food and develop a taste and craving for grass… they graze like a cow, eating whatever plants they see “the other” cows eating.
Boanthropy isn’t new. It’s even referred to in the Bible, with King Nebuchadnezzar. He was king of the Neo-Babylonian Empire from 605 BC to 562 BC, the dude who conquered Judah and Jerusalem, and sent the Jews into exile. He was also credited with building the Hanging Gardens of Babylon. But he was constantly babbling about his great achievements, so he was humbled by God for being boastful. In the Book of Daniel, he basically lost his sanity, and lived like an animal for seven years. It says that he “was driven from men and did eat grass as oxen.” Lucky for him, God took pity on him and later restored his sanity, so he then praised and honored God.
The cause of boanthropy is still unknown. Many link it with religious perceptions, while others think it’s related to witchcraft and black magic. Most likely, it’s an additional aspect of another psychological disease, such as schizophrenia. The person is probably experiencing severe delusions, and that affects their sense of self, their belief that they exist as a human being. But since the causes of boanthropy aren’t well understood, treatment isn’t exactly defined. That said, if a human is seen grazing and mooing, they clearly need help. Now, I’ve never had a patient with boanthropy, but I can tell you that some serious psychotherapy and pharmacotherapy would be in order, and the primary goal would be to treat the underlying condition, to help the individual give up the state of delusion and realize they’re human.
I read an account online of a person suffering from boanthropy. Apparently he had stopped eating people food, despite his family’s increasingly frantic attempts to get him to do so, and he was dying. I mean, hello, malnutrition, he was only eating grass. Anyway, he was so sickly and weak, he begged to be butchered, so the villagers called the butcher, who was clearly really smart. When he came, he appraised the man’s body condition as he would any animal, and said that the man was too thin, that he must be fattened up with milk and meat for at least one year before he could be butchered. The man heard this and began to take the milk and meat, and started gaining weight. Eventually, this apparently helped him realize his delusion, and he stopped behaving like a cow and started acting like a human again. This wasn’t in a journal, just a random account on the interwebs, so I can’t vouch for the veracity of the story, but thought it was interesting.
Ultimately, they don’t seem to realize what they’re doing at the time, but everything they do, from their behavior, to their diet, to the sounds they make, people with boanthropy moooove through life like a cow. Ha!
Like people with boanthropy, people with clinical lycanthropy also believe they can become animals, but in this case, it’s wolves and werewolves, or lycanthropes. Isn’t that a great word? Fun fact, the word lycanthrope comes from the Greek words lykos, meaning “wolf,” and anthropos, meaning “human being.” So everyone knows the legend of the werewolf, right? It’s the fearsome creature who only takes the form of a human until the night of the full moon, at which point they become a bloodthirsty beast… blood curdling scream!!!!
Clinical lycanthropy is actually another very rare and scary psychiatric syndrome involving a delusion that the affected person can transform into, or has transformed into, a wolf. Basically, these people claim that they can physically shapeshift into wolves and werewolves, and often, the symptoms include them relaying their “transformation experience” during a moment of clarity. I guess other symptoms would include howling at the moon? I joke, but this is a real thing, although exceedingly rare. Since 1850, there have been 56 original case descriptions of people who believed they were metamorphosing into an animal, 13 of which met the criteria for clinical lycanthropy. Once again, the cause is unknown, but several theories exist. Aside from being a garden variety delusion, another potential cause involves lesions or other physiological issues within the cerebral cortex, which is responsible for a person’s perception of their own body. Interestingly, studies have actually shown that when sufferers of clinical lycanthropy undergo a “transformation,” they display unusual levels of brain activity in these regions, suggesting that they may genuinely perceive themselves as other than human. It’s interesting that we’ve actually done imaging studies on people as they “transformed.” I guess it’s become a real phenomenon.
If you search it, there are all sorts of forums and discussions on the interwebs about being a werewolf, the differences between werewolves and vampires, and how to get volunteers to “donate” their blood to lycanthropes. I remember seeing a guy on some tv show saying he had like five people that allowed him to drink their blood- he kept them in circulation- so he didn’t take too much from any one. Get it? Drank blood in circulation. Ha! He really did say that, but not as a joke. Anyway, he seemed perfectly rational as he talked about it. Again, it’s most likely a delusional state, secondary to another psych disorder, like schizophrenia or even bipolar disorder, though I’m sure he- and all those other werewolves out there- would disagree.
Also known as Shrinking Penis or Genital Retraction Syndrome- yikes- Koro syndrome is a delusional disorder in which a person feels that his genitals are retracting into his abdomen, and that they may totally disappear one day, and even possibly kill him… all of this without any physical proof of the retraction. It primarily strikes males, but females occasionally suffer from a variation of koro in which they believe that their nipples are retracting. Interestingly, koro often appears as an epidemic in which multiple cases are reported simultaneously within a specific geographic area. That should give you an idea of an underlying issue associated with koro… mass hysteria.
First identified in ancient China, koro almost always follows an identical pattern: the sufferer first experiences a tingling sensation in the genitals, followed by a rapid onset panic attack, which quickly leads to a sudden and pervasive fear that the genitals are disappearing. In Asia, this fear is almost always accompanied by an imminent fear of death, although interestingly, this element is often missing from reports in other parts of the world.
Koro is clearly heavily influenced by cultural beliefs, which also helps explain why epidemics are common. Outbreaks may be blamed on any number of things, including an invading force, an individual rival, or extramarital affairs. I read that in some West African outbreaks, sufferers believed that their genitals were being stolen for occult reasons, rather than retracting into their bodies. In most cases, indigenous treatment is recommended, and that might include an exorcism, rest, herbal treatments, or other healing practices. “Defeating the foe” is sometimes the recommended treatment in some koro outbreaks. That sounds cool. Doctor, what should I do? Defeat the foe! Apparently, koro sufferers often ask friends or relatives to physically manipulate their genitals to stop them from retracting, which sometimes leads to injury. Ouch! Thankfully, the anxiety and hysteria from koro generally subsides very quickly when a culturally acceptable treatment is used.
Koro happens around the world, including the Western world. Here, koro is treated as a specific phobia, with psychotherapy and antidepressant medications commonly prescribed. Clearly, it’s important to rule out physical causes for the koro symptoms, as pain, tingling, and similar physical symptoms that are common in koro could also indicate an underlying physiological condition. Captain Obvious says that here in the west, we would perform a full workup to determine exactly which factors are in play. Captain Obvious also says that it’s a good idea to first visit the urologist if you’re experiencing these symptoms. That’s my PSA for the day: see a urologist if your genitals are tingling.
That’s a good place to stop for today. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in officeand on Amazon.
Thank you and be well people!
The Scariest Mental Disorders of All Time
Hello, people! I hope everyone had an excellent Thanksgiving! Is everybody on tryptophan overload? I know I am, but man was the turkey great this year! And the stuffing, the mashed potatoes, the gravy, the pineapple casserole… you get the idea. Anyhoo, last week and 5 pounds ago I finished up our series on the dark side of ADHD. I hope everyone learned something. Squirrel!! Again, if you don’t get that joke, check out the series. This week, I want to talk about the weirdest and scariest psych disorders out there. I remember this section from med school- it really caught my attention- you’ll see why shortly. Imagine suffering from a mental illness that causes you to believe your significant other is an imposter, hell bent on harming you, or one that convinces you that books are for eating, not reading. Or that your genitals are shrinking? YIKES!! Or the ultimate… that you have somehow become the walking dead. Pretty scary, right?
While a very small percentage of people are forced to live with these unusual disorders, 450 million people worldwide suffer from mental illness. In the United States alone, one in four families is affected. While some mental disorders, like depression, usually occur naturally, others are the result of brain trauma or other injuries. Although it’s certainly fair to say that any mental illness can be scary for those suffering from it- as well as their families- there are a few rare disorders that are especially terrifying. Those are what I’m going to talk about this week, so jump on the empathy train and buckle up, people… it’s about to get wild.
Also known as Body Integrity Disorder or Amputee Identity Disorder, Apotemnophilia is a disorder that sort of blurs the lines between neurology and psychiatry- we aren’t certain of the origins- so I’ll call it a neuropsych disorder. Whatever it is, apotemnophilia is typically characterized by the overwhelming desire to amputate or permanently damage healthy, functional parts of the body. More rarely, affected individuals have the express desire to be paraplegic, and in some exceptionally rare cases, they seek sensory deprivation, such as blindness or deafness. Oddly enough, the first description of this condition traces back to a series of letters published in Penthouse magazine in 1972, but the first scientific report of this disorder came about in 1977 with the medical description of two cases. As happens, two have become many, and now there may be thousands of people with apotemnophilia desiring amputation. They seem to gather on the interwebs, and some even have their own websites seeking support or pleading their cases. I mean, Captain Obvious says that the vast majority of surgeons won’t just amputate healthy limbs upon request… hello, Hippocratic Oath… so some sufferers of apotemnophilia feel forced to perform amputations on their own. DIY surgery? That’s a very dangerous scenario to be sure. But there have been some cases who have had a limb removed by a doctor, and most are reportedly very happy with their decision.
Since little was known about it, one American shrink made an attempt to further illuminate the disorder by surveying 52 volunteers desiring amputation. Thanks to his work, a number of key features were identified: there seems to be a gender prevalence, as most individuals are men, as well as a side preference, with left-sided amputations being most frequently desired. He also found that there was a preference toward amputation of the leg versus the arm. Until recently, the explanation for apotemnophilia has been in favor of a psychiatric etiology; it was thought to be a pathological desire driven strictly by a sexual compulsion. But a neurological explanation has recently been proposed, in the form of damage to, or dysfunction of, the right parietal lobe, thereby leading to a distorted body image and subsequent desire for amputation. In order to investigate this potential etiology, recent studies have utilized electrophysiological and neuroimaging techniques in an attempt to identify neurological correlates of body representation impairments. That work is ongoing. What’s interesting is that, in my experience, most of these folks seek limb amputation primarily to “feel complete” as they put it, as opposed to wanting to satisfy any sexual proclivities, but the debate about the reasons behind the desire rage on as studies continue. Sounds a little oxymoronic, to remove something to feel more complete, but that’s apotemnophilia.
Also known as imposter syndrome or Capgras syndrome after Joseph Capgras, a French psychiatrist who was fascinated by the illusion of doubles, Capgras is a debilitating mental disorder in which one irrationally believes that the people and/ or things around them have been replaced by identical imposters. Sort of like Leonardo Di Caprio in Inception, but without a totem to tell if you’re in the real world. Whether it’s a close friend, spouse, family member, pet, or even a home, people suffering from Capgras feel that their reality has been altered, that the real thing has been substituted for a fake. And if that weren’t bad enough, even worse, the imposters are usually thought to be planning to harm them. Capgras is usually transient, ranging from minutes to months, but unfortunately, also usually recurrent.
Capgras syndrome is most commonly associated with Alzheimer’s disease or dementia, both of which affect memory and can alter one’s sense of reality. Schizophrenia, especially paranoid hallucinatory schizophrenia, can cause episodes of Capgras syndrome, as this also affects one’s sense of reality and can cause delusions. In rare cases, a brain injury that causes cerebral lesions, especially in the back of the right hemisphere, can also cause Capgras syndrome, as that’s the area of the brain that facilitates facial recognition. Rarely, people with epilepsy and migraine may also experience temporary Capgras syndrome as well. There are several theories on what causes the syndrome. Some researchers believe that it’s caused solely by a problem within the brain, by conditions like atrophy, lesions, or cerebral dysfunction, while others believe that it’s a combination of physical and cognitive changes, causing feelings of disconnectedness. Still others believe that it’s a problem with processing information, or an error in perception which coincides with damaged or missing memories. For all we know about the brain, there is still so much we don’t. Occurring more commonly in females than males, Capgras is relatively rare, and is most often seen after traumatic injury to the brain. No matter the how and why, Capgras is upsetting for both the person experiencing the delusion and the person who is accused of being an imposter, and it’s easy to see why it’s one of the scariest disorders of all time.
Diogenes Syndrome is more commonly referred to as simply hoarding, and is one of the most misunderstood behavioral disorders. Named after the Greek philosopher Diogenes of Sinope- who was, ironically, a minimalist- this syndrome is usually characterized by the overwhelming desire to collect seemingly random items, to which an emotional attachment is then formed. In addition to uncontrollable hoarding, people with Diogenes syndrome often exhibit extreme self neglect, apathy towards themselves or others, social withdrawal, and no shame for their habits. It is very common among the elderly, those with dementia, and people who have at some point in their lives been abandoned, or who have lacked a stable home environment. Occurring in both men and women, people with Diogenes syndrome often live alone, tend to withdraw from life and society, and are seemingly unaware that anything is wrong with the condition of their home and lack of self-care. The conditions they live in often lead to illnesses like pneumonia, or accidents like falls or fires, and in fact, it’s often through these situations that the person’s condition becomes known.
Diogenes syndrome is often linked to mental illnesses such as schizophrenia, obsessive compulsive disorder, depression, dementia, and addiction, especially to alcohol. While there are defined risk factors for developing Diogenes, having one or even more doesn’t necessarily mean it will occur. In many cases, a specific incident becomes a trigger for the onset of symptoms. This can be something like the death of a spouse or other close relative, retirement, or divorce. Medical conditions may also trigger symptom onset: stroke, congestive heart failure, dementia, vision problems, increasing frailty, depression, and loss of mobility due to any number of reasons are the most common medical triggers.
This condition can be difficult to treat, and it can be very frustrating to care for people who have it. While Diogenes syndrome is sometimes diagnosed in people who are middle aged, it usually occurs in people over 60. Symptoms usually appear over time, and in early stages, generally include withdrawing from social situations and avoiding others. People may then start to display poor judgment, changes in personality, and inappropriate behaviors. Due to the associated isolation, people typically have this condition for a long time before it’s diagnosed. Warning symptoms in an undiagnosed person may include skin rashes caused by poor hygiene, fleas or lice, matted, unkempt hair, overgrown toenails and fingernails, body odor, unexplained injuries, malnutrition, and dehydration. The person’s home generally exhibits signs of neglect and decay, with possible rodent infestation, overwhelming amounts of garbage in and around the home, and an intense, unpleasant smell. Despite all of these factors, people with Diogenes syndrome are typically in denial of their situation and usually refuse support or help.
Most people cringe at the first sniffle that may indicate a potential cold or illness, but not people with Factitious disorder, as this scary mental disorder is characterized by an obsession with being sick. Factitious comes from the Latin word meaning artificial, so as the name suggests, people with factitious disorders will present artificial symptoms of real medical conditions. They will often go to incredible lengths to imitate symptoms of a real medical condition, and some will go so far as to intentionally harm themselves to feign symptoms. I’ve seen people inject bacteria into their bodies, intentionally contaminate lab tests, and take hallucinogenic drugs to feign symptoms of whatever illness they’re aiming for, and they’re often willing to be hospitalized and even undergo unpleasant or painful medical tests in order to further their efforts. I should note that factitious disorders are similar to hypochondriasis, in that the symptoms or complaints are not the result of having true, tangible medical conditions, but there is one key difference between factitious disorders and hypochondriasis: people with hypochondriasis believe that they are ill, whereas people with factitious disorders know that they are not.
There are basically three types of factitious disorders. The first is Munchausen syndrome, where people will repeatedly fake symptoms of medical problems. The symptoms will usually be exaggerated, and they tend to go to great lengths to convince others that those symptoms are real. Munchausen syndrome patients have been known to undergo multiple unnecessary medical procedures, even surgeries, and they tend to go to different medical facilities so as not to be detected. The second is Munchausen by proxy, which is like Munchausen, but when by proxy, the person suffering from factitious disorder will force someone else into the patient role. Most commonly, it is the parent(s) or caregiver(s) forcing children into the proxy role, putting them through various medical procedures, making up symptoms that the child has, encouraging the child to lie, falsifying medical reports, and/or altering tests to give the appearance of a sick child. The third is Ganser syndrome, which is a rarer factitious disorder that mostly occurs amongst prisoners, whereby they’ll display faked psychological symptoms such as psychosis. At times, they know they’re not going to get anything out of it, but they’ll give it a try anyway. Psychological testing and sharp shrinks usually tell the true tale with Ganser syndrome.
It can be difficult to identify factitious disorders because the perpetrators are often very adept in feigning symptoms, and they may go to great lengths to physically cause symptoms. I had one case where a woman was admitted to a hospital complaining about vomiting blood, and she insisted on receiving surgery. When an endoscopy didn’t show any stomach bleeding or other source of blood, she shoved her fingers up her nose to make it bleed down her throat. The ruses almost always include elaborate stories, long lists of symptoms, and jumping from hospital to hospital. As you can imagine, it’s incredibly difficult to get an accurate depiction of how prevalent factitious disorders are, because many people are so masterful at faking their symptoms. The estimated lifetime prevalence in clinical settings is 1.0%, and in the general population, it is estimated to be approximately 0.1%, but it ranges widely across different studies, from 0.007% to 8.0%. In one study of patients in a Berlin hospital, it was shown that approximately .3% of hospitalized patients had a factitious disorder. I suspect that whatever the actual number is, these disorders may be much more common than previously thought. Since people with factitious disorders can be very persistent, physicians have to carefully monitor people for it.
