Don’t sleep On This …

Don’t Sleep on this…

Hello, people! Welcome back to a brand new blog for a brand new year! It’s been a tough one for moi thus far, as I got the gift no one wants… covid. It’s been gnarly, but thankfully, I’m starting to feel more like myself again. This week, we’re starting a new series on a very important topic that I hear a lot of complaints about: sleep. Sleep is a vital part of life; we spend up to one-third of our lives doing it, and can’t live without it. It’s a lot like sex… everyone wants it, and some people get more of it than others. 

Lots of go getters and workaholics will say “I’ll sleep when I’m dead.” But the problem is that that might be sooner than you want it to be if that’s your point of view. Why is this? Why is sleep so important? What happens in our bodies and brains during sleep? Why is it so hard for some people to fall asleep, while others are out cold before their heads hit their pillows? How can we get better sleep? How does sleep- or lack thereof- affect mental health? One of my patients recently told me about her latest sleepwalking escapades. What’s that all about? These are just some of the questions I’ll be addressing in this series. 

We’ll start with the first question: why do we sleep? At the most basic level, it makes us feel better. A sleepless night usually leads to a dull, lethargic day, but a good night of sleep makes us feel more alert, more energetic, happier, and better able to function. It is as necessary as food, and one way to think about the function of sleep is to compare it to that life-sustaining activity, eating. Hunger is a mechanism that has evolved to ensure that we consume the nutrients our bodies need to grow, repair tissues, and function properly, and feeling tired essentially serves the same purpose. Eating and sleeping are not very different, and both are regulated by powerful internal drives. Going without food produces the uncomfortable sensation of hunger, while going without sleep makes us feel overwhelmingly sleepy. And just as eating relieves hunger and ensures that we obtain the nutrients we need, sleeping relieves sleepiness and ensures that we obtain the sleep we need. But the question remains: why is it necessary? What is the function of sleep? 

Despite decades of research and many discoveries about other aspects of sleep, the question of exactly why we sleep has been difficult to answer. Scientists have developed several theories, but as is the case with so many human processes, it’s unlikely that a single theory will ever be proven correct, as sleep is necessary for many biological functions. 

Inactivity Theory, aka Adaptive Theory

One of the earliest theories of sleep, sometimes called the adaptive or evolutionary theory, suggests that inactivity at night is an adaptation that served as a survival mechanism by keeping organisms out of harm’s way at times when they would be particularly vulnerable. The theory suggests that animals that were able to stay still and quiet during these periods of vulnerability had an advantage over other animals that remained active. For example, they weren’t killed by nocturnal predators and didn’t have accidents during activities in the dark. Through natural selection, this behavioral strategy of inactivity presumably evolved to become what we now recognize as sleep. But for every yin there’s a yang, and a simple counter argument to this theory is that it may be safer to remain conscious in a dangerous environment, in order to be able to react to an emergency. So there doesn’t seem to be any major advantage to being unconscious and asleep if safety is paramount. I mean, yeah, you’re less likely to be run over by a car, but it’s easier to be eaten if you’re just laying there, conveniently waiting for the predator to get you. 

Energy Conservation Theory

The energy conservation theory of sleep suggests that a main purpose of sleep is to reduce a person’s energy use during certain periods when it’s inconvenient and less efficient to hunt for food. This is backed up in our biology, as research has shown that our metabolic rate is significantly reduced during sleep, by as much as 10 percent in humans, and even more in other species. According to this theory, sleeping allows us to reduce our overall caloric requirements by spending part of our time functioning at a lower metabolism. Although it may be less apparent to people living in societies in which food sources are plentiful, one of the strongest factors in natural selection is competition for, and effective utilization of, energy resources. The theory supports the proposition that sleep is a process of natural selection; we’ve evolved to sleep to expend less energy for a certain amount of time each day. And in fact, research suggests that humans getting 8 hours of sleep can produce a daily energy savings of 35 percent over complete wakefulness.

Restorative Theory

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?

Emotional Well-Being

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. 

Weight Maintenance

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.

Immune Health

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.

Heart Health

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!

MGA

Learn More

Scariest Psych Disorders,The Finale

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.

Kluver-Bucy Syndrome

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.

Aboulomania

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. 

Paris Syndrome

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.