Experts have not identified one solid cause of factitious disorders. Some experts believe that these people suffer from a sense of inadequacy or unstable self worth, and use the factitious behaviors to get attention and sympathy, and this essentially defines their self worth. Most likely, they’re caused by a combination of emotional aspects. Such an obsession with sickness often stems from past trauma or serious illness, and it can be linked to a history of hospitalization or sickness during childhood which the patient tries to recreate, in order to return to normalization. Another possible cause is that someone close to the person really was chronically ill, and the person became jealous of the attention, and began to feign symptoms in order to get that same attention. People with factitious disorders will almost always insist that their symptoms are real, even despite clear medical evidence to the contrary, and this makes them very difficult to treat. Unfortunately, most factitious patients will steadfastly deny it and refuse any sort of treatment, but when help is sought, it’s often able to be at least limited with psychotherapy.
That’s a good place to stop for this week. Next week, we’ll talk about more weird and scary psych disorders. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
The Dark Side of ADHD
Hello, people, welcome back to the blog! Last week, I told you all about SAD, seasonal affective disorder, a depressive disorder that exhibits a seasonal pattern, usually late fall through spring, though it can have a spring/ summer pattern. I thought it was timely, since we were approaching its usual start point; symptoms seem to begin shortly after we “fall back” and winter arrives. Speaking of which, we had our first hint of winter this weekend- or at least what passes for winter here in SoFla- as temps dipped below 60 late Saturday night…. brrrrr! Sunday was kind of gray outside, but temps were really nice. Anyhoo, this week, I’m starting a new series on the dark side of ADHD, attention deficit hyperactivity disorder.
When you think about ADHD, you probably think of a 9 year old boy running around in circles, laughing his head off, totally out of control. While that certainly can be the case, the real faces of ADHD may surprise you. Think of your boss, your mail carrier, or your kid’s teacher… anyone has the potential to have ADHD, even if you don’t see what you think of as the classic symptoms. What most people know about ADHD comes from pop culture… they hear ADHD and think of that 9 year old boy, or maybe Dug the talking dog from the movie Up. Remember him? He couldn’t even complete a sentence without being distracted by an imaginary squirrel. Squirrel!! It was funny, right? Squirrel!! Maybe you’ve made a joke about being ‘sooo totally ADHD’ after you’ve gotten distracted and lost your train of thought? Hey, you’ve got to have a sense of humor to get through this life, and psych disorders sometimes make easy punchlines. But ADHD is a real disorder, and it affects real people in real ways, so it’s important that you’re informed about it, that you understand it, as that’s the basis of empathy. Empathy is where it’s at, and that’s the true point of this blog, to understand what people with ADHD experience on the daily. That’s not to say we can’t laugh about it, because sometimes it’s funny. Squirrel!! But if you understand it, you’re much more likely to laugh with, and not at, and that’s the ultimate point here.
So, what is it? ADHD is a neurological disorder, typically characterized by difficulty in sustaining attention, a lack of impulse control, and impaired working memory. There are three forms of ADHD: inattentive, hyperactive-impulsive, and combined types. By the way, ADHD is the official, medical term for the condition, regardless of whether a patient demonstrates symptoms of hyperactivity. We used to call that condition, having an attention deficit but without hyperactivity, ADD- actually some people still do- but that’s now technically considered to be an outdated term for describing inattentive type ADHD. So they’re all called ADHD now, no more ADD, and just the type or form varies. Inattentive type ADHD is characterized by a lack of attention to details, an inability to follow or remember instructions, and getting distracted easily. Hyperactive-impulsive type is marked by the stereotypical symptoms, things like fidgeting, running around, and talking too much. And shockingly, combined type is a combination of inattentive and hyperactive-impulsive ADHD types, and people with this type can exhibit both types of symptoms. Regardless of type, ADHD symptoms impact every aspect of a person’s life, and can seriously limit a person’s ability to study or work, and this can lead to stress, anxiety, and depression.
Prevalence statistics for ADHD vary widely, but it’s considered the most common childhood neurodevelopmental disorder. The symptoms of ADHD typically first appear between the ages of 3 and 6, and the average age of diagnosis is 7 years old. Squirrel!! According to the American Psychiatric Association, 5 percent of American children (ages 4 to 17) have ADHD, but the Centers for Disease Control and Prevention puts the number at more than double that, stating that 11 percent of American children carry the diagnosis. In my opinion, the actual number is closer to the CDC’s statistic, but may actually be higher still. And contrary to what some people believe, ADHD isn’t just a childhood disorder. Today, about 4 percent of American adults over the age of 18 deal with ADHD on a daily basis.
People with ADHD experience hyperactivity, impulsivity, and inattention in varying degrees. Not everyone with ADHD is noisy and disruptive. A child may be quiet in class, for example, while facing severe challenges that they do not express. The effects of ADHD features vary widely from person to person and even within a person, as they may find that their experience of ADHD changes over time. Squirrel!! Features and behaviors also seem to vary by gender; females with ADHD tend to have more difficulty paying attention, while males tend to have more hyperactivity and impulsivity. Depending on the type a person has, ADHD will have a predominantly inattentive presentation, a predominantly hyperactive and impulsive presentation, or a combined presentation that includes both types of behaviors.
This can manifest in innumerable ways, many you might not even realize unless you experience them. Some behaviors related to inattention might include daydreaming, being easily distracted, squirrel!, having difficulty focusing on tasks, making “careless” mistakes, appearing to not listen while others are talking, being late, having difficulty with time management and organization, difficulty completing projects, frequently losing everyday items, avoiding tasks that need prolonged focus and thought, and difficulty following instructions.
Hyperactivity and Impulsivity
Hyperactivity presents in any number of ways, and can vary widely, especially depending on the person’s age. In children, impulsivity often presents as conduct issues, so we think of a child “running amok” around a classroom. With age, overt behavioral symptoms usually become less conspicuous, as adults have generally learned to restrain themselves from these telltale behaviors. But they may manifest conduct issues in other ways, like blurting out things they didn’t mean to say. Some other behaviors related to hyperactivity and impulsivity include restlessness, the person seeming to be unable to sit still, being constantly “on-the-go,” running or climbing at inappropriate times, having difficulty taking turns in conversations and activities, constantly fidgeting or tapping the hands or feet, excessive talking and/or noise making, workaholism, and taking unnecessary risks.
Causes and Risk Factors
We don’t know exactly what causes ADHD, but we do know that a large component is genetic. About 85% of people diagnosed with ADHD have someone in their family who also has it. We have identified some risk factors, and these include brain injury, fetal exposure to stress, alcohol, or tobacco during pregnancy, fetal exposure to environmental toxins during pregnancy, or from a young age, low birth weight, and preterm birth. Diet may play a role, and some factors are random, just down to an individual brain’s wiring.
One question that’s asked a lot is if kids can outgrow ADHD. The answer is yes, but it rarely happens. That said, at one time, it was suggested that up to 40 percent of children outgrow their diagnosis, but recent research has proven this is wrong. Unfortunately, fewer than 10 percent actually outgrow it; the rest still meet the clinical definition of the disorder. Generally, what actually happens is that the presentation of symptoms changes as the person ages, but the underlying disorder remains. As the person matures and enters adulthood, overt behavioral symptoms usually become less conspicuous, and excessive motor activity becomes less common. Squirrel!! Hyperactivity is usually changed from being an external behavior to an internal state, so it can appear to others that the person’s ADHD has gone away, along with its most obvious symptom. But in reality, only the presentation has changed.
In other words, a 35 year old can’t get away with the same behavior that a 9 year old can, so instead of being a 9 year old running around willy nilly, laughing maniacally, the now 35 year old has an inner restlessness, and channels that into something else, like becoming a workaholic or an adrenaline junkie. Many adults with ADHD become workaholics, they like to keep their brains in overdrive. ADHD symptoms can also change for the better depending on stress levels, environment, and the amount of support a person receives. For example, establishing a routine and having understanding family members, friends, co-workers, and colleagues that can assist or help compensate for certain issues as needed are two ways to make symptoms seemingly decrease or disappear. In addition, the person may develop coping skills that address their symptoms well enough to prevent ADHD from interfering with their daily lives. Some do it so well that it appears as though they’ve outgrown it, but in reality, they’ve found working solutions. It’s sort of like watching a duck on a pond. Or maybe a squirrel! The duck looks still and serene on the surface, everything under control, but beneath the water, its little feet are paddling furiously.
I’ve seen many patients create their own little systems and methods to cope and compensate for their symptoms, to varying levels of success. I remember an ADHD patient that was very forgetful and terrible with time management especially. She had alarm clocks set to go off to remind her to set other alarm clocks, and her life was all color coded post its in strategic places to remind her to do whichever thing. I couldn’t understand it to save my life, much less keep up with it, but it worked for her. Pretty darn well, actually. But if the batteries in one alarm clock died- this was years ago, when people used alarm clocks, and they were radios too, imagine that- her entire life unraveled. She would get behind and it was like dominoes. But if her alarm clocks went off properly and her post its didn’tblow away, you’d be hard pressed to know she had ADHD. On the surface, she looked like she had it all under control, no problem, but below, her feet were constantly paddling, she was working overtime to keep it all together.
The term “attention deficit hyperactivity disorder” wasn’t used in medicine until the 1980s, although symptoms of the disorder were discussed in the early 1900’s. Back then, the diagnosis was typically thought to relate to the child having family members with psychiatric disorders, or the result of poor parenting. Squirrel! Strangely enough, some of these myths and stereotypes persist even today. We’ve busted some of those today, and next week, we’ll talk about what it’s really like to have ADHD, how it affects someone’s day to day life.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Hello, people… welcome back to the blog! Last week, we finished our two part series on phobias, and it seems everyone enjoyed it. I got a lot of great feedback on it, and people have been sharing their weird phobias with me even more than ever… I’ve really added to my list of doozies! This week, I wanted to talk about a topic I ran into recently, seasonal affective disorder, or SAD.
What is SAD? In the shrink bible, the DSM-5, it’s identified as a type of mood disorder. It’s not a standalone, but is specified as a major depressive disorder with a seasonal pattern, meaning that it happens every year at the same time, typically starting in fall or early winter and ending in spring or early summer. Because of this, some people call SAD the “winter blues,” but this is misleading, as there is a rarer form of seasonal depression known as “summer depression” that begins in late spring or early summer and ends in fall. And while the two types obviously share many symptoms, interestingly, their profiles are slightly different. More on that in a moment.
First, let’s talk statistics. In the United States, the percentage of the population affected by SAD is about 5%, but varies widely based on geographical location, from 1.4% of the population in Florida, to 9.9% in Alaska. This should give you a clue about one of the main factors associated with SAD, the amount of available sunlight. SAD may begin at any age, but it typically starts between the ages of 18 and 30, and as with other types of depression, SAD is much more common in women; they are three times more likely to be affected than men.
Calling SAD the “winter blues” makes it sound like no big deal, but people with SAD experience serious depression- the mood changes and symptoms are very similar to chronic depression- and these symptoms can have a major impact on their lives for 40% of the year, as symptoms usually occur during the fall and winter months and typically improve with the arrival of spring, with January and February being the most difficult months in the US. While temporary, SAD symptoms can be overwhelming, and in some cases, it can seriously interfere with daily functioning. Thankfully, it can be treated, and that’s why I decided to cover this topic. Recognizing the disorder is very important because it can cause such serious psychosocial impairment, but it’s not just important to recognize it… getting help is key, because acute treatment can be very effective, and maintenance treatment can actually prevent future episodes.
People with SAD experience mood changes and symptoms similar to depression, and these can vary from mild to severe. Everybody gets bummed out from time to time, those everyday feelings of sadness or fatigue brought on by life’s ups and downs- even during the holidays- but depression is a different animal.
Seasonal depression is marked by some specific symptoms, and these may include:
-Sleeping more than usual and still feeling drowsy and fatigued during the day
-Loss of interest in activities that once brought you joy
-Increase in purposeless physical activity, like pacing and hand wringing; an inability to sit still
-Slowed movements or speech, severe enough to be observable by others
-Feeling irritable and anxious
-Feeling guilty, worthless, hopeless, sad, tearful
-Desire to isolate, not wanting to see people
-Difficulty thinking, concentrating, or making decisions
-Increased appetite, overeating, and weight gain
-Cravings for carbohydrates
-Physical symptoms, such as headaches
-Thoughts of suicide or death
Clearly you don’t have to have every one of these to have SAD, and as with anything else, symptoms occur on a spectrum. Some people with SAD have mild symptoms and basically feel out of sorts or cranky, while others have symptoms that totally interfere with relationships and work. As I mentioned earlier, spring and summer SAD is much less common, but still occurs. The symptom profile is a little different; instead of people eating their way through it as a result of increased appetite, it’s difficult to get summer SAD people to eat at all, as they tend to have zero appetite. In my experience, it also seems to feature more agitation, almost manic type behavior.
What causes SAD? Like so many disorders, the cause isn’t completely understood, but we know that the body uses sunlight to regulate sleep, appetite, and mood. It’s believed that the decreased sunlight in the fall and winter months disrupt the body’s circadian rhythm. Lower light levels in winter disrupt the body clock, leading to depression and tiredness. As seasons change, people already naturally experience a shift in their biological internal clock that can cause them to be out of step with their daily schedule, so people may be more vulnerable during this time. The change in season, with shorter daylight hours, can lead to a biochemical imbalance in the brain, specifically in levels of serotonin and melatonin, two hormones that affect sleep and mood. SAD has been linked to this imbalance. There are risk factors involved as well. You’re more likely to develop SAD if you have an existing form of depression, or a relative with SAD or another form of depression. And Captain Obvious says that SAD is much more common in people living far from the equator where there are fewer daylight hours, so living somewhere where you expect months of darkness during the year isn’t the best plan if you have any of the risk factors.
The main feature of SAD is that your mood and behavior shift along with the calendar. So how do you know if you have it? If for the past 2 years, you:
-Had depression or mania that starts as well as ends during a specific season
-You didn’t feel these symptoms during your “normal” seasons
-Over your lifetime, you’ve had more seasons with depression or mania than without
I should note that sometimes it takes a while to diagnose SAD, because it can easily mimic so many other other conditions, like chronic fatigue syndrome, underactive thyroid, low blood sugar, viral illness, and/ or other mood disorders. If you suspect that you or a loved one may have it, the best course of action is to see a physician. There are online resources available as well, from the Center for Environmental Therapeutics, at cet.org. More on that at the end of this blog.
Clearly, you can’t stop the changing of the seasons, but there are some things you can do to combat SAD, including light therapy aka phototherapy, antidepressant medications, talk therapy aka cognitive behavioral therapy, or a combination of all three. Meds are usually brought in as adjuvants if light therapy is insufficient in reducing symptoms. Wellbutrin XL was the first drug approved specifically for SAD in the United States, and I’ve seen some success with it. Symptoms will generally improve on their own with the change of season, but it happens far more quickly with treatment. Treatment course differs depending on how severe your symptoms are, and of course, depending on whether you have another type of depression or bipolar disorder. For some people, simply increasing exposure to sunlight can help improve symptoms of SAD, and it’s recommended that people get outside early in the morning to get more natural light. If this is impossible because of the dark winter months, then phototherapy is key.
As I mentioned, light affects the biological clock in our brains that regulates our circadian rhythm, a physiological function that may induce mood changes when there’s less sunlight in winter. We know that natural or “full-spectrum” light can have an antidepressant effect. In phototherapy, you mimic that by sitting about 2 feet away from a light box, usually a 10,000-lux light box specifically, so that full spectrum bright light- about 20 times brighter than normal room lighting- shines directly upon you, but indirectly into your eyes. You do this for 15 minutes per day to start, and the times are increased as necessary with a max of 30 to 45 minutes a day, depending on your response. If using a weker lightbox, such as those that emit 2,500 lux, it will require much longer, about two hours of exposure per day.
Light therapy should be done in the early morning, upon waking, to maximize treatment response. Morning therapy also helps to specifically correct any sleep-wake cycle issues contributing to the symptoms. Please people, don’t look directly at the light source of any light box, to avoid possible damage to your eyes. I’ve heard of some practices that provide light boxes for patients with SAD. Again, the Center for Environmental Therapeutics has info on this. I’m sure you can also rent light boxes, and I know you can purchase them, but they’re expensive, and health insurance companies don’t usually cover them. But if you have SAD and live in a “dark” winter area, they can be worth their weight in gold.
Optimum dosing of light is crucial, since if done wrong it can produce no improvement, or partial improvement, and that can potentially lead to worsening of symptoms. I read some research that found that even a single, one hour light session can improve symptoms of depression in people with SAD. It varies; some people recover within days of using light therapy, most see some improvement within one or two weeks of beginning, but a few take longer. To maintain the benefits and prevent relapse, light treatment is usually continued through the winter, until you can be out in the sunshine again in the springtime. Because of the anticipated return of symptoms in late fall, I highly recommend that SAD patients begin phototherapy when fall first starts, even before feeling the effects of SAD. If the SAD symptoms don’t go away, your physician may increase light therapy sessions to twice daily. While side effects are minimal, be cautious if you have sensitive skin or a history of bipolar disorder. Common side effects of light therapy include headache, eyestrain, nausea, and agitation, but these effects are generally mild and transient, or disappear with reducing the dose of light.
Cognitive behavioral therapy or CBT can also be an effective treatment for SAD, particularly if it’s used in conjunction with light therapy and/ or medication. CBT involves identifying negative thought patterns that contribute to symptoms, and then replacing these thoughts with more positive ones. For many of my patients, I utilize all three modalities for treating SAD, as this has shown the most benefit.
… is worth a ton of cure in this case. So what can you do to avoid SAD?
Get out! Get as much natural sunlight as you can. Spend some time outside every day, even when it’s cloudy, as the effects of daylight still help. If it’s too cold out, let the sunshine in… open your blinds, and sit by a sunny window, even at work. If trees block the sunlight, trim them. I have a SAD patient that has her trees pruned way down in early fall so she can get as much light in the house as possible.
Eat a healthy, well-balanced diet. Our diets do more than provide us with energy, they also impact our mental health. A healthy diet rich in fruits and veggies and low in processed garbage can help curb feelings of depression by reducing inflammation in the body, which is a big risk factor for depression. Pass up all those sweet starchy “foods” in favor of lean proteins and veggies. This will help you have more energy, even if you’re craving carbs bigtime. If you recall the blog on Vitamin D, research has found that people with SAD often have low levels, so people with SAD are also often encouraged to increase their intake of Vitamin D through supplementation, in addition to diet and sunlight exposure.
Stay Active! Exercise is a great way to naturally combat the imbalance of brain neurotransmitters like serotonin, norepinephrine, and dopamine that can contribute to depression. When you exercise, your body produces endorphins, the mood boosting hormones that counteract serotonin and dopamine deficiencies that can bring you down. Exercise for 30 minutes a day, five times a week. That doesn’t have to mean you’re tied to the gym pumping iron all the time… Do something structured, but also pick an activity you enjoy and do it. Gardening, walking, dancing, and even playing with your kids can all be good forms of exercise.
Stay Connected! Social connections can be a great defense against depression. Whether you talk on the phone, video chat, or better yet, meet in person, keep in regular contact with friends and family for a healthy and happy mind. Experiencing depression of any kind isn’t a sign of weakness and shouldn’t be dealt with alone. Social support is very important, so stay involved with your social circle and regular activities. If you’re experiencing symptoms of depression that keep you in, seek help. Ask your physician what treatment options are available.
When should you call your physician? If you feel depressed, fatigued, and cranky at the same time each year, if it seems to be seasonal in nature, you may have a form of SAD. Talk openly with your physician, and follow their recommendations for lifestyle changes and treatment.
The Center for Environmental Therapeutics, CET, is a non-profit organization that provides information and educational materials about SAD, along with free, downloadable self-assessment questionnaires and interpretation guides, to help you determine if you should seek professional advice. All of that can be found on their website, cet.org.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Freaky Phobias, part deux
Hello, people- I hope everyone had a great weekend! Last week, I introduced the subject of phobias, and we’ll continue that discussion today. Fear is an important evolutionary tool, allowing humans to survive dangerous encounters and develop appropriate responses to hazardous situations. But when fear becomes debilitating, when it becomes a greater threat than the actual person, place, or thing causing it, it has become a phobia. Phobias are a type of anxiety disorder where a person has a persistent, excessive, unrealistic fear of an object, person, animal, activity, or situation. That leaves the field pretty much wide open, and in fact, a person can have a phobia of almost anything. They’ll try very hard to avoid that thing, otherwise they’re basically forced to white knuckle through it with much anxiety and distress, potentially to the point that it produces physical symptoms like nausea and dizziness, and possibly even a panic attack.
Everyone has something they fear to some extent, and for most people, it doesn’t affect one’s quality of life. But for patients with diagnosable phobias, the level of fear and discomfort when confronted with specific objects or situations can be exceptional, and can significantly impact their daily life. Some phobias are very specific, so this limits the impact the phobia has. As an example, a person may only fear spiders and cats- meaning they have arachnophobia and ailurophobia- and so they live relatively free of anxiety simply by avoiding spiders and cats. But some phobias pose an issue in a wider variety of places and situations, so they affect people’s lives more drastically. For example, symptoms of acrophobia- the fear of heights- can be triggered by looking out the window of a high rise office building, by climbing a ladder, or by driving over a tall bridge, just to name a few. Because it comes into play in so many places and forms, acrophobia has a much greater impact on the person’s life, and it may influence or even dictate the person’s employment type, job location, driving route, recreational and social activities, and/ or home environment.
Cause and Risk Factors
There is always an argument about whether a particular psychological trait or symptom is genetic in origin or a product of one’s environment… the old “nature vs. nurture” debate. Most of the time, the proper answer is “both,” and in fact, that’s the case with phobias. The reasons why phobias develop aren’t fully understood, but research does indicate that both genetic and environmental factors play a role.
Specific phobias tend to begin in childhood, a time when developing brains are still learning appropriate ways to respond to the world around them, and phobias can start in any number of ways. A child may develop a phobia of dogs after being bitten by one, but there are many more subtle ways that a child’s brain can take in information that teaches them to fear something. For example, they could learn to fear a dog by watching a movie that features a scary dog, or by watching a family member respond in fear to a dog’s bark or presence. Ultimately, fear is easily passed from one person to the next, either through watching and learning, or through genetic inheritance.
Certain phobias have been clearly linked to a very bad first encounter with the feared object or situation, though researchers don’t know if this first encounter is required, or if phobias can simply occur in people who are more likely to have them. As to what makes a person more likely to have them, there is no phobia gene- it’s never that easy- but we know that when it comes to risk factors, there is a genetic component. Research and surveys indicate that individuals with a parent or a close relative suffering from a specific phobia are three times more likely to develop that same phobia. That said, more research is needed to elucidate the genes responsible for triggering these phobias.
In addition to a complex interplay of genetic and environmental factors, a person’s temperament can also contribute to risk of developing phobias. A negative affect, meaning a propensity to feel negative emotions such as disgust, anger, fear, or guilt, seems to increase the risk for a variety of anxiety disorders, including specific phobias. Behavioral inhibition, often due to parental overprotectiveness, especially in childhood, is another risk factor for phobia development. A history of physical and/ or sexual abuse also increases the likelihood of an individual developing a specific phobia.
Phobias can be debilitating, but fortunately, there are ways to treat them. One treatment method that’s used very successfully is exposure therapy. We’ve discussed this before in relation to OCD; it’s a type of cognitive behavioral therapy, aka CBT, whereby you are repeatedly presented with your phobic trigger in a controlled manner, and you challenge yourself to get through it. It’s done in the presence of a therapist, and they essentially talk you through it, discussing what you feel, why you feel it, what is happening, and what you fear may happen. Afterwards, there’s usually discussion about feared outcome versus actual outcome, and what thoughts helped you get through the exposure. It’s often done in stages, as opposed to jumping straight in the deep end. For example, let’s say you have an insect phobia; you might start by just thinking about an insect, then move to looking at a picture of one, and then maybe being close to one in a terrarium, and eventually, even holding a living one.
Anxiety reduction techniques may also be helpful in combating phobias, things like yoga, breathing exercises, meditation, and mindfulness. The ultimate goal is to be mindful of the trigger, as opposed to afraid of the trigger. Unfortunately, the majority of patients don’t seek treatment for phobias, and of those who do, many don’t follow through. As a result, only 20% percent of people recover completely from them; the majority of people experience a recurrence of their phobia, which is referred to as a relapse. Captain Obvious says if you have a phobia, your best bet is to get the help of a medical professional for treatment.
It might (but really shouldn’t) surprise you to hear that celebrities have phobias too. Just for funsies, here are a few I found while surfing the interwebs.
Tyra Banks has been very open about her long standing fear of dolphins. She doesn’t swim in the ocean, because she imagines them swimming near her and touching her legs.
Christina Ricci has a fear of indoor plants, botanophobia, and says that touching a dirty houseplant feels like torture.
Khloe Kardashian has a phobia of belly buttons. Her half sister Kendall Jenner revealed that she struggles with trypophobia, an aversion to the sight of holes. She says that pancakes, honeycomb, and lotus heads are too much for her to take.
Nicole Kidman has been deathly afraid of butterflies since childhood, and would do anything to avoid having to go through the front gate of her home if even one butterfly was sitting on it.
Jennifer Aniston has a serious fear of being underwater, due to a traumatic experience she had as a child.
Billy Bob Thornton has a fear of antiques; according to him “…old, mildewy French/English/Scottish stuff, dusty heavy drapes and big tables with carved lions’ heads…” creeps him out.
Oprah Winfrey has an intense dislike for chewing gum that goes back to her childhood days. Growing up poor, her grandmother used to try to save gum to chew more than once, so she put it on the bedpost, or stuck it on the cabinet for later. Apparently little Oprah used to bump into it, and it would rub up against her, and gross her out. Evidently, she even barred gum-chewing in her offices.
Kyra Sedgwick is apparently terrified of talking food. Her husband, Kevin Bacon, actually had to turn down an apparently lucrative offer to be featured in ads for M&M’s for fear that she would leave him.
Katie Holmes has a longtime fear of raccoons, and once barked at one in an effort to scare it away. It worked… it left, but her phobia stayed.
Jake Gyllenhaal developed a phobia of ostriches while filming “Prince of Persia: The Sands of Time” after the animal trainers warned him not to make any noise around them, because “they’ll tear out your eyes and rip out your heart.”
Helen Mirren has a fear of phones, and evidently never returns calls because the phone makes her so nervous.
One of Channing Tatum’s biggest fears is porcelain dolls. Yep, Magic Mike is afraid of dolls.
Tyrese Gibson has no problem performing stunts in action movies, but he won’t get near an owl for any amount of money.
Singer Adele has a serious fear of seagulls after a scary incident in her childhood, when one flew in and swiped an ice cream she was eating. Its claw scratched her shoulder, leaving physical- and emotional- scars.
Megan Fox can’t stand the feeling of dry paper, so when she reads through scripts, she constantly licks her finger to keep it wet.
Alfred Hitchcock lived with ovophobia, the fear of eggs. People who worked with him claimed cracking an egg made him gag, and he once told a reporter “…Have you ever seen anything more revolting than an egg yolk breaking and spilling its yellow liquid?”
Actor, producer, and musician Johnny Depp has a phobia hat trick- three phobias- clowns, spiders, and ghosts.
Sean “P. Diddy” Combs has a phobia of people with a long second toe, to the point that it influences his dating life. He must see the toe on the first date… it’s mandatory. He may not go for a kiss, but he’s definitely going to check out that second toe, to see if it’s too long.
Ellen Page has a phobia of tennis balls, and can’t even watch a tennis match on television.
Kristen Bell is afraid of pruney fingers, specifically the feeling of pruney fingers on normal skin, and even wears gloves when she goes in the water to avoid touching herself with her own pruney fingers.
Some fun phobia facts…
In the United States, approximately 19 million people suffer from various phobias, with varying levels of severity.
The prevalence of phobias is approximately 5% in children, 16% in teenagers, and 3% to 5% in adults.
Women are nearly twice as likely to be affected by a phobia as men are, but men are more likely to seek treatment for phobias.
Symptoms of phobias tend to begin in early to mid childhood, with the average age of onset being about 7 years old.
While specific phobias usually begin in childhood, their incidence peaks during midlife and old age.
Phobias can persist for several years, decades, or be present throughout one’s life in 10% to 30% of cases.
The presence of a phobia is strongly predictive for the onset of other anxiety, mood, and substance use disorders.
Specific phobias can and do affect people of all ages, backgrounds, and/ or socioeconomic classes.
A part of the brain called the amygdala is responsible for triggering specific phobias.
There are approximately 400 specific phobias, and new ones are added to the list as necessary. Some are rare, unusual, or downright weird. Here are a few of those.
Ablutophobia, fear of bathing
This phobia can sometimes be the result of a traumatic, water-related incident, especially if it involves bathing during juvenile years, though many sufferers will grow out of this phobia as they get older. This phobia can cause a great deal of social anxiety and friction as it can often result in unpleasant body odor.
Anatidaephobia, fear of being watched by a duck
This is funny, but it’s for real. People with this phobia fear that no matter where they are, or what they’re doing, a duck is watching them. Not a hen, not a rabbit, specifically a duck, like Daffy.
Arachibutyrophobia, fear of peanut butter sticking to the roof of your mouth.
While this may sound like a minor issue, this phobia likely stems from a fear of choking or inability to open one’s mouth. While some sufferers may be able to eat small amounts of peanut butter, especially if it’s not very sticky, many will not eat peanut butter at all for fear of it sticking to the roof of their mouth.
Arithmophobia, fear of math
While plenty of people hated math class, arithmophobia takes this anxiety to the next level. This phobia isn’t so much a fear of numbers or symbols, as it is a fear of being forced into a situation where one has to do math, especially if that person’s math skills are subpar.
Chirophobia, fear of hands
This phobia can be a fear of one’s own hands or another’s. This is often the result of a traumatic event like a severe hand injury, or a persistent condition like arthritis.
Chloephobia, fear of newspapers
This phobia is often connected to the touch, sound, and smell of newspaper. Sufferers may become anxious at the sound of a rustling newspaper, or from the smell of newspaper ink and paper.
Eisoptrophobia, fear of mirrors
Sometimes referred to as spectrophobia or catoptrophobia, sufferers are often unable to look at themselves in a mirror. In more severe cases, this anxiety can even extend to reflective surfaces like glass or standing water. One genesis of this phobia revolves around the superstitions tied to mirrors, the fear of seeing something supernatural or breaking a mirror and being cursed with bad luck. In other cases, this phobia can stem from low self-esteem and an aversion to seeing oneself.
Geniophobia, fear of chins
This one sounds a little unreal, because how can anyone fear a chin, but people with this phobia have an aversion to chins, and cannot interact or look at people whose chins bother them. It’s unclear if this is all chins or Jay Leno chins…
Genuphobia, fear of knees or kneeling
People who have this phobia have a fear of knees, their own and/ or someone else’s. This gives me flashbacks to confirmation classes, with all the kneeling, aka genuflecting.
Globophobia, fear of balloons
This phobia often originates from a traumatic event, often when a popping balloon causes a scare at a young age. Sufferers of this phobia can have varying levels of anxiety, with some casually avoiding balloons, while other, more severe cases are prohibited from being anywhere near a balloon. Globophobia is also often linked to the fear of clowns, coulrophobia.
Hippopotomonstrosesquipedaliophobia- I kid you not- is the phobia of long words. Of course a 15 syllable word represents this fear…can people with it even say what they’re afraid of? Hmmm…
Omphalophobia, fear of belly buttons
Just like Khloe Kardashian! Sufferers will often avoid areas like the beach, where exposed belly buttons are common. This phobia can be the result of a previous infection in the umbilicus, but can also just be random. In severe cases, sufferers may cover up their own belly button with tape or a bandaid. Interestingly, this phobia may be related to trypophobia, the fear of holes that Kendall Jenner, Khloe Kardashian’s half sister has… hello, genetics!
Optophobia, fear of opening your eyes
This phobia is generally the result of a traumatic event, especially during childhood. This phobia can be extremely debilitating, as sufferers will often avoid leaving their homes, and naturally seek out dark or dimly lit areas.
Nomophobia, fear of not having your cell phone
This is an anxiety that so many people feel to varying extents, but it becomes a phobia when the anxiety turns into a consistent fear or panic at the mere thought of being without a mobile phone. This phobia also extends to having a phone with a dead battery or being out of service, thereby making the phone unusable. Someone with nomophobia will feel intense anxiety if they have no phone signal, have run out of data or battery power, or even if their phone is out of sight. Nomophpia is often connected with an addiction to phones and the need to be constantly connected. A recent study showed that many people under the age of 30 check their phone at least once every 10 minutes- 96 times a day- so this is far more common than you can imagine.
Plutophobia, fear of wealth
This phobia deals less with the fear of physical monetary currency and more with the anxiety around wealth or being wealthy. Sufferers dread the responsibility and weight that accompanies wealth, and fear that they will be targeted for their wealth, and subsequently put into danger. They may even sabotage their career or money-making opportunities in an attempt to avoid feeling it.
Pogonophobia, fear of facial hair
This fear is often the result of a traumatic experience with someone who has significant facial hair or a beard. Beards also partially hide someone’s face, creating an additional layer of anxiety for those that struggle in social situations, or reading social cues. In more severe cases, a sufferer of pogonophobia may not even be able to look at a picture of someone with a beard.
Sanguivoriphobia, fear of vampires
Sufferers have a fear of vampires and blood eaters. In fact, the word literally translates to ‘fear of blood eaters’. At least people with this won’t have to sit through the torture of the Twilight movie series.
Somniphobia, fear of falling asleep
While some people just can’t do without their regular eight hours a night, sufferers of this phobia may associate going to bed with dying, or fear losing time while asleep.
Turophobia, fear of cheese
A fear of cheese can often be traced back to an incident with cheese, especially in early childhood. Being forced to eat cheese, especially when lactose intolerant, can create an aversion to, and anxiety towards, cheese. More severe cases can even result in fear just from the sight or smell of cheese.
Xanthophobia, fear of the color yellow
This is a difficult phobia to deal with, as some things in nature and many man made things are yellow. Sufferers may fear something seemingly benign like a flower, school bus, or wheel of cheese. This phobia could be an artifact, originating from survival-based evolution, as animals that are brightly colored, like frogs or snakes, are sometimes poisonous or venomous.
That’s a good place to end for this week, before everyone develops bibliophobia, the fear of reading! I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in officeand on Amazon.
Thank you and be well people!
N-acetyl Cysteine… New Miracle for Bipolar?
Hello, people… hope everyone is well! In last week’s blog, I introduced you to N-acetyl cysteine, or NAC, an amino acid supplement that’s garnering some serious attention in shrinky circles, as it has shown major potential to help treat multiple psych conditions. Recall from last week that NAC is most renowned for its ability to replenish levels of the body’s strongest antioxidant, glutathione, while it also regulates the very important neurotransmitter, glutamate, acta as an anti-inflammatory, and assists the body’s detoxification system.