Cotard Delusion

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!

MGA

Learn More

The Scariest Mental Disorders of All Time

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.

Apotemnophilia

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.

Capgras Delusion

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

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. 

Factitious Disorder

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!

MGA

Learn More

Seasonal Affective Disorder

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. 

SAD Symptoms 

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

-Low energy

-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

-Decreased libido

-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. 

Diagnosis

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.

SAD Treatment

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.

Light Therapy

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.

SAD Prevention

… 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!

MGA

Learn More

Freaky phobias ,part deluxe

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.

Treatment

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. 

Celebrity Phobias

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.  

Unusual 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!

MGA

Learn More

Freaky phobias

Freaky Phobias

Hello, people… welcome back to the blog! Last week, we finished a two part series on N-acetyl cysteine, the latest and greatest amino acid supplement that’s showing major promise in helping to treat some heavy hitting psych disorders, especially bipolar depression. This week, I want to talk about a very intriguing topic… phobias.  

What is a phobia? A phobia is an irrational fear of something that’s unlikely to cause you any harm. I want to highlight the most important point here: irrational fear. Irrational, without rationale. What does that mean exactly? It generally means not thinking, but sometimes it means thinking, but without logic. So a phobia is when you’re afraid of something, often without even thinking about it, sometimes despite thinking about it- which just causes more anxiety btw- and the thing that you’re afraid of is usually nothing to be afraid of in the first place. But despite that fact, the fear can be intense. The word phobia comes from the Greek word phobos, which means fear or horror. Generally, the name of the phobia is a telling label, one basically made up as the need arises, typically by combining a Greek (or sometimes Latin) prefix that describes the phobia, along with the -phobia suffix. For example, the fear of water is named by combining hydro (water) and phobia (fear), so you end up with hydrophobia.

When someone has a phobia, they experience very intense fear of a certain object, thought, or situation. This fear is more extreme than fear in the normal everyday sense, and it develops when a person has an exaggerated or irrational perception of danger about a particular thing. But where’s the line? Being a little wary of spiders isn’t the same as being arachnophobic, right? And btw phobias aren’t always entirely irrational… some spiders ARE dangerous- they can kill you- so they should be avoided. But a phobia will assume that ALL spiders- even a teeny tiny harmless house spider- is a real threat. That’s how phobias are a little different than regular fears, because they cause significant distress, potentially enough to interfere with life at home, work, and/ or school. You’re afraid of serial killers, I’m afraid of serial killers, I imagine everyone is afraid of serial killers. Actually, are serial killers afraid of serial killers? Hmmm… don’t know. Anyway, is this a phobia? Not for most folks, but it sure is for some. What’s the difference? It has to do with interference. Why and how does that phobia, that thing, interfere with your life? Because people with phobias actively avoid the phobic object or situation- that’s another difference- they’ll do nearly anything to avoid it- or else they’ll just white knuckle through it with super intense fear and anxiety. Are you so afraid of serial killers that you avoid going to a nearly deserted truck stop diner at midnight, or so afraid of them that you refuse to leave your house… ever? If you’re the latter, you might have foniasophobia, fear of dying at the hands of a serial killer. 

Ultimately, phobias are a type of anxiety disorder. Anxiety disorders are very, very common- I see them all day long- and they’re estimated to affect more than 30 percent of U.S. adults at some point in their lives. Specific phobias affect fewer people, with an estimated 12.5 percent of American adults experiencing one at some time in their lives. You can have a phobia without having a true anxiety disorder, and you can have an anxiety disorder without having a phobia, though I can’t think off the top of my head of a patient with a generalized anxiety disorder that hasn’t told me about a specific phobia, though I’m sure there are some. 