The rationale for administering NAC for psych conditions is based on those roles: being a precursor of glutathione, as well as its action as a modulating agent of glutamatergic, dopaminergic, neurotropic, and inflammatory pathways. Those are the mechanics of NAC, the how and why it’s beneficial for brain function: NAC helps to produce glutathione, which, being the chief free radical scavenger, takes up all those nasties, reducing cellular damage. NAC also acts as an anti-inflammatory, so it decreases the blood levels of molecules that cause inflammation in the body and brain, such as interleukin-6, which incidentally may play a role in the pathogenesis of schizophrenia, bipolar disorder, and depressed mood. A third mechanism of action that has been proposed for NAC involves the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine. Let’s talk about those two for a moment.
As the most abundant neurotransmitter in the brain and CNS, glutamate plays an important role during brain development, as well as helping with learning and memory. Glutamate is an excitatory neurotransmitter. What is that? Excitatory neurotransmitters have excitatory effects on the neuron, meaning that they increase the likelihood that the neuron will fire a signal- called an action potential- in the receiving neuron. Because neurotransmitters can increase action potential, you can then probably imagine why neurotransmitter levels are very important. At high concentrations, glutamate can overexcitenerve cells and cause more neuronal firing. Prolonged excitation is toxic to nerve cells, and causes damage over time. So having excess glutamate, as an excitatory neurotransmitter, causes more neuronal firing, and you can actually damage cells this way. In fact, you can excite cells to death… a process referred to as “excitotoxicity.” Having too much glutamate in the brain has been associated with neurological diseases such as Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, stroke, and ALS, amyotrophic lateral sclerosis or Lou Gehrig’s disease. Problems in making or using glutamate have also been linked to a number of mental health disorders, including autism, schizophrenia, depression, and obsessive-compulsive disorder, OCD. Glutamate is also a metabolic precursor for another neurotransmitter called GABA, gamma-aminobutyric acid. GABA is the main inhibitory neurotransmitter in the central nervous system- the flip-side of the coin- which decreases the likelihood that the neuron it acts upon will fire. That’s why glutamate is so important, it’s the dominant neurotransmitter used for neural circuit communication, and it’s estimated that well over half of all synapses in the brain release glutamate.
Dopamine is the “feel good” neurotransmitter that’s strongly associated with pleasure and reward. It’s a contributing factor in motor function, mood, and decision making, and is also associated with some movement and psychiatric disorders. Dopamine is released when your brain is expecting a reward; when you come to associate a certain activity with pleasure, just the anticipation alone can be enough to raise dopamine levels. It could be a specific food, sex, shopping, or just about anything else that you enjoy. If your go-to comfort food is homemade chocolate chip cookies, your brain may increase dopamine levels when you smell them baking or see them come out of the oven. Then when you eat them, the flood of dopamine you receive acts to reinforce the craving, causing you to focus on satisfying it in the future. Dopamine is all about the cycle of motivation, reward, and reinforcement. Now imagine that you’ve been jonesing for those cookies all day, but your co-workers scarfed them all down while you were sidetracked by a conference call. Your disappointment might well lower your dopamine levels and dampen your mood. It might also intensify your desire for chocolate chip cookies, making you want them even more. Dopamine plays the main role in all of that, but keep in mind that dopamine doesn’t act alone. It works with other neurotransmitters and hormones, things like serotonin and adrenaline. Aside from its “feel good” function, dopamine is involved in many body functions, including blood flow, digestion, memory and focus, mood and emotions, motor control, pain processing, sleep, stress response, heart and kidney function, pancreatic function, and insulin regulation. Once again, as with all neurotransmitters, levels are important… theright amount of dopamine generally equates to a good mood. Ultimately, dopamine contributes to feelings of alertness, focus, motivation, and happiness, and a flood of dopamine can produce temporary feelings of total euphoria.
Those mechanisms I mentioned- glutathione reducing cellular damage, anti-inflammatory action, and the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine- are the proposed how NAC works, but why does NAC help people with varying psych diagnoses? Why might it work across so many conditions? This is the most intriguing thing to me. First and foremost, it seems to target biological pathways that are common across many mental disorders. For example, we know that patients with bipolar disorder have significantly higher levels of oxidative stress, and higher glutamate concentrations in their brains, especially during acute mania. It’s been suggested that people with schizophrenia may have the same, and that this may predispose them to changes in neuronal cell membranes and mitochondrial function that later manifest as symptoms of schizophrenia. It appears that NAC supplementation, by increasing CNS glutamate levels and reducing overall oxidative stress, may reduce the severity of these psychotic symptoms.
A meta-analysis and systematic review of placebo-controlled studies on NAC as a stand-alone treatment of depressed mood in people diagnosed with major depressive disorder, bipolar disorder, and other psychiatric disorders, found evidence for “moderately improved” depressed mood and improved global functioning. In a four-month, double-blind study, individuals treated with NAC plus their usual antidepressant improved more than individuals taking a placebo with their antidepressant medication.
In a large, six-month, double-blind study, individuals with schizophrenia who had failed to respond to multiple trials on antipsychotics were treated with 1,000 mg NAC twice daily versus a placebo, while also taking their usual antipsychotic medication. Those taking NAC experienced moderate improvements in symptoms of apathy and social withdrawal, the so-called “negative” symptoms of schizophrenia, as well as improvements in day-to-day functioning, and fewer of the abnormal involuntary movements that are commonly caused by some antipsychotic meds.
NAC has also been investigated as a treatment for substance use disorders, with promising results. The findings of small, placebo-controlled studies suggest that NAC helped heavy Cannabis users to reduce their use, and that it may reduce the intensity of withdrawal and cravings in people in early stages of cocaine recovery. As in mood disorders, the beneficial effects of the NAC may be related to its role in restoring neurotransmitter activity that has been affected by chronic substance abuse.
In addition to its mood-enhancing benefits, there is evidence that NAC may reduce trichotillomania (compulsive hair pulling) and other impulse control disorders, like nail-biting, skin picking, and pathological gambling. There was one eight-week, open-label study on pathological gamblers, and over 80 percent of them responded to NAC. They were then subsequently enrolled in a six-week, placebo-controlled trial, and continued to report “significant reductions” in gambling.
As for potential treatment targets, a systematic review of all of the evidence suggests that NAC may be effective at treating major depressive disorder, bipolar disorder, drug addiction, obsessive-compulsive disorder, impulse control disorders, autism, schizophrenia, Alzheimer’s disease, and even certain forms of epilepsy, specifically progressive myoclonic seizures. NAC has also been shown to potentially reduce the severity of mild traumatic brain injury in soldiers, and animal studies show that it can improve cognition after moderate traumatic brain injury. Other disorders such as anxiety and ADHD have some interesting preliminary evidence, but require larger studies.
The jury’s still out as to the mechanism, whether NAC’s benefits are the result of glutathione reducing cellular damage, the anti-inflammatory action, or the actions on glutamate and dopamine. Even though we don’t know exactly why yet, on a clinical level, NAC seems to help with ruminations, the difficult to control, extreme negative self-thoughts. These thoughts are very common in depression and anxiety disorders, and also in eating disorders, schizophrenia, and OCD. NAC seems to help some patients when other modalities, even meds and psychotherapy, haven’t helped much. It doesn’t always work, but when it does, irrational thoughts seem to gradually decrease in intensity and frequency. Negative thoughts, like “I’m a bad person,” “Nobody likes me,” or ruminations about other people or other issues that can’t seem to be quieted by reasonable evidence to the contrary- those really pesky negative thoughts that keep intruding on someone’s awareness, hour after hour, day after day, despite all efforts to control them- seem to decrease with NAC. If they do continue to occur, they’re less distressing, and can be observed from more of a distance, and are less likely to trigger depression or other negative effects.
Overall, NAC seems pretty special. Its ability to successfully cross the blood-brain-barrier to increase CNS glutathione levels, while reducing glutamate and overall oxidative stress, in addition to its anti-inflammatory properties- all conditions linked to depression and other mental health disorders- makes it an interesting treatment candidate for many psych conditions. If you take NAC, you’re basically giving your body an efficient way to soak up excess glutamate, an excitatory neurotransmitter that’s not good in excess concentrations. You’re also reducing oxidative stress and inflammation by giving it glutathione. As a result, this seems to help alleviate a number of different mental health conditions: depressed mood, schizophrenia, impulse control disorders, and substance use disorders. Studies indicate that people benefit from taking anywhere between 250 mg to 500 mg daily. Lower doses are better because high doses of NAC can sometimes redistribute heavy metals into the brain… this is not a good thing, so you obviously want to avoid that. You can take NAC with leucine, another amino acid, as taking leucine with it prevents mercury from being reabsorbed into the central nervous system. As always, please bear in mind that large placebo-controlled studies are needed to confirm the beneficial effects of NAC in mental health care, and to determine safe, optimal dosages for standalone or adjunctive treatment. But if you think it might be helpful, talk to your physician to determine if NAC is a good supplement choice for you.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
The Dark Side of OCD
Hello, people~ welcome back to the blog! The last few installments, we’ve been talking about some of the more unusual subtypes or presentations of OCD. Last week, I told you about POCD, pedophilia OCD. This is a devastating harm based subtype that causes people to worry that they might be attracted to children, and could potentially act on that attraction. To reiterate, these are not predators that actually want to harm or molest children. They are simply- or not so simply- obsessed with the idea that they could. Somewhere along the line, that becomes locked in their brain due to the OCD, and they worry about it incessantly. As a result, they avoid all contact with children, and this can have a huge impact on family dynamics. It causes a great deal of shame and guilt for the person who has it, as they fear being judged by others, while always judging themselves very harshly. And it can also be very damaging to the children in that person’s life, since they miss out on the time and affection that person would have otherwise devoted to them. As you can imagine, all of these things often lead to a great deal of anxiety and depression, and many times, people with POCD suffer through it alone. This week, we’ll be continuing the series with a look at perfectionism.
Perfectionism is a pretty self-explanatory subtype, the obsession with appearing and being “perfect.” Perfectionism is kind of an unusual trait. It isn’t unique to OCD; not all perfectionists have OCD, and not all people with OCD are obsessed with being perfect. But perfectionism underlies many OCD subtypes, as it can contribute to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, perfectionism can really be thought of as its own OCD subtype; when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, it falls into a class of its own.
Perfectionism can look very different from person to person, but there are some common overarching themes. Perfectionists feel the need to follow rules very rigidly. I’m sure you’ve heard the addage “Anything worth doing is worth doing right.” Some versions end with “well,” but this isn’t strictly true for perfectionists, it must be right. Things must be done in a certain way- perfectly- or not at all. This is tough to live up to at best, and the pressure to achieve this standard can become so great, that at times it’s far easier to give up on doing something altogether. In addition, perfectionists generally need to feel that they are in control of a situation at all times. By definition, they are excessively concerned with making mistakes, especially when other people could potentially see those mistakes. Ultimately, they think that these errors have some bearing on their overall value as a person, that they define them. They also tend to have an overwhelming need to please others. As a result, relationships with authority figures- people like bosses and parents- can be fraught with anxiety. Perfectionists also have trouble with prioritizing. They can’t make a list of five things they want to accomplish, and then decide which to give 100 percent effort to, 80 percent, and 50 percent. That doesn’t work for them, it’s very all or nothing. Every time they came across a task, whether it’s a strength of theirs or a weakness, whether they have expertise in it or not, they always feel like they must perform it at a high level.
There’s nothing wrong with doing things well, or with being very diligent and detail oriented. These are great qualities, and they work well for people, when they’re functional qualities. But when it gets in the way of getting things done- when it becomes dysfunctional- it’s a problem. I had a patient that was a student, a freshman in college, and he loved school. He was all about it, very intelligent, studied a lot, and worked so hard on papers and projects. Too hard as it turns out. He would begin a lab write up or a paper, but would edit as he wrote. He would then write more, then edit that; then he’d try to stitch them together and get frustrated. Ultimately, he’d have to start all over again. It just went on and on in this way, and it took him forever to do a very simple write up. Something that took his peers maybe a couple of hours tops would take him days of work, because it was nearly impossible for him to write it start to finish, then edit start to finish, a reasonable number of times. There was never an end point- he always felt it needed to be better- and was compelled to improve on it, so sometimes he simply couldn’t finish things. His brain just didn’t want to let him.
Many years ago, I worked with young children in a hospital setting, with a wide array of diagnoses. One young girl, about nine years old, would undoubtedly have a diagnosis of perfectionism. I remember her very well, but her parents made an especially unique impression. When I gave them my assessment, it was quite clear that her being a perfectionist wasn’t a problem for them- this was written all over their faces. The mother especially, she had a little smile, almost of satisfaction or even pride. It was like I was telling them it was a good thing, or maybe too much of a good thing, like having too much money. She was a great student, very precocious, and a great kid, very meticulous. But if she did something imperfectly, if it didn’t meet her standards- which I suspect she may have learned from her mom, or her mom had a hand in planting- it was a problem. She would begin something with such enthusiasm, which was so great to see given her anxiety; but once she realized the task wasn’t going to be up to par, she would just give up and shut down. It was like watching a bright beautiful flower wilt and wither right in front of you. A sad thing at nine years of age.
This is basically a form of avoidance, which is a common compulsion for perfectionists. Better to totally blow something off than to not do it perfectly. Another example of this is something my student patient would do. If he was late for class, he couldn’t bring himself to go in. If he could see from the window that the professor had already started lecturing, and the students were all sitting there, facing front and listening, he would imagine how it would feel to open the door, and have all those heads turn to look at him. He couldn’t take that, everyone seeing his screw up, so he just wouldn’t go, he’d skip class. Then the next class, he was so concerned about showing his face after missing the previous one, it had a tendency to snowball. Even though he was smart and worked very hard, between his lack of participation in class and his issues in completing tasks, he ended up receiving poor grades, or even failing classes, with shocking regularity.
Perfectionism is difficult for those with it to gain insight about, because it’s so engrained within their personality. They like to be focused, discerning, fastidious, and detail oriented. Sometimes it works well for them, but when it works against them, it takes much longer to realize it. All of this makes it hard to treat. Despite the suffering it causes, many times, patients initially resist the idea of abandoning their ways completely. And I get that. Some elements of perfectionism backfire, but there are parts that are beneficial, that help people reach their goals. You don’t want to necessarily eradicate it from their lives altogether, throw the baby out with the bathwater. I understand the hesitation. Somewhere in the dysfunction is function. In my student patient’s case, there were times he got A’s on papers. It took him 40 hours instead of two, but the end result was good, no argument there. So how do you find the happy medium, how do you eliminate the dys- from the functional in treatment? We want people to work hard, to be attentive, accurate, and competent. In treating it, and designing exposures, we don’t want to make a person act stupidly or underperform- proofing and editing is good if you don’t want to send out a paper to your professor, or letter to your boss, filled with typos. That would be nearly impossible to get them to do anyway, even if it was designed as an exposure to treat them. We don’t want to weed out the good parts, or necessarily challenge the outcome or the goal, but we need to challenge how they’re getting there. In the case of my student patient, the exposure would be to write without editing, start to finish, one draft, even if there were mistakes. Other ideas would be to show assignments to other people before they’re turned in, as well as to put max time limits on how long a project can take. Practice doing things well, instead of perfectly, to help them see that they can in fact deal with imperfection. That’s the true reality anyway- nothing is ever perfect. If you want perfection, to the point that you reject anything less than that, you’re going to end up rejecting things you shouldn’t, and missing out on a lot in the bargain.
That makes me think of a book about OCD by Judith Rapoport called The Boy Who Couldn’t Stop Washing. It’s about a law school student with contamination obsessions that agonized over cleaning his apartment. He obsessed about how long the cleaning would take, and especially about how quickly it would get dirty again. He eventually started to avoid going home, so that its cleanliness would be maintained; it wouldn’t be disturbed by the messiness of his living in it. This escalated to the point that he wound up sleeping on a park bench, willingly homeless, all to avoid his apartment. This might seem radically counterintuitive. How could a person with contamination obsessions- who’s afraid of germs- stand to sleep outside, in a park, with all the dirt that goes with it, all for the sake of cleanliness? This is the dark side of OCD when you have perfectionism.
I was thinking about positive perfectionism, and out of curiosity, read about the top career choices for perfectionists. Clearly, positive perfectionism can give a person a set of traits that can help them excel in life, especially in certain careers. Accuracy, attention to detail, persistence, conscientiousness, and organization lend themselves well to roles where design, math, and very complex procedures are essential to their tasks. Mechanics, inspectors, accountants, surveyors, tailors, and engineers would be top choices. Artists and creative types seem to suffer the most from perfectionism. Claude Monet, the highly celebrated French Impressionist, was a perfectionist… the perfectionist impressionist! I read that he was set for an exhibition in May of 1908, featuring his newest works, the result of three years of work. But when he took his final look, he decided the paintings weren’t good enough. Amid great protests, he took a knife and a paint brush to the paintings- worth $100,000 at the time- defacing them irrevocably. Today, they would be priceless. His actions prompted all sorts of ethics discussions; should an artist have the right to destroy his own work? Evidently at least one expert thought so, and actually praised him for being a true “arteest” and told the New York Times, “It is a pity, perhaps, that some other painters do not do the same.” A similar, but more tragic story is told in a book from 1886 called L’œuvre, translated as The Masterpiece. It tells the story of another artist who becomes obsessed with creating a large canvas that he worked on incessantly, but it never satisfies him. He kept painting on more and more layers, to the point that the canvas was destroyed. Then he would start over, again and again. He became so distraught and depressed that eventually, he went insane.
So how do you tell the difference between healthy and unhealthy perfectionism? The difference is when you move from a detail oriented, conscientious place, to a rigid and controlling one. When the ideas of perfection prevent you from doing anything at all, a healthy sense of perfectionism has been taken over by a dysfunctional one; putting you in a place where mistakes are catastrophic, where they say something about you, where you have to live up to other people’s expectations. This induces such anxiety that it becomes crippling, because eventually everything needs to be perfect- even things that other people would never even notice start needing to be perfect. Once again, the pressure from that becomes so intense, it’s easier to just forget it, to give in altogether. But in my view, the only way to truly fail at something is to not try at all. If you fail at something, it’s not because you’re not perfect, but because you didn’t try. Most perfectionists don’t subscribe to this; they seem to mostly have a fear of being average. They want to succeed perfectly, but if they’re going to fail, they’re going to do so spectacularly. A healthier point of view is to accept that nothing is ever perfect… but it won’t be anything if you don’t do it in the first place.
Thank you and be well people!
OBSESSIVE COMPULSIVE DISORDER (Darker Subtypes)
Hello, people! Welcome back to the blog, where we’re continuing our discussion of some darker OCD subtypes. Last week we talked about emotional contamination OCD, which is when people become obsessed with the idea that they may become “infected” by the thoughts or beliefs of another person. This can happen any number of ways; through air, electronic media, by touch, by talking about them, or even by being in the presence of someone who’s been in their presence. It’s difficult to deal with- trying to avoid this influence can become so consuming that it completely alters the course of a person’s life. This week, we’re going to talk about a particularly devastating subtype called pedophilia OCD, which features an obsession with the idea that you might be attracted to children, and could potentially act on that attraction.
Before we get started, I want to make a very important distinction. People with pedophilia OCD or POCD are not people you need to hide your children from. They are not predators, and have no actual desire to molest children. They have an unusual form of OCD where an idea basically gets trapped in their brain, and because of the OCD, it gets twisted in such a way that they worry they may act on it. Maybe they see a news segment that gives details on a molestation case, or they read an article, or participate in a discussion; that may be all it takes. The idea of harming a child is as horrifying to them as it is to you and to me, but unfortunately, the OCD allows the possibility to take root. They wonder if their worry about pedophilia means they have desire. They fear they could act, and they obsess about the fear. It can be very debilitating. I’ve had patients that were so afraid of what they “could” do that they were often unable to get out of bed in the morning. They think these thoughts must mean something… why would they have them otherwise? It can be a real mind screw.
Pedophilia OCD is an example of harm based OCD, and there may be many variations on that general theme. It may be a fear that they may hurt or kill strangers, or even parents or siblings. For any person with harm based OCD, the biggest fear is that they are dangerous. The object of harm can remain the same for years, or may change for no obvious reason. A patient I consulted on, a 20-something named Heidi, obsessed about harming her boyfriend. She would find herself worrying she might push him down the stairs, stab him with the carrot peeler, or run him over with her car. She worried about it for three years before she admitted it to anyone… three years! Can you imagine? Once she initiated therapy for that, the focus shifted to a pedophilia based fear; she worried she might molest her baby nephew. It was her first time as an aunt, and she loved the little guy. She didn’t want to hurt him, it was just her OCD talking to her, filling her head with nonsense. She constantly wondered ‘Am I attracted to this; do I want to molest him? Why did I have this thought? This must mean something about me…. this must be who I am.’
It was a nightmare for her. She couldn’t trust herself to be alone with her new nephew, and yet was understandably afraid to tell her sister she was having these thoughts. She wasn’t able to sleep at night, worried she would do something to him while everyone was sleeping. Eventually, she confessed what she was thinking to her mother. With her support, she was then able to talk to her sister, and then her whole family, who all supported her. Sadly, not all do; but she was able to turn to them to seek reassurance. This is a fairly common compulsion for people with stereotypical OCD- they compulsively need another person to tell them what they’re obsessing about isn’t true. Heidi would call her sister or mom and tell them when she was having these scary thoughts, and they would reassure her that she was a good person, she wasn’t going to molest him. It helped take the edge off, but only for about ten seconds. Then it was back to worrying. Remember that OCD is a disorder of doubt. Even after she was diagnosed with OCD, at the back of her mind, Heidi was even unsure if her thoughts came from that, or if it was truly something darker.
Sometimes pedophilia OCD thoughts first center on a parent. People with it may wonder if perhaps they’re attracted to a parent, and/ or if they were molested as children, if something was done to them to cause the thoughts. That’s never happened in any of the cases I’ve been involved in, it’s simply the obsessive mind looking for reason. These thoughts torment people with pedophilia OCD, and many say that they thought they were going crazy before they were diagnosed with OCD. If their fears revolve around molesting children, they will do all they can to avoid them, and not even talk about them. When they can’t avoid the topic, their anxiety and uncertainty is multiplied. They will desperately review every movement they made around a child to help them figure out whether their actions were inappropriate, and they’ll constantly seek reassurance from loved ones, provided they’re aware of it. If not, they suffer alone. They know they would never hurt a child, but they can’t trust themselves, so they really need to hear it from someone else. Self-compassion is often non-existent, self-loathing is more the rule. They believe they should be able to control their thoughts. Since they can’t, they constantly judge themselves, and that often leads to depression.
As you can imagine, it’s hard for them to seek treatment, because they’re afraid of being judged. They live in fear that family and friends will find out the “true” nature of their thoughts, and they’ll be ostracized, labeled as a pedophile, as disgusting or evil. People with POCD feel extreme shame and guilt for their thoughts. Most people don’t understand that pedophilia OCD is not the same as pedophilia. Imagine this: you see a kid and you’re like, ‘Awww, so cute!’ If you have POCD, your next thought is something like, ‘Oh, my god. Does that mean I’m a pedophile?’ Clearly, babies are cute, everyone knows that, nothing wrong with it. But the POCD tries to spin it, so if you have it, it makes you worry that you’re a deviant.
Last week, I talked about exposure therapy for OCD, and POCD is treated the same way- it requires putting the person face to face with the ideas and “temptations” of pedophilia. Just reassuring them that they’re not a pedophile doesn’t work; they don’t believe it. Instead, people with POCD have to become comfortable with the uncertainty, with the risk that their very worst fears are true. Then they have to figure out how to live their lives despite that risk. POCD exposures might include going to a park where children are playing, or to a children’s store, maybe handling clothing. They could watch that pageant show with the nutty parents- might as well try to get a laugh while working on it. At some point, exposures might re-introduce behaviors the person has been avoiding- like having someone who has been avoiding changing a diaper or giving a bath start doing so again- even if it makes them anxious and fearful. As scary as it can be for them, not doing these things can be much more damaging to the children in that person’s life, since people with POCD often avoid giving affection, spending time, or caring for children because of their fears. Ideally, as exposures continue, the person begins to understand that what they’re afraid of isn’t true. The goal is for them to learn that they can trust themselves to do these things without molesting a child or hurting them in any way. As hard as it may be to get there, every patient I’ve worked with has been willing to do whatever it took to reach that realization. It may not make 100% of the obsessive thoughts stop, but it gives them the ability to call bs on them and keep it moving.
Speaking of, that’s it for this week. Next week, another OCD subtype, perfectionism.
Thank you and be well people!
The Darker Side of OCD
Hello, people! Last week we finished up our discussion on the importance of vitamin D, so I hope everyone spent a few minutes in the sun over the weekend to get a dose… gotta have it! This week, we’re starting another series on OCD, Obsessive Compulsive Disorder. What’s the first thing that comes to mind when you hear about OCD? It’s probably neatness, everything in its exact place, like making sure all the edges of the silverware are perfectly aligned in the drawer. Or maybe it’s repetitive hand washing, counting steps, or checking the locks on all the doors in the house. While those stereotypical obsessions are definitely common symptoms, in reality, OCD can involve any persistent, intrusive, obsessive thought that causes anxiety; it’s then generally paired with a behavior that attempts to quell that anxiety. But the scope of it can reach much further than worry over germs or counting and checking, as it is limited only by the person’s mind. Some obsessions are much darker, incorporating a person’s deepest darkest fears and worries. How about obsessing about killing your mother? All of your thoughts center on how you’d go about it, how it would feel. While these types of obsessions may be less common, they can clearly be much harder to talk about, and for that reason, can remain undiagnosed for years, even if a person seeks help. In the best case scenario, it can take an average of 14 to 17 years for people to find treatment, even though OCD usually emerges in childhood.
Think about having an obsession centering on a bodily function, let’s say swallowing. How many times do you swallow in a day, whether eating or drinking or not… ever noticed? Probably not, unless that happens to be an obsessive thought for you. Do you ever worry about the ability to swallow when you need to… do you doubt it? Can you imagine how debilitating something like that could be? And most people have more than one obsession that draws their focus. I did have a patient with OCD who thought he was Jesus, so all of his obsessions centered on that. He dressed like Jesus, wore his hair and beard like Jesus, and acted like Jesus- or how I imagine Jesus would act- with this “peace, brother” persona that he never dropped. He was court ordered, but totally harmless. The total effect was, well… honestly, kinda eerie. That could’ve been me- for some reason, it gave me flashbacks to confirmation classes as a kid. Anyhoo, he was so sure of his true identity that he would only date women named Mary. Yep. Sometimes in OCD, all of the obsessions are present in the mind at once, competing for attention, while at other times, one will take center stage, while the others wait in the wings. Depending on the year, the day, or even the minute, OCD can look completely different, even within one individual.
At its core, OCD is a disorder of doubt. A person can’t be sure that their thoughts aren’t indicative of something that may happen in real life. They can’t be sure of their safety, their intentions, their motives, or even their true realities. And yet, most people with OCD are completely, and usually painfully, aware that what they’re thinking isn’t true. For example, a person with a contamination obsession knows deep down that they don’t need to wash their hands for the 100th time, but they cannot get past the possibility that there could be germs lingering there. They’re haunted by the reality that there could be. Are those germs dangerous… could they make them sick, even kill them? That doubt is what they obsess over. So they continue to wash. When people find out what I do, at cocktail parties and the like, they’ll sometimes ask me, what’s the weirdest/ worst/ scariest symptom or diagnosis you see? Well, when it comes to OCD, there’s really no hierarchy to suffering- one obsession isn’t necessarily inherently worse than another- the worst obsession is the one that’s right now. Still, some forms of OCD are more challenging to deal with, diagnose, and treat. To start with, the content of some obsessions are so taboo that people simply won’t divulge it, so they suffer without finding the help they need. Sometimes they don’t even know that they have OCD, that that’s what’s driving these obsessive thoughts. So this week we’ll be talking about the darker side of OCD, examining some lesser known types you may have never heard of.
Before we start, a note on these subtypes. Although all forms of OCD have symptoms in common, the way these symptoms present themselves in daily life differs a lot from person to person. Usually, OCD fixates around one or more themes, and some of the most common themes are contamination, harm, checking, and perfection. The content of a person’s obsessions isn’t ultimately the important part, though it’s certainly what feels important in the moment. Someone’s subtype is really just their manifestation of symptoms- the particular way their OCD affects them. What does the mind focus on, and what thoughts and actions result from this focus? Psych geeks like me call a condition like OCD “heterogeneous” because it varies so much from one person to the next, but there are a few common “clusters” of symptoms. There’s a lot of discussion about these symptom clusters, and even more debate about whether or not they should be classified as more specific categories or subtypes. But there are clear groups of obsessions and compulsions that pop up regularly in people with OCD. Many clinicians try not to talk about subtypes because there isn’t any real research backing them. They’re not perfect categories or neat little boxes you’re supposed to fit into, so if you have OCD, it’s not worth spending too much time trying to figure out which subtype you fit into if it’s not immediately apparent. That said, for lots of folks with OCD, the immediate recognition of their own experience in a list of subtypes is a powerful thing, and may actually be the start of the treatment process.
So ultimately, I’ve chosen to go with calling these subtypes, but you can call them forms of OCD, or whatever you want, really. The point is that the symptoms seem to fall into groups naturally, and the info just needs to be out there so there’s more awareness of what lots of folks with OCD struggle with on a daily basis. Imagine that you’ve thought of yourself as truly- and totally uniquely- messed up for a long time. No way anyone has ever had the thoughts you have, or so you think. All of a sudden, you’re crusing the interwebs and see a list of symptoms that match yours exactly. Recognizing yourself in this OCD subtype, you’re not alone anymore- there are enough people like you out there to have your own type. Maybe you don’t have to feel hopeless anymore, because other people have clearly faced similar struggles, with similar types of obsessions and compulsions. There’s no realization that comes close to that kind of hope. Listing subtypes may be an imperfect way of categorizing OCD, because people may mistakenly think of them as distinct conditions rather than common manifestations of the same diagnosis, but I think it’s the way it should be. All of that said, keep in mind that there are hundreds of different ways OCD can show up in someone’s life- people don’t fit in boxes, they can have more than one subtype, and while the subtypes are relatively stable over time, they can change- new symptoms can appear and old ones might fade. Not a lot of rules when it comes to the brain’s capacity for imagination and change. So now, finally, we’ll begin discussing some unusual OCD subtypes, just to illustrate the mosaic of experiences associated with the diagnosis, and to illuminate some of what goes on in the OCD mind.
Hyperawareness OCD is an obsession with a part of the body, or with an involuntary bodily function. The patient I mentioned earlier, with the swallowing obsession, had hyperawareness OCD. It’s also called sensorimotor or somatic OCD. At any given moment, your brain, through your entire CNS, is sending and receiving signals about what different parts of your body are doing- like where your hands are, what your heart rate is, or if your stomach is empty or full. These are done subconsciously, so most people don’t pay attention to them. Everyone blinks and swallows, but very rarely do you give it any consideration. With sensorimotor OCD, a function like this can become an obsession. A person can get stuck in this place where they become hyperaware of some part of their body, or of the signal controlling it in their brain. I had a patient obsessed with blinking. Every morning, her first thought upon waking was to check to make sure she was still blinking, or still able to blink. And the thought persisted throughout the day… am I blinking now? It was consuming her life, not only was it the first thing she thought about, but also the last. She even kept herself awake with it, because she would close her eyes to sleep and would have to open them and make sure she could still blink.
When anyone starts to think about things like involuntary processes- even for people without OCD- they can become heightened. If thinking about “it” makes it happen, and if “it” happening makes you think about it… well, you can see how easily this could lead to an obsession in the mind. To make matters worse, a lot of the anxiety in OCD lies in the person’s fear that they’ll never stop thinking about the blinking or swallowing, or whatever the obsession may be. And of course, the more they monitor it, the more they try to control it, the less automatic it feels, the more controlled it feels, and the more it seems like they’re never going to stop thinking about it. It’s a never ending cycle, and it produces a lot of other obsessions like, what if this drives me crazy, what if I never stop, if I’m permanently distracted by it? And in fact, my blinking patient also had a tendency for projection, so she imagined obsessing over blinking for the rest. of. her. life… ife… ife… ife…. I should point out that I make light of it, because one of the ways to combat an obsession is, oddly enough, to examine it in detail, so that includes looking at the futility of obsessing over an automatic bodily process that you cannot control… forever. It sounds counterintuitive, but dealing with it that way is a form of mindfulness- for those of you who read my blog on that many moons ago- examining whatever the thought may be, and the body part it involves, in an effort to soothe and assure. It can’t control it, but it can help lead to acceptance of the thought, which can take away its power.
While sensorimotor OCD is relatively rare, in addition to blinking, the top three obsessions also include swallowing and breathing; but it can focus on the function of literally any part of the body. It can even involve non-functional parts, like the location of a mole or freckle, or hyperawareness of normal occurrences like itching or heart rate. As you can imagine, it can be very debilitating and isolating. My swallowing patient had a very hard time eating in front of anyone- these obsessions tend to be very self-propagating- and she was too anxious over being anxious about her swallowing. And it’s very difficult to talk about these symptoms, even with a therapist or a shrink, so unfortunately, people really suffer. It’s easier to just keep it simple and tell people that you have OCD and let them think you spend all your time straightening silverware or washing your hands, rather than risk being judged for the other manifestations. It’s a tough situation- while I understand it may be easier, it’s not necessarily better in the end. Some clinicians don’t understand sensorimotor OCD, or recognize that people with it have compulsions. Compulsions are the actions or rituals the person is basically “required” to complete in order to make the obsession, and therefore the resulting anxiety, stop. For instance, in contamination OCD, the obsession is germ exposure, and the compulsion is the continual hand washing. But in sensorimotor OCD, the compulsions are there, but they’re just not obvious. It’s more about the mental rituals taking place in sensorimotor, like reviewing or checking to see how that bodily sensation feels, or maybe trying to actively replace the obsessive thought with another thought.