In the shrink bible, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, aka the DSM-5, it outlines several of the most common phobias, and they typically fall within five general categories:

-Fears related to animals, like spiders, dogs, and insects

-Fears related to the natural environment, like heights, the dark, and thunder

-Fears related to blood, injury, or medical issues, like injections, blood draws, and medical catastrophes, like falls and broken bones

-Fears related to specific situations, like flying, riding in an elevator, being on an escalator, and driving over bridges

-Fears of other more random things like loud noises or choking

The thing is, these categories encompass an infinite number of specific objects and situations. A person can conceivably be afraid of anything they can physically do, think about, or feel. And let me tell you, I’ve heard some doozies. Some people are genuinely afraid of some weird stuff! Not even making fun… most of the time, they’ll even tell you it’s weird too. One of my patients that I’ve treated forever has a wind phobia, anemophobia, or sometimes called ancraophobia. Whatever it’s called, she hates wind… anything more than a light breeze is like nails on a chalkboard for her. What’s really wild is that this very specific, and fairly rare phobia appears to be genetic for her- it runs in her family- and she never even knew that until they all “hurricaned” together several years ago. She, her father, who evidently never really admitted it, and her aunt on her father’s side… all three of them were climbing the walls together during the hurricane. And apparently she always hated wind. As a kid, she would get up in the middle of the night… even if, maybe even especially, when it was storming… and hello, windy… and climb up on a barstool to take down her mom’s windchimes! Every one of them, and evidently she had a lot. Why? Because they drove her looney, listening to the wind blow them around… ding!! Ching ching bing!!! Ding ding da ding!!! She told me that they all made different noises, varying tones, high and low, and she said that every one of them just reminded her how bloody windy it was. For her mom, that sound was relaxing, but for her… not so much! Now, was she actually worried that the wind would blow her away, like Dorothy, off to Oz? Nope. She always knew that wouldn’t happen. She knew she was perfectly safe in her concrete block constructed house, but nonetheless, the wind made her beyond anxious. That, my friends, is a phobia. Totally irrational. And she’d tell you so herself.

Phobias come in all shapes and sizes, and because there really are an infinite number of objects and situations, the list of specific phobias is very, very long. Did you know that there’s even such a thing as a fear of fears? Phobophobia. How about that? And it’s actually more common than you might imagine. That’s one of the problems with fear, it often begets itself. If you have a panic attack because you go sailing in a 28 foot sloop in 12 foot seas, you may end up with not just a phobia about sailing, but a phobia of water and waves. And because the impact of the fear was so intense that it produced physical symptoms of a panic attack, you can even wind up with a phobia of having a panic attack. Yep, and you can be so afraid of having a panic attack that you can cause yourself to have one. Kid you not.  

While there are potentially hundreds, maybe even thousands of different types of phobias, there are some that affect the population at much higher rates than others. Here are a few of the most commonly diagnosed phobias, along with some interesting points on each.

Arachnophobia 

The fear of spiders, or arachnids, is possibly the most well-known of all phobias, and it’s estimated that arachnophobia affects roughly 1 in 3 women and 1 in 4 men.

Ophidiophobia 

Ophidiophobia is the fear of snakes. Interestingly, both ophidiophobia and arachnophobia are thought to be rooted in human evolution, meaning we evolved to fear these critters. It was a matter of survival, so humand learned it generation over generation, to the point it stuck in our DNA. Pretty amazing, no? 

Acrophobia

This is the fear of heights, which affects over 20 million people. Acrophobia can affect a person in a variety of situations, including air travel, crossing bridges, and even travelling up an escalator. It can be extremely limiting, because this fear in particular is frequently associated with anxiety attacks as well as avoidance of the phobia trigger, and this often prevents people with acrophobia from participating in activities that most of us take for granted.

Cynophobia

This is the fear of dogs, and unfortunately, often stems from a personal traumatic experience in the patient’s past, maybe a bite or an attack. I’m a dog lover, and have never had a negative experience with a dog, so while I can’t understand it from an experiential standpoint, I have great empathy for people that are so afraid of dogs for whatever reason that they miss out on the love and companionship they can provide. Cynophobia is an interesting one to me, because it is one of the most commonly treated phobias. In fact, 36 percent of all patients who seek phobia treatment actually do so for cynophobia, which gives you an idea of how much it impacts their lives.

Social Phobia 

Social phobia involves fear centered around social situations and interactions. Among the most common symptoms of social phobia is fear of public speaking, but it can center on any number of situations, like starting conversations, speaking on the phone, meeting new people, speaking to authority figures, and even eating and drinking in front of others. Social phobia typically first appears during puberty, and it can be lifelong if not properly treated.  

Agoraphobia 

Agoraphobia is the fear of entering open or crowded places, of leaving one’s home, or of being in places or situations that trigger a feeling of helplessness, or where a quick escape would be difficult, such as being on public transportation, like an airplane. Agoraphobia is its own unique diagnosis, and is often associated with panic disorder and panic attacks; roughly one-third of patients with an existing panic disorder will also go on to develop agoraphobia as a comorbidity. Statistically, it’s more prevalent in women than men, with two-thirds of patients being female.

Aerophobia 

Speaking of being on airplanes, aerophobia is the fear of flying, and it affects an estimated 8 million people. Given today’s world of travel and transportation, this one can be particularly difficult to avoid, but it can be addressed with various techniques, like exposure therapy. More on that next week.

That’s a good place to stop. Next week, more on freaky phobias; among other things, we’ll talk about how to rid yourself of them. Because while you might assume that once a person gets to the other side of their phobia and knows they lived through it, that it would go away all by itself… you’d be wrong most of the time. Wah wah waaaah. We’re going to talk about just why the hell that is. 

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

Thank you and be well people!

MGA

Learn More

N-acetyl Cysteine…New Miracle for Bipolar

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!

MGA

Learn More

N-ACETYL CYSTEINE

N-Acetyl Cysteine

Hello, people! Last week, we finished up our discussion on the darker side of OCD and talked about the most difficult subtype to deal with, the pure hell of pure obsession OCD, aka Pure O. As promised, we’re back this week with a new topic, N-acetyl Cysteine, or NAC. NAC is an amino acid used by the body to build antioxidants. Antioxidants are vitamins, minerals, and other nutrients that protect and repair the body’s cells from damage, usually referred to as oxidative stress. Historically, NAC has been used mainly in emergency rooms to treat people who overdose on acetaminophen… I’ve ordered it innumerable times for this very purpose. These days, it can be purchased as a supplement OTC, and new studies have begun investigating its effectiveness as both a stand-alone and adjunctive treatment for depressed mood associated with depression, bipolar disorder, schizophrenia, OCD, and trichotillomania, as well as abuse and dependence on nicotine, Cannabis, and cocaine. And it has shown some promising results. 

Before we get to that, let’s talk about some things NAC does in the body. 

1. NAC is essential for making the body’s most powerful antioxidant, glutathione. Along with two other amino acids- glutamine and glycine- NAC is needed to make and replenish glutathione, which helps neutralize free radicals that can cause oxidative stress- damage to cells and tissues in your body. It’s essential for immune health and for fighting cellular damage, and some researchers believe it may even contribute to longevity. Its antioxidant properties are also important for combatting numerous other ailments caused by oxidative stress, such as heart disease, infertility, and some psychiatric conditions. More on those later.

2. NAC helps detoxify the body to prevent or diminish kidney and liver damage, helping to prevent deleterious side effects of drugs and environmental toxins. This is why doctors regularly give intravenous NAC to people with acetaminophen overdose. It’s usually organ failure that gets you in acetaminophen overdose, and NAC helps to prevent or reduce damage to the kidneys and liver, increasing the chances of survival. NAC also has applications for other liver diseases due to its antioxidant and anti-inflammatory benefits.

3. NAC helps regulate levels of glutamate, the most important neurotransmitter in your brain, and this may improve some psych disorders and addictive behavior. While glutamate is required for normal brain function, excess glutamate paired with glutathione depletion can cause brain damage. This state- excess glutamate with glutathione depletion- is commonly seen in certain psych disorders; specifically, it’s thought to contribute to bipolar disorder, schizophrenia, obsessive-compulsive disorder, and addictive behavior.

For people with bipolar disease and depression, NAC may help decrease symptoms and improve overall ability to function, and research suggests that it may also play a role in treating moderate to severe OCD. In addition, an animal study implied that NAC may minimize the so-called negative effects of schizophrenia, such as social withdrawal, apathy, and reduced attention span. NAC supplements can also help decrease withdrawal symptoms and prevent relapse in cocaine addicts, and preliminary studies show that NAC may decrease marijuana and nicotine use and cravings. Many of these disorders currently have limited or ineffective treatment options, so NAC may be an effective option for individuals with these conditions. More on this in a moment.