Given the lack of understanding, one of the biggest barriers to treatment is the isolation that the patients feel. Meds are helpful, and there are specially licensed therapists for treating serious OCD. Regardless of the subtype, treatment essentially the same. The gold standard of treatment is exposure and response prevention therapy, or ERP, which is sort of a combined approach. I’ll talk more about that later, but as with anything else, acceptance is key. If you’re a person that thinks about blinking, then you’re a person that thinks about blinking. Hopefully treatment stops that, but if it doesn’t, are you going to let it run your life? Once there’s acceptance, that then becomes the question, as opposed to being concerned about it. That’s where mindfulness comes in. If you pay attention to your blinking, then that’s one thing, but if you’re worried about it, that’s kind of pointless. You’ve proven you’re doing it right, and that your blink isn’t broken, about 18 times in the last minute alone. Did you know that that’s the average number of times a person blinks in one minute, 18? Sounds like a lot. Anyway, there’s a difference between watching your behavior in a mindful way, and not trying to change it, versus actively thinking about it and trying to figure out if you’re doing it the “right” way. Personal acceptance of anything means being less judgmental about the internal experience of it. Admittedly, it’s a lot easier said than done. There shouldn’t be any trivializing how upsetting it would be to think about blinking, or swallowing, or where a mole is. These things may seem banal to you, but they may be the center around which another person’s life revolves. When you think about accepting anything, but especially OCD, maybe just ask yourself, what would my patient Jesus do?
Next week… more OCD subtypes! I hope you enjoyed this blog and found it to be interesting, and of course, educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Hello, welcome back to the blog, people! We’re continuing our look at thyroid disease. Last week, we took a pretty deep dive into diagnosis, especially lab tests. I mentioned that the TSH (thyroid stimulating hormone) test is considered by most practitioners as the gold standard test, as it regulates the release, and therefore balance, of the thyroid hormones T4 and T3. A T4 (thyroxine) test is commonly ordered with the TSH, as together, they offer a good snapshot of overall function, as well as suggest a cause for an abnormality. A T3 (triiodothyronine) test is usually only ordered to support a diagnosis of hyperthyroidism, as it’s not very helpful in hypothyroidism, since it’s the last hormone to be affected. Thyroid antibody tests can also be run to help identify different types of autoimmune thyroid conditions, such as Hashimoto’s hypothyroidism and Graves’ Disease hyperthyroidism.
There are different recommendations on how to screen for abnormal thyroid hormone levels, and your health insurance may “help” determine what tests are done and when. In most US states, and probably elsewhere as well, you can order your own thyroid tests on the interwebs, and this may be a more affordable way to have them done. You can find plenty of analyzers there too, so you can enter your results if you’re confused about what they mean.
A TSH alone can be a sufficient screening test for abnormalities, and it can be followed by a T4 and/or T3 should any be found.
Generally speaking, an elevated TSH, with or without low T4 or T3, is associated with hypothyroidism, and a low TSH with high T4 and/or high T3 is associated with hyperthyroidism. I should note that in order to receive a diagnosis of hyperthyroidism, lab tests must demonstrate that one or both thyroid hormones are elevated, so there must be a high T3 and/ or T4.
In addition to lab tests, diagnosis of thyroid disease generally involves a review of signs and symptoms, physical examination of the neck to feel for masses or nodules, while noting the condition of hair, nails, and eyes, with imaging and ultrasound tests to further evaluate findings if needed. A primary care physician can make the diagnosis and formulate an effective treatment plan, but a physician who specializes in the thyroid, an endocrinologist, is very helpful, and may be required in some cases.
Once diagnosed, treatment is aimed at correcting the imbalance and returning thyroid hormone levels to normal, in order to alleviate the symptoms the person is experiencing. This can be done in a variety of ways, depending on the cause, and whether the imbalance has resulted in a hyper- or hypothyroid condition.
Several treatments for hyperthyroidism exist. The best approach depends on your age, personal preference, physical condition, and the underlying cause and severity of your disorder.
Taken by mouth, radioactive iodine is given to a large percentage of adults with hyperthyroidism, as it effectively destroys the cells of your thyroid, preventing it from making high levels of thyroid hormones. It also causes the gland to shrink, which may make it a good choice in cases of goiter. Symptoms usually subside within several months, and excess radioactive iodine disappears from the body in weeks to months after treatment is discontinued. This treatment may cause thyroid activity to slow enough to actually be considered underactive, meaning that it may result in secondary hypothyroidism; so you may eventually need to take medication every day to replace thyroxine. Common side effects include dry mouth, dry eyes, sore throat, and changes in taste. Precautions may need to be taken for a short time after treatment to limit or prevent radiation exposure to others.
Medications like methimazole (aka Tapazole) and propylthiouracil gradually reduce symptoms of hyperthyroidism by preventing your thyroid gland from producing excess amounts of hormones. Symptoms usually begin to improve within several weeks to months, but treatment typically continues for at least one year, and often longer. For some people, this clears up the problem permanently, but other people may experience a relapse. These drugs can be pretty gnarly. If you’re allergic, you can develop skin rashes, hives, fever, or joint pain. They can make you more susceptible to infection, and can cause serious liver damage, sometimes even leading to death. Because propylthiouracil has caused far more cases of liver damage, it should really only be used when you can’t tolerate methimazole.
Beta blockers such as propranolol and Inderal are usually used to treat high blood pressure. They don’t affect thyroid levels, but they can ease some symptoms, such as tremor, sweating, rapid heart rate, and palpitations. For this reason, your physician may prescribe them to alleviate symptoms until your thyroid levels are closer to normal. For patients with temporary forms of hyperthyroidism, ie thyroiditis, inflammation of the thyroid gland, beta blockers may be the only treatment required. Once the thyroiditis resolves, they can be discontinued. These medications are generally well tolerated, but aren’t recommended for people who have asthma, and side effects may include fatigue and sexual dysfunction.
In a thyroidectomy, most of your thyroid gland is permanently removed. If you’re pregnant, can’t tolerate antithyroid drugs, and don’t want or can’t have radioactive iodine therapy, you may be a candidate for thyroid surgery- although this is usually an option of last resort, as it is permanent. Risks of this surgery include damage to your vocal cords and parathyroid glands, those four tiny glands situated on the back of your thyroid gland that help control the level of calcium in your blood. Postoperatively, you’ll need lifelong treatment with synthetic hormone to supply your body with normal amounts of thyroid hormone. If your parathyroid glands are also removed, you’ll need medication to keep your calcium levels normal as well.
If you have hypothyroidism, low levels of thyroid hormones, the main treatment option is to replace the hormone. Daily use of the synthetic form of thyroid hormone thyroxine, called levothyroxine, ie Levo-T and Synthroid, restores adequate hormone levels, and reverses the signs and symptoms of hypothyroidism. Determining proper dosage may take time, but you should start to feel better soon after you start treatment. To determine the proper initial dosage, your physician may check your TSH level after six to eight weeks. With a proper diet, the medication will gradually lower cholesterol levels elevated by the disease, and may also reverse any weight gain. Treatment with levothyroxine will be lifelong, but because the dosage you need may change, your physician should check your TSH levels periodically as needed. If you have coronary artery disease or severe hypothyroidism, your physician may start treatment with a smaller dose and increase it gradually. This progressive replacement allows your heart to adjust to the increase in metabolism.
Having excessive amounts of this hormone can cause side effects, such as increased appetite, insomnia, heart palpitations, and tremor or shakiness. It causes virtually no side effects when used in the appropriate dose and is relatively inexpensive, but try to stick to the same brand, as there can be some variances in dosing. Don’t skip doses or stop taking it because you’re feeling better; if you do, your symptoms will return. Food hinders absorption of levothyroxine, so it should be taken on an empty stomach at the same time every day. Ideally, you take it in the morning and wait one hour before eating or taking other medications. If you take it at bedtime, wait four hours after your last meal or snack. Certain medications, supplements, and even some foods may seriously affect your ability to absorb it. Tell your physician if you eat large amounts of soy products or a high fiber diet, or you take other medications, such as iron supplements or multivitamins that contain iron, aluminum hydroxide, which is commonly found in antacids, and calcium supplements.
Thyroid Disease: Prognosis
Generally speaking, even if you have a thyroid disease, you can usually live a normal life without many restrictions, as long as you have appropriate treatment. The overall prognosis varies depending on your diagnosis. With hypothyroidism, your levels and overall symptoms may improve with medication, but it’s a condition you’ll be treating for the rest of your life. You’ll take medication daily, and your physician will likely monitor you to make adjustments over time if needed. But this is not necessarily the case with hyperthyroidism. If antithyroid medications work, then your thyroid hormone levels will most likely return to normal without any further issues. That said, once you have any form of thyroid disease, your physician may need to monitor your condition with occasional blood tests to make sure your thyroid hormones are at optimal levels.
Thyroid Disease: Complications
As with any disease, early diagnosis and treatment of symptoms improves the long term outlook. The complications of undiagnosed, uncontrolled, and/or inadequately controlled thyroid disease can lead to a number of health problems that can affect your long term quality of life, and in some cases, can even be life threatening.
Even if you are under treatment or have received treatment for thyroid disease, if you start to notice signs of any of the following issues, see your physician to check your thyroid levels, or seek emergency treatment when appropriate.
Some of the most serious complications of hyperthyroidism involve the heart. These include a rapid heart rate, a heart rhythm disorder called atrial fibrillation, which increases your risk of stroke, and congestive heart failure, a condition in which your heart can’t circulate enough blood to meet your body’s needs.
Excess thyroid hormone interferes with your body’s ability to incorporate calcium into your bones, so untreated hyperthyroidism can lead to weak, brittle bones and osteoporosis.
People with Graves’ Disease can develop eye problems, including bulging, red or swollen eyes, sensitivity to light, and blurry or double vision. When left untreated, severe eye problems can lead to vision loss.
Red, swollen skin
People with Graves’ disease can develop Graves’ dermopathy. This affects the skin, causing redness and swelling, often on the shins and feet.
Thyroid storm, aka thyrotoxic crisis, is a life threatening hypermetabolic state induced by excessive release of thyroid hormones, resulting in a sudden worsening of symptoms. An individual’s heart rate, blood pressure, and body temperature can reach dangerously high levels, causing delirium. This requires urgent medical attention, as without prompt, aggressive treatment, thyroid storm is often fatal.
Constant stimulation of your thyroid to release more hormones may cause the gland to become larger, a condition called goiter. Although it’s generally not painful, a large goiter can affect your appearance and may interfere with swallowing or breathing.
Hypothyroidism puts you at greater risk for heart disease and heart failure, and can raise your levels of LDL, low-density lipoprotein or “bad” cholesterol.
Mental health issues
Hypothyroidism can cause depression that becomes more severe over time. You may notice decreased interest in activities you used to enjoy. It can also cause slowed mental functioning, and memory or concentration lapses.
Long term uncontrolled hypothyroidism can cause damage to your peripheral nerves that carry information from your brain and spinal cord to the rest of your body. Peripheral neuropathy causes pain, numbness, and tingling in affected areas, most often the legs and feet.
Uncontrolled hypothyroidism can cause you to have aches and pains in your joints and muscles, as well as tendonitis.
Low levels of thyroid hormone can interfere with ovulation, which greatly impairs fertility. In addition, some autoimmune causes of hypothyroidism can also impair fertility.
Myxedema is a life threatening condition that can result from undiagnosed hypothyroidism. The term “myxedema” can be used to mean severely advanced hypothyroidism. But it’s also used to describe skin changes in someone with severely advanced hypothyroidism. The classic skin changes include swelling of your face, including lips, eyelids, and tongue, and/ or the swelling and thickening of skin anywhere on your body, but especially on your lower legs. Signs and symptoms include intense cold intolerance and drowsiness, followed by profound lethargy and unconsciousness. In people with severe hypothyroidism, trauma, infection, exposure to the cold, and certain medications can trigger a life threatening condition called myxedema coma, which causes a loss of consciousness and hypothermia, extremely low body temperature. If you have signs or symptoms of myxedema, you need immediate emergency medical treatment.
That’s all for this week, folks. Next week will be devoted to thyroid disease and mental health issues.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
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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.
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!
Alprazolam Use Disorder
Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right.
If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder.
Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction.
This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug.
Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:
-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.
-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.
-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.
-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.
-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.
-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it.
-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use.
-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.
-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.
-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.
As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.
Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:
-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.
-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.
-Continued Xanax use despite hazardous circumstances.
-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.
-Continued Xanax use despite experiencing one or more negative personal outcomes.
-Using more Xanax or using it for longer than recommended or intended.
-An inability to stop using Xanax despite an ongoing desire to do so.
-Obsessive craving for Xanax.
-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.
-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.
-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.
These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
Please feel free to share the love! Share blogs and YouTube videos with family and friends.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
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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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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Thank you and be well people!
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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Steroids: Seductive Today, Sinister Tomorrow
An Appointment and Cautionary Tale
I got a new patient who came into my office- we’ll call him Rocky- and he said to me, “Ya know, I’m here because I’ve been having trouble with rage.” And then he just looks at me expectantly. After eleven words, he’s waiting for me to open my desk drawer and take out my magic wand. Bing! You’re cured! He’s clearly never been to a shrink. We talk here.
In all honesty, I didn’t even need a magic wand at that point, because between those eleven words and my eyes, I had already diagnosed him. I should’ve waved my pen at him like a wand and said “Stop using steroids. You’re cured.” Instead, I said, “Let’s explore this a bit.”
He says “I’m worried, I might be bipolar….” How did I just know he was going to say that? It is so typical. At 32 years of age, Rocky’s a big boy, unnaturally bulky, looks like he’s been lifting a lot of weights. Compared to his trunk, his head looks like somebody washed it in hot water. His face is oily, pock-marked with acne and scars. I’m noting all these things, jotting them down on my pad, jot jot, as he goes on. “…and I like to go to the gym to blow off some steam…” Rages jot. Acne jot. Oily skin jot jot. Bacne jot. Receding hairline jot jot. “…and lately everybody just pisses me off and I can’t…” Angry jot jot.“…I mean, I can bench a lot. So the other day, I was with my buddy and I finally figured it out; I realized that he’s jealous; that’s his problem with me…” Paranoia jot jot. “…and I know I’m his competition. I undercut him all the time. He would love to see me fail and close up shop, but…” Ah ha. Psychotic? jot jot. All of this is very typical with steroid use and abuse. “…so anyway, I can push harder, lift more, ya know? I work at it! The steroids help, but the work is all me.” Bingo! Finally! Now we’re getting somewhere.
So tell me about that…the steroids. Who’s prescribing? “Oh no, I am buying it at the gym.” Well, how much are you using? “I’m doing 200mg every two days.” Injecting testosterone cypionate, 200mg Q 2 days jot jot jot jot jot. Buys at gym jot jot. And how long have you been using them? “Uhh, maybe about three years?” Times 3+ years jot jot jot. Do you think maybe you have a problem? “Oh, no. No.” Denies problem jot jot. I explain that he’s at a max dose for someone who has virtually no gonad function. Confusion jot. I explain that means someone who produces no natural testosterone. I spell it out. You’re taking the max dose that a person with no gonad function, zero testosterone would take, and that’s on top of your normal testosterone levels. Or I should say your natural testosterone levels. So you would be way above normal- ten times normal levels or more. And you’re wondering why you’ve been having these rages? Losing control? Loses control jot jot. Banging on s÷=%t at home jot jot jot. Screaming at wife jot jot. Have you ever hit her? “No. I haven’t hit her. But I’ve wanted to hit something. My fists are clenched and I want to tear something apart with my bare hands.” Denies hitting wife jot jot. Clenched fists jot jot jot. Believes he’s bipolar jot jot. I tell him that he’s not bipolar. Steroids are the problem here. He says, “No, it’s not. Can’t be.” No. It’s the steroids, I’m sure. Rocky says, “Ya know, I’ve been reading, and I’m saying it’s probably bipolar.” He’s just holding on to the bipolar excuse. Addicted jot jot. I mean, he would rather be bipolar- actually fight to be bipolar- than admit that his precious steroids are the sole root of his many issues. Denial jot. Steroids don’t cause a typical high, it’s more of an exhilarating positive feeling, an energized, almost super power feeling. For dudes like Rocky, with his temperment, he is all about that musclebound feeling of power.
Have you noticed your hairline is receding. “Oh. You can tell?” Umm, yeah, I can tell- it’s like three inches back from where it should be- that’s why I mentioned it. That’s what steroids do. “Really?” Really. Bipolar doesn’t do that. Have you noticed your oily skin and acne on your back? “Yeah, I have.” Yeah. Bipolar doesn’t do that either. Guess what does. You get really argumentative and pissy. Some people actually become psychotic. “Oh, I’m not psychotic, man.” Really? But, you know, in our conversation, you said you’re always worried about people at the gym being jealous and giving you side eye and you said people are trying to destroy your business. You know, maybe you’re getting a little paranoid. “Oh, I am not paranoid.” Uh huh, yeah. I tried to explain. When you’re getting paranoid, you don’t know you’re getting paranoid. He saw all these deep meanings and he was making these deep connections, why people would be tracking him and why government agencies would be interested in monitoring his business. Rocky is in the nursing home business. He’s not even actually running a nursing home, he just provides services to nursing homes. It’s not like he’s involved with any government agencies. He’s contracted to bring in ancillary services to nursing homes. It’s a fairly big business and he’s been pretty successful financially, but there was no root in reality for the paranoia he was demonstrating.
I asked him if he noticed anything else, like maybe breast enlargement? “Ahh, maybe a little bit, but no big deal.” Mmm hmm. + breast development jot jot jot. He says, “You know, my muscles got bigger, I got leaner, and my endurance increased. I felt trimmer, more energetic.” You said your endurance went up, how much cardio do you do, Rocky? He says, “Well, I used to do more, but man, I’ve gotten so much bigger that it’s hard to breathe when I do heavy cardio, you know?” No, I don’t know, because I don’t abuse steroids. Androgenic erythrocytosis jot jot jot. That means that you have increased the number of red blood cells in your blood, so your blood becomes thick and viscous like oil. You have so many red blood cells, it’s tough for your heart to beat, it’s tough for your lungs to get oxygen, because there’s drag from the increased viscosity, so when you do cardio, you can’t breathe. “Yeah, yeah. I can barely run. I used to do triathlons. I can’t do them anymore, but I can lift way more weight.” Yeah, because not only are the steroids making your blood thick like oil with RBCs, the thick blood makes the left heart ventricle- the one that does most of the pumping of the blood- thick. It’s a muscle, so the thick viscous blood overworks it as it tries to pump that thick gross blood through, so it makes that left ventricle wall thick, really thick. So instead of having a thin elastic pump that pumps blood in and out easily, you get this thick, wide left ventricle wall that cannot pump effectively. It enlarges the left ventricle wall, so you can’t pump good oxygen rich blood through. It’s called hypertrophy. With all those factors going on, it’ll cause hypertension. “Oh, yeah, I take medicine for that.” Like no, big deal. Aah, I just take medicine for the damage that I’m causing myself. Duh! + hypertension jot jot jot. + medication jot jot. And did you tell the doctor that prescribes that med that you’re using steroids? “No.” Nice. Prescribing Dr. unaware of illicit steroid use jot jot jot jot jot. Do you know that hypertension leads to kidney disease? “Really? My kidneys work good I think.” I’m thinking ‘maybe for now’ to myself. You think you look good on the outside, although you’re balding, your skin is oily, you have pitted acne scars on your face and acne on your back and you’re growing boobs like a teenage girl and your testicles are microscopic and you have low to no sperm and your penis doesn’t work… and you can’t breathe with any amount of exertion because your blood is thick and gross so your heart is all enlarged and your blood pressure is so high you have to take medication like a man more than twice your age. And you’re causing all of it! Through your steroid addiction. And as if the physical side isn’t bad enough, now it’s affecting you mentally. You’re paranoid, on the verge of psychosis…really you’ve got a toe or two over that line if you want the truth. So no matter how big your muscles are, no matter how good you think you look (and my raised eyebrows were clearly saying that was debatable) you are destroying your body. “Um, like what? How?” Now he’s really listening. I continued. Do you understand what hypertension actually is and does? Cause and effect? How about atherosclerotic plaques. What are those? What do they mean? The arteries in your heart become lined with plaques that are basically made of fat. These fat plaques are sticky, so as your thick gross blood slogs through the arteries, the fat plaques gather and narrow the arteries, so you cannot push blood through the arteries. Eventually, they clog off. It’s like a tunnel being filled with more and more muck, so there’s not enough room for blood to flow through and you get a heart attack and die. But before that happens, you’re incapacitated with high blood pressure because your thick oversized left ventricle is trying to push your thick gross blood through arteries that are filled with fatty muck, athersclerotic plaque filled arteries. “I didn’t know all that.” I’m sure you don’t, but I’m not done educating you yet. It gets better. Well, actually worse.
Education jot. Steroids decrease HDL, which is the good cholesterol that helps keep your arteries open. And it also raises the LDL, which is the bad cholesterol that causes the fatty plaque to build up. So lowers the good while raising the bad. Got that? “Yep. Got it.” So that causes hypertension, and makes you prone to heart attacks and strokes. Did you know that hypertension also makes your kidneys malfunction? I didn’t think so. Right now, your kidneys are trying to pump under hypertension, and that kills them. The gross viscous blood thick with red blood cells kills them. So your kidneys shut down. Do you like to be able to take a piss? To be able to clean your thick slaggy blood of all the toxins you make? He nodded that yes, he rather liked to be able to take a piss and clear his thick slaggy blood of all the toxins he makes. I thought so. Enjoy it while it lasts. Before long, a machine will do that for you: four hour sessions, three times a week…if you’re lucky enough to live that long. If the massive heart attack doesn’t kill you first. Honestly, Rocky looked like he was about to have a heart attack right now. I know I’m hitting him pretty hard with all of this at once, but this guy was in a romantic relationship with his precious steroids, and I need him to break it off, clean and quick like. But wait, there’s more!
Now, with all this bad stuff going on, the little vessels throughout your body do not pump blood as well because they are clogged and they are hypertensive. So all those tissues, joints, and bones are starved of nutrients and oxygen. You get something called avascular necrosis. Avascular means without vasculature- blood vessels- and necrosis means death. It’s everywhere, but especially in the hips, with the ball and socket joint. The little vessels that feed the balls of your hip joints, where the femur meets your hip? Hello, the blood supply gets occluded- it gets starved- and then it gets dead. So you can recognize all the steroid abusers out there: they’re the 40 year olds using wheelchairs and walkers, whining about the pain in their hips. Balding, acne, boobs, erectile dysfunction, heart problems, kidney issues, disability, chronic pain. On and on. Oh yeah, it’s pretty bad, but it gets worse. His face fell. I couldn’t let up now. You enjoy being able to lift weights? You enjoy being physically capable? Like a zombie, he mumbled on a sigh “Yes…” I’m glad you do. But don’t get too used to it. Because if you keep this crap up, keep injecting that garbage, you’ll build your muscles up beyond what your body can handle. You’ll build them up- your muscles will get bigger- but your ligaments and tendons can’t be built up, and they can’t support these unnaturally large muscles. Do you know what muscles without ligaments and tendons do? Not much. Without healthy ligaments and tendons, big muscles are useless for anything but causing pain, debilitating pain. When you’re pumping iron, lifting really heavy weights, your ligaments and tendons get damaged. In no time, the muscle size supercedes the ability of the damaged ligaments and tendons, so you get irreversible chronic muscle pain. Sounds great, right Rocky? Oh, wait, and to top it all off, now you’re having psychological effects. You’re having rages. You want to tear something apart with your bare hands. You said that. What’s scary is that right now, at this moment, you have the physical ability to do that. If somebody pushed you too far on a bad day, you might go there. You could kill someone. I’ve seen it happen to a patient. A guy a lot like you. He came in here young and dumb and I explained everything to him, just like I’ve done with you. For several years, I begged him to stop. He refused to listen; didn’t believe me. Ultimate in denial. He’s in prison now for the next 30 years; that equals a life sentence for him. It’s scary. What’s even scarier is that if you keep this crap up, keep sticking yourself with that needle, you won’t be able to tear somebody apart for long. You might want to, but you’ll be too debilitated. That guy in prison? He’s in a wheelchair now 90% of the time. He uses a walker sometimes- when he can stand the pain- which isn’t often.
I’ll make this very plain. You are addicted to steroids. They are physically wrecking your body, the body you seem to worship. Oily skin, acne, bacne, boobs, receding hairline, balding, teeny tiny testicles, a penis that you can’t get up…and no sperm to come out of it anyway. And that’s just the stuff on the outside that people can see! Your insides get wrecked too. Thick slaggy gross blood, hypertension, atherosclerosis, heart attack, stroke, kidney dysfunction, erectile dysfunction, avascular necrosis, chronic pain. And now you’re raging, scaring the crap out of your wife, you’re paranoid, becoming psychotic. You have nothing positive happening in your life. So it’s your call, Rocky. I can help get you off the train here before it runs your ass over. He was nodding very slowly, but clearly shell-shocked. Look, how about this. Don’t use for two weeks and see me again. You’ll have some time to digest all of this. Can you do it? If you can’t- if you feel like you’re gonna hit that needle- I’ll see you sooner. Here’s my cell number. Call me anytime, but especially if and when you’re tempted to use. Deal? “Deal.” We shook on it.
Dx: steroid addiction, assoc features jot jot jot jot
Pt agrees to d/c use jot jot jot
F/up 2 weeks, will call/ see sooner prn jot jot jot jot jot
Here’s the bottom line on steroids people. Your body just does not like these drugs in excess. There may be some use for them in people with anemia, in people who have wound healing problems, a temporary use in people with HIV or cancer who do not want to eat, and in muscle wasting diseases for short periods of time and in very regulated doses, okay…fine.
But, for my Olympic athlete patients, my professional athlete patients: you all know who you are. All of my Rocky’s out there: cut it out! You’re sterile, can’t get it up, scared everyone’s gonna see your breasts, hello, they are! I know you’re saying ‘but I cycle them on and off, doc!’ I say bullshit. No, it causes permanent damage to heart, kidneys, tendons, and ligaments. Not to mention the cosmetic aspects: the oily skin, the acne on your face and back, the balding, receding hairline… and you say ‘oh, but to minimize the breasts I use an estradiol’ (an anti-estrogen, because testosterone breaks down to estrogen, so if you use an anti-estrogen in someone who is abusing testosterone or testosterone-like drugs, you will not get the breast enlargement) Yes, that’s true. I’ll give you that. But, you still get all that other crap, guys! Hellllo!! All my elite athletes, you all whine like ‘No, no, no, I need it to stay competitive, because everybody else is doping!’ Whatever! You are addicted to the high, the performance, and the cosmetic enhancement. You get big muscles, tiny balls, and tinier brains. You also get limp and sterile, permanent damage to the ventricles, the heart, and the kidneys, hypertension, and its host of other problems. You are predisposing yourself to coronary disease, heart attack, and stroke. You become delusional, and you fly into rages when the wind blows.
As you are my patients, I’ve probably told you about other patient stories. For those that haven’t heard them: one steroid abuser was very paranoid and psychotic, but of course didn’t know it, because you will not see yourself becoming psychotic. He was stopped at red light. I don’t know what he was doing, but when the light changed green, he didn’t go right away. So the car behind him honked. He started ticking like a time bomb, and the car kept honking, but for whatever reason, he still didn’t go. Instead, with the light still green, he got out of his car. With a golf club. He went off, banging on the guy’s car with the golf club, and he just didn’t stop. Eventually, they called the police. The police came and they had to subdue him with a tazer because he was out of control. When he was transported to the emergency room, he continued there, even continuing to spit and scream, even after being put in four-point restraints. Finally, he had to be pharmacologically restrained with a freaking rhino dart. Unbelievable. I mean, he was all black and blue, like he had been beaten, but he did it by thrashing, all by himself. His whole affect was totally inappropriate. I know that some people are beaten by police for no reason; they don’t deserve it, but this maniac was taking every opportunity to hit the police officers for absolutely no reason. In the hospital, he was arguing with nurses, disturbing the entire emergency department for no reason. His wife finally came in, but even she couldn’t calm him. He just lost it, in every sense. He was (or had been) on the road to being Mr. Olympia or some such title. He was 190 pounds, and bench pressing over 450 pounds. It was just crazy. Eventually, but not long after, he went into kidney failure. But it wasn’t from the steroids. Yeah, right. Denial!! jot jot
You know, it also causes immune suppression, so you don’t fight off pathogens like viruses, like COVID-19, like any bacteria. I had someone who had a heart attack and died. He was 25. Another stroked out in his late 30’s. These patients are Olympians, professional athletes, and really elite level people. They’re so hyper-disciplined about their diets and their training and supplements and sleep patterns and all of that. But they’re abusing steroids. It’s a crazy dichotomy. Some have made it. Big success stories that stopped and then did it the right way. But many don’t. Right now I have a 45-year-old man who is just going into kidney failure. And the one with psychosis that killed the guy that set him off. He’ll die in prison. Now I have Rocky. I hope I opened his eyes.
Remember, people… just because you cannot see what’s going on doesn’t mean the steroids aren’t destroying you. They are. But you can get there without them. And PS, for those that are wondering, there is a steroid withdrawal: headaches, drowsiness, decreased appetite, weight loss, fatigue, depression, dizziness. It’s a mess when I get them off, especially when they do high dose. It takes two to four weeks, and they are miserable, cranky, irritable, and obnoxious people to deal with when they are in withdrawal. I use benzodiazepines, things to help them sleep; I sometimes add anti-psychotics because they can’t see themselves drifting to the psychotic lane, sometimes hearing voices and seeing things. It’s a spectrum. And lots of misreading events in reality… “Those people are talking about me. They’re plotting against me. Those police officers are here to get me, or that group of people talking over there are planning something against me or these workers are not working because they are all in a grand plot against me. They are very faint signs and forms of psychosis. Hearing voices and seeing things, disorganized speech and behavior is the extreme. But there can be the unextreme, the misreading, the over-emotional abnormal response to normal events, thinking people are plotting.
Probably from age 10 to 30 is when most people started and abused the steroids. And too often, it’s a one way trip, once they start, they get lost in it. You know, “I am superman now” and they don’t stop, and then they stroll into my office and then I deal with them when they are 45 to 50 and that’s when their kidneys shut down, when they get a heart attack, when they are debilitated with degenerative disk disease from lifting too heavy weights, their ligaments and tendons go, they become sterile, they cannot have kids, they’re in constant horrible chronic pain. They have heart problems and kidney problems, and that’s what gets them. If they have heart and kidney failure, to the point where the organs have just given up, that’s what kills them.
Hopefully not Rocky jot jot jotLearn More
*Reader Discretion/ Age Advisory*
Pedophilia: Predators in Your Back Yard
Pedophilia has become a topic of increased interest, awareness, and concern for both the medical community and the public at large. In my nearly thirty years of practice, I am sad to say that I have treated far too many victims of pedophilia and sexual predation of every unimaginably horrific kind; those narratives are indelibly etched into my memory. In the last decade or so, increased media exposure, new sexual offender disclosure laws, web sites listing the names and addresses of convicted sexual offenders, and increased investigations of sexual acts with children have increased public awareness about pedophilia. That’s definitely a good thing. The passing of laws, like Megan’s Law in 1996, authorizes local law enforcement agencies to notify the public about convicted sex offenders living, working, or visiting their communities, and has helped expose pedophiles living amongst us, and this allows parents to better protect their children.
But in the age of the internet, cyber predators can stalk their victims from a safe distance before ever suggesting they meet. They can be very cunning, and they often lie about their age/ gender/ status/ likes/ dislikes; they play online team video games to attract children, and they make up customized stories, tailor made to lure specific victims. Because of these realities, it’s important for everyone to understand pedophilia, its rate of occurrence, and the characteristics of both pedophiles and sexually abused children.
In recent years, the law has taken a tougher stance on dealing with pedophiles and sexual predators, and exposure is often the order of the day for the media, as these cases play out in the wide open. You need only note the allegations of sexual predation in the priesthood or in the Boy Scouts to realize that predators are everywhere, even in some unlikely places. Who can forget Jared Fogle, the smiley faced Subway spokesman who lost 200-plus pounds, supposedly by eating only sub sandwiches? Who would’ve ever guessed that he was actually a predator, targeting children of middle school age, a demographic he often found himself in the company of during his well paid and nation wide lectures about healthy eating habits. That age group was his preference, but he wasn’t discriminatory by any stretch of the imagination. He made that quite clear in the surreptitiously taped conversations he had with a “friend” who was actually working undercover for the FBI. I was physically repulsed when I heard those recordings, and even as I remember them now, I can actually taste and feel the bile rising in my throat. Ultimately, in 2015, Fogle was adjudicated as guilty of charges of child pornography and having sex with minors, and was sentenced to more than 15 years in prison. He apparently passes the time by filing frivolous lawsuits against the Feds and Donald Trump, all without the aid of his attorney.
A name synonymous with sexual predation since the millennium, especially here in Palm Beach County, is of course Jeffrey Epstein. This multimillionaire financier dirtbag was a predator incarnate, who, over a period of at least 15 years, lured a procession of girls as young as 14 to his Palm Beach mansion to perform nude bedroom massages for money; massages that often ended with Epstein groping or sexually assaulting the girls. All told, investigators found evidence that Epstein preyed on at least 80 girls total, here and in New York.
One of my patients, I’ll call her Dominique, was one of at least 15 girls from Royal Palm Beach High School alone, who Epstein sexually exploited in that aforementioned bedroom 15 years ago, and she will live with those memories forever. At the time, it was a not-so-well-kept secret among RPBHS students, teachers, and administrators that girls were being sexually exploited in return for gifts of cash, expensive cars, trips, and shopping sprees courtesy of their Sugar Daddy; but nobody reported their concerns to authorities at the time. Epstein masterminded an underage sexual assault scheme, paying girls $200 for each new victim they recruited, instructing them to target vulnerable girls, often on the verge of homelessness and desperately needing money, and “the younger the better.”
Dominique drove a convertible Mercedes, courtesy of Epstein, flew in his jet to travel on trips with him to Mexico and the US Virgin Islands, and met some very famous and influential people, including a former POTUS, a ridiculously wealthy computer nerd, and one particularly slimy smarmy one that calls Britain’s monarch “Mummy.” Dominique told me that she and the other girls would skip school, hang out at his house, float around in the pool, go out on the boat, or head to Worth Ave for lunch, followed by black card shopping. The girls also drank alcohol and did drugs, made available by Epstein, of course. Consumption of alcohol and drugs is a way that predators groom their targets, to seduce them, make them more comfortable and less inhibited, and hamper their ability to resist.
The girls traded sexual favors in exchange for all of the cash and material gifts he gave them, and Dominique said that oral sex and intercourse were just an acceptable part of the deal; it was very much a simple transaction. The better the girls were, the more they pleased him, the more money and gifts he would give them. It was a calculated and infinitely alluring arrangement, all by Epstein’s diabolical design, and before she knew it, Dominique was in over her head, but yet unable to cut ties. Thankfully, the law intervened and cut those ties for her, for once and for all. Now she’s moving on with her life and looking forward to the future, all while still dealing with the extreme damage done in the past.
When any of his girls became nervous or ever questioned activities, Epstein had a remedy for those circumstances as well. He used his “assistant” Ghislaine Maxwell as a beard to make the girls feel more comfortable; sort of an older sister vibe, a figure for them to look up to and emulate. She played a key role in the scheme, and she’s currently awaiting trial on sex trafficking charges and who knows what else. In his first two charges here in Palm Beach County (soliciting a minor for prostitution and procuring minors for prostitution) Epstein made a sweetheart deal with the Florida DA’s office, spending 13 months (of an 18 month sentence) in a private wing of the Palm Beach County Jail on Gun Club Road, but he was still allowed to go to “work” on Palm Beach Island six days a week for twelve hours each day. I consider that incomprehensible. Then after he served his tiny time here, he was facing more charges in New York for sex trafficking of girls as young as 14 and conspiracy to commit sex trafficking. Apparently, the Feds also had a lot more charges up their sleeves, and were investigating every single thing in his life. At his arraignment in New York, Epstein pleaded not guilty to all charges. If convicted, he would have faced up to 45 years in prison. But, evidently, he couldn’t take the heat. He was found hanging in his cell by the guard that may have been too busy sleeping to guard him. The coroner’s manner of death was listed as suicide, but his family and other conspiracy theorists say he was murdered. Either way, he’s gone, as is the opportunity for his victims to face him in open court and tell their truths.
Below, I define pedophilia and associated terms, and discuss a generalized profile of a typical pedophile or sexual predator, and go over what you can do to protect children from such predators.
Pedophile, Hebephile, Ephebophile, Predator, or Child Molester?
I want to clarify some terms related to pedophilia. A pedophile is a person who is primarily attracted to prepubescent children, usually defined as under the age of 12. A common mistake is to define a pedophile as anyone attracted to another person that is below the age of majority; but this definition would include people attracted to teens, which is incorrect. Even a late adolescent (like 15 or 16 years old) can be a pedophile, if they have sexual interest in prepubescent children. A hebephile is a person who is primarily attracted to others in their young to mid-teens, while an ephebophile is a person who is primarily attracted to others in their mid-to-late adolescence. Captain Obvious says that a child molester is anyone who molests a child, but without regard to their sexual attractions or preferences. Their act of molestation is not typically linked to sexual desire or interest. In the interest of time for this blog, I will not divide or differentiate the term predator into hebephile or ephebophile, and the terms pedophile, predator, and molester will be used interchangeably.
Pedophilia is a psychiatric disorder in which an adult or an older adolescent is sexually attracted to young children. Pedophiles can be anyone: rich or poor, young or old, of any race/ creed/ color, educated or not, and professional or not. Despite this wide array of potentially inclusive characteristics, pedophiles do often demonstrate similar attributes. Please note that these are just possible indicators, and you should never automatically assume that individuals with these indicators or characteristics are pedophiles. But noticing these characteristics in a person, in combination with questionable behavior, could be a red flag that someone may be a pedophile or sexual predator.
All parents want to protect their children from predators, but how do you do that when you don’t know how to spot one? Anyone can be a pedophile/ predator/ child molester, so identifying one can be difficult, especially because most of them are initially trusted by the children they abuse. Below, I’ll go over which behaviors and traits are red flags, what situations to avoid, and how to deter predators from targeting your child.
Understand that there is no one physical characteristic, appearance, profession, or personality type that all child predators share. They may appear to be charming, loving, and totally good-natured, while also adept at harboring predatory thoughts. That means that you can’t just dismiss out of hand the idea that someone you know could be a child predator. Anyone can turn out to be a pedophile or predator.
Most pedophiles are known to the children they abuse. Thirty percent of children who have been sexually abused were abused by a family member; that can include mother, father, grandmother, grandfather, aunts, uncles, cousins, stepparents, and so on. Sixty percent of children who have been sexually abused were abused by an adult that they knew, but who was not a family member. That means that only ten percent of sexually abused children were targeted by a total stranger. In most cases, the child predator turns out to be someone known to the child through school or some other common everyday activity, such as a neighbor, teacher, coach, clergy member, tutor, music instructor, or babysitter.
Traits of Pedophiles or Sexual Predators
-Majority are men over 30 years of age, regardless if victims are male or female
-Heterosexual and homosexual men are equally likely to be child molesters
-Notion that homosexual men are more likely to be child molesters is completely false
-Female child predators are more likely to abuse boys than girls
-Often single and/ or with few friends
-Some have mental illness, such as a mood or personality disorder
-Many have a history of physical and/ or sexual abuse in their own past
Behaviors of Pedophiles or Sexual Predators
-Display more interest in children than adults -May have a job or volunteer in a position allowing them unsupervised access to a child
-Will contrive other ways to spend time with children (act as helpful neighbor or coach)
-Tend to talk about or treat children as though they are adults
-May refer to a child as they would refer to an adult friend or lover
-Often say they love all children or feel as though they are still children
-May prefer children nearing puberty who are curious about sex but sexually inexperienced
-Common for the pedophile to be developing a long list of potential victims at any one time
-Many believe their proclivities aren’t wrong: it’s healthy for the child to have sex with them
-Almost all pedophiles have a pornography collection, which they protect at all costs
-Many predators also collect “souvenirs” from their victims, which are also very cherished
Other Noteworthy Characteristics
Look for signs of grooming. The term “grooming” refers to the process that the child predator undertakes in order to gain a child’s trust, and sometimes the parents’ trust as well. Over the course of months, or even years, a pedophile will become an increasingly trusted friend of the family; they will likely offer to babysit, take the child shopping or on trips, or spend time with the child in any number of ways. Many child predators won’t actually begin abusing a child until full trust has been gained; this exhibition of patience and restraint is unnerving in the grand scheme of things.
Child predators look for children who are most vulnerable to their tactics, whether they are shy, withdrawn, handicapped, lacking emotional support, come from a broken, dysfunctional, and/ or underprivileged home, come from a single parent home lacking supervision, or just aren’t getting enough attention at home. Pedophiles work to master their manipulative skills and unleash them on these vulnerable children by first becoming their friend; this quickly builds the child’s sense of self-esteem and brings them closer to the predator. The pedophile may refer to the child as special or mature, which appeals to their need to be heard and understood. They basically strive to give the child whatever is lacking in their home. This sounds altruistic, but in reality, it’s just another empty ploy, used by the predator to distance the victim from their family and draw them nearer to them. Often, the next step is to entice them with adult activities, like looking at sexually explicit pictures and magazines and watching x-rated movies.
Pedophiles and predators don’t only need to earn the trust of their mark; they must also work very hard to convince parents that they are a nice, responsible person and capable of supervising their child or children in their absence. They may make it seem like they’re doing the parent(s) a favor by watching them or taking them out, “Oh, I don’t mind taking little Johnny to get an ice cream cone and then to the park, that way you can just relax and put your feet up for awhile.” This is how a child predator manipulates parents, instills a false sense of security, and gains their trust. Pedophiles will foster a close relationship, and even forge a friendship, with the parent(s) of a mark in order to get close to that child. That friendship with the parent(s) is just the ticket to get the predator through that front door. Once inside the home, they have many opportunities to manipulate the children and use guilt, fear, and love to confuse them. If the child’s parent(s) works, they may offer after school babysitting or tutoring, and this gives them the private time needed to abuse the child.
Pedophiles often refer to children in angelic terms; they use descriptive words like innocent, heavenly, divine, angel, pure, and other words that may describe children, but seem inappropriate and/ or exaggerated. They may also fixate on a specific feature on a child’s face or body, and talk incessantly about it, making unusual and age inappropriate comments like, “Oh, that baby girl has the prettiest lips I’ve ever seen, they look so soft, and they’re the perfect shade of pink,” or “Wow…she’s going to be really hot when she grows up and fills out,” or “I’ll bet she’s going to grow up to be a real tease, ya know what I mean?” These are examples of how pedophiles and predators sexually objectify children, by speaking to or about them in a way that is not age appropriate and is not acceptable.
A pedophile will often use a range of games, tricks, and activities to gain the trust of and/ or deceive a child. One of the predator’s main goals is to make sure the child won’t tell anyone about the inappropriate contact. What they do or say to ensure this silence depends on the age of the victim. For younger children, they may suggest a pact of secrecy; secrets are valuable to most kids, because they’re seen as something very “grown up” or “adult” and a source of power as well. For older children, the predator may threaten their victim, warning them that nobody would believe them if they told, and that people would make fun of them, and that they would lose all their friends if they told. In rare cases, the predator may even threaten bodily harm. Some predators just don’t care if the world knows what they’re doing; they feel above everyone else, like nobody and nothing can touch them, a la Jeffrey Epstein. As the relationship progresses, they incorporate some sexually explicit games and activities like tickling, fondling, kissing, and touching. The predator will behave in a sexually suggestive way, and have no issue exposing a child to pornographic material, bribing the target child, flattering them, and then worst of all, showing them affection and love. Be aware that all of these tactics are ultimately used to confuse your child and isolate them from you.
Now that you know some general traits of pedophiles and predators as well as some behaviors to be aware of and look out for, let’s move on to protecting your child from predators.
How to Protect your Child(ren)
One of the first things you can and should do is find out if, and how many, sex offenders live in your neighborhood. There are subscription services that show you everything about the offenders and then send you updates with alerts when new sex offenders are released from jail and/ or if a registered sex offender moves near you. But, unless you need all the bells and whistles for some reason, you can always go to one of several free sites that will allow you to search a sex offender database by zip code, neighborhood, and by offender name if you suspect someone specific of being a sex offender. Here is my disclaimer: while it’s good to be aware of potential predators, realize that it is illegal to endeavor to take any kind of action against registered sex offenders.
Dru Sjodin National Sex Offender Website
The Florida Department of Law Enforcement Sexual Offenders and Predators Search https://offender.fdle.state.fl.us/offender/sops/home.jsf
Another way to protect your child is to supervise their extracurricular activities. Being as involved as possible in your child’s life is the best way to guard against child predators. They will look for a child who is vulnerable and who isn’t getting a lot of attention from his or her parents, and they will cozy up to them, and then will do everything in their power to convince the parents that they are of no danger to their child. Show up at sporting games, practices and rehearsals, chaperone field trips and all other trips out, and spend time getting to know the adults in your child’s life. Make it obvious to everyone that you’re an involved and present parent. If for some reason you can’t be there for a trip or other outing, make sure that at least two adults you know well will be chaperoning the trip. Don’t ever leave your child alone with adults that you don’t know well. Remember that rule even goes for relatives too, as they can also pose a threat. The key here is to be as present as possible.
Set up a nanny cam if you hire a babysitter. Obviously, there will be times when you won’t be able to be present, so use other tools to make sure your child is safe. Set up hidden cameras in your home so that inappropriate activity will be detected. No matter how well you think you know someone, you always need to take precautions for your child’s safety.
Teach your child about staying safe online. Make sure your child knows that predators often pose as children or teenagers in order to lure children in. Monitor your child’s use of the internet, keeping rules in place to limit their “chat” time. Have regular discussions with your child about whom he or she is communicating with online. Be sure your child knows to never ever give out your address or phone number, or send any pictures to a person they met online; and that they must not ever meet someone in real life that they’ve only communicated online with. As a parent, you must know that children are often very sneaky and secretive about online behavior, especially when encouraged by others to keep secrets, so you’ll need to be vigilant about staying involved in your child’s online activity.
Make sure your child is feeling emotionally supported. Since children who don’t get a lot of attention are especially vulnerable to predators, make sure you are spending a lot of time with your child and that he or she feels supported. Take the time to talk to your child every day and work toward building an open, trusting relationship. Child predators will always ask, or demand, that their marks keep their secrets from their parents. Ensure that your children understand that if a person has asked them to keep a secret from you, it’s because they know what they’re doing is wrong. Express ongoing interest in all of your child’s activities, including schoolwork, extracurriculars, and hobbies; and let your child know that he or she can tell you anything, and that you’re always willing to talk.
Teach your child to recognize inappropriate touching. Many parents use the “good touch, bad touch, secret touch” method. It involves teaching your child that there are some appropriate touches, like pats on the back or high fives; there are some unwelcome or “bad’ touches, like hits or kicks; and there are also secret touches, which are touches that the child is told to keep a secret. Use this method to teach your child that two types of touches aren’t good, and if and when these touches happen, he or she should tell you immediately, even if the person touching them tells them that they can’t or shouldn’t tell. Teach your child that no one is allowed to touch him or her in private areas, and that they are not to touch anyone in their private areas. Many parents define private areas as those that would be covered by a bathing suit. Children also need to know that an adult should never ask a child to touch their own private areas or to touch anyone else’s private areas, and if someone tries to touch them or tells them to touch someone else, tell your child to say “no” and walk away. And again, reinforce the directive of telling them to come to you immediately if someone touches them the wrong way.
Recognize when something is out of sync with your child. If you notice that your child is acting differently for no obvious reason, pursue the issue to find out what’s wrong. Regularly asking your child questions about their day, including asking whether any “good,” “bad,” or “secret” touches happened that day, will help open the lines of communication and create an important daily dialog. If your child tells you that he or she was touched inappropriately or doesn’t trust an adult, never summarily dismiss it. Always trust your child first. Along those same lines, never dismiss a child’s claims just because the adult in question is a valued member of society or appears incapable of such things. That’s exactly what a predator or pedophile wants, it’s their stock in trade. They’re counting on adults not listening to child victims so that they can continue to get away with molesting them.
By age 12, kids should already have gotten basic sex education explained by their parents, including what everything is called, what it does, and how it works. Parents explaining it all to their kids themselves will prevent a predatory teacher or friend from misleading them about sex for their own nefarious purposes. Make sure your child already knows everything they need to know about what’s what and what is and isn’t acceptable behavior, before they are taught very different lessons and definitions through rumor and innuendo discussed on the monkey bars or over ham and cheese sandwiches in the cafeteria.
A child aged 14 and under may not recognize that there’s a difference between a grumpy teacher giving extra homework and a strange acting teacher that insists on kissing them on the cheek before leaving the room. They can’t really differentiate, because at this age, they simply file both of these things in their brain under ‘annoying.’ So if your child tells you vague stories about the teacher making sex jokes or touching them, or being ‘annoying’ and asking all kinds of ‘private stuff,’ you must consider the possibility that there might be something hinky going on. When and if a child mentions that their teacher is acting strangely, asking about their family and siblings, making them uncomfortable by grilling them for private information, and/ or is pushing for pictures, you must guide that child, and tell them how to react to, and deal with, these ‘annoying’ things.
But I cannot stress enough that you must be realistic in your approach! Telling your kids to run away screaming bloody murder if the teacher touches their back, or telling them to yell ‘no!!’ and smack the teacher’s hand away if an innocent touch grazes a shoulder as the teacher walks down the rows of desks in the classroom. Those reactions will not help the situation for several reasons. First of all, chances are that they won’t hit a teacher under any circumstances, but they surely won’t do so if that teacher is actually and truly grooming them, all while filling their head with smooth assurances that they’re a good guy, on their side, and only there to help them.
So, what’s a parent to do if they suspect something’s hinky, but have no concrete proof? If the child is age 14 and under, there are a couple of possibilities to consider. The first one is to instruct the child that if this person touches them, or asks questions or makes suggestions that makes them feel uncomfortable, that they should tell this person that they have told their parents about this issue (of inappropriate touching or making them uncomfortable with questions or whatever the case may be) and that their parents weren’t happy to hear about it. This would definitely take some serious chutzpah on the child’s part, but I think it would also empower them, and that’s never a bad thing. The second option would be to have the child deliver a message to the person that touches them, or asks questions and makes suggestions that makes them feel uncomfortable. One of the parents would create the message by getting a piece of paper and jotting a quick note on it; it should simply say ‘Stop touching my son/ daughter, Johnny Smith/ Jenny Smith’ or ‘Please stop asking my son/ daughter, Johnny Smith/ Jenny Smith so many questions, as they make him/ her very uncomfortable’ or whatever the issue may be. Then finish the note with the date and the parent’s autograph. Then the parent can put the signed note in an envelope and give it to their child, and instruct them that they are to give the envelope to the person who is touching them inappropriately, at the time they are touching them inappropriately, despite being asked to stop; or give the envelope to the person who is asking them questions and making suggestions that make them uncomfortable, at the time they are making them uncomfortable, despite being asked to stop. It is important to make sure the child gives the note to this person when they are red handedly doing what they have asked them to stop doing. This can be a very tricky situation, so make sure to give this a lot of thought. Keep in mind that employing one of these two tactics will only have a positive effect if you are absolutely sure that this person is ignoring a child’s personal boundaries and going too far with touching inappropriately or asking questions and making suggestions that make the child uncomfortable, all despite being asked to stop. You must be sure that this is a deliberate act of a magnitude that is unacceptable. One impulsive hand on the shoulder doesn’t meet the criteria to qualify here.
Remember that the most important thing you can do to protect your child is to pay attention to them and really listen when they speak. Keep the lines of communication open, let them know you’re on their side, assess their needs and desires, talk to them, and basically, just be the best parent you can possibly be. The bottom line is that if you don’t pay attention to your child, someone else will.
These days, it seems like pedophiles and predators really have the odds stacked in their favor; they get away too easily due to lack of evidence, and even when they are caught and jailed, they get out early for good behavior. One factor that works against the pedophile is that eventually, the children they molested will grow up and recall the events that occurred, and hopefully they will report them. Often, pedophiles and predators are not brought to justice until such time occurs, and even then, they get off far too lightly. That makes victims even angrier, as they feel like they are victimized twice- first by the predator, and then again by the justice system. More than anything, victims of pedophiles and sexual predators want to protect other children from the same fate that befell them.
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