4. NAC can help relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in the air passageways. As an antioxidant, NAC helps replenish glutathione levels in your lungs, and reduces inflammation in the bronchial tubes and lung tissue. People with chronic obstructive pulmonary disease (COPD) experience long-term oxidative damage and inflammation of lung tissue, which causes airways to constrict, leading to shortness of breath and coughing. NAC supplements have been used to improve these COPD symptoms, leading to fewer exacerbations and less overall lung decline. In a one-year study, 600 mg of NAC twice a day significantly improved lung function and symptoms in people with stable COPD. But those with chronic bronchitis can also benefit from NAC. Bronchitis is the term for when the mucous membranes in your lungs’ bronchial passageways become inflamed, restricting airflow to the lungs. Not much fun. By thinning the mucus in the bronchial tubes, while also boosting glutathione levels, NAC may help decrease the severity and frequency of wheezing and coughing in respiratory attacks. In addition to relieving COPD and bronchitis, NAC may improve other lung and respiratory tract conditions like cystic fibrosis, asthma, and pulmonary fibrosis, as well as symptoms of garden variety nasal and sinus congestion due to allergies or infections. Ultimately, NAC’s antioxidant and expectorant capacity can improve lung function in everyone by decreasing inflammation and breaking up and clearing out mucus.

5. NAC boosts brain health by regulating glutamate and replenishing glutathione. The neurotransmitter glutamate is involved in a broad range of learning, behavior, and memory actions, while the antioxidant glutathione helps reduce oxidative damage to brain cells associated with aging. Glutamate levels are subject to the three bears law: you need some, but too much isn’t good, as it’s an excitatory neurotransmitter. Because NAC helps regulate glutamate levels and replenish glutathione, it may benefit those with brain and memory ailments. The neurological disorder Alzheimer’s disease slows down a person’s learning and memory capacity, and animal studies suggest that NAC may slow the loss of cognitive ability in people with it. Another brain condition, Parkinson’s disease, is characterized by the deterioration of cells that generate the neurotransmitter dopamine. Oxidative damage to cells, and a decrease in antioxidant ability, contribute to this disease, and NAC supplements appear to improve dopamine function as well as disease symptoms, such as tremor.

6. NAC may improve fertility in both men and women. Approximately 15% of all couples trying to conceive are affected by infertility, and in nearly half of these cases, male infertility is the main contributing factor. Many male infertility issues increase when antioxidant levels are insufficient to combat free radical formation in the male reproductive system, leading to oxidative stress and cell death, culminating in reduced fertility. In some cases, NAC has been shown to combat this, improving male fertility. One condition that contributes to male infertility is varicocele. This is when veins inside the scrotum become enlarged due to free radical damage; surgery is currently the primary treatment. In one study, 35 men with varicocele were given 600 mg of NAC per day for three months post-surgery. The combination of surgery and NAC supplement improved semen integrity and partner pregnancy rate by 22% as compared to the control group with surgery alone. Another study in 468 men with infertility found that supplementing with 600 mg of NAC and 200 mcg of selenium for 26 weeks improved semen quality. Researchers suggested that this combined NAC/ selenium supplement should be considered as a treatment option for male infertility. In addition, NAC may improve fertility in women with polycystic ovary syndrome (PCOS) by inducing or augmenting the ovulation cycle which is altered by the condition. 

7. NAC may stabilize blood sugar by decreasing inflammation in fat cells. High blood sugar and obesity contribute to inflammation in fat tissue. This can lead to damage or destruction of insulin receptors, which puts you at a much higher risk of type 2 diabetes. When insulin receptors are intact and healthy, they properly remove sugar from your blood, keeping levels within normal limits. When the insulin receptors are damaged, blood sugar levels are more difficult to control. Animal studies show that NAC may stabilize blood sugar by decreasing inflammation in fat cells, keeping receptors happy, and thereby improving insulin resistance. That said, human research on NAC is needed to confirm these effects on blood sugar control.

8. NAC may reduce heart disease risk by preventing oxidative damage. Oxidative damage is caused by free radicals, and this type of damage to heart tissue often leads to heart disease, causing strokes, heart attacks, and other serious cardiovascular conditions.

NAC may reduce heart disease risk by reducing oxidative damage to tissues in the heart. It has also been shown to increase nitric oxide production, which helps veins dilate, improving blood flow. This expedites circulation and blood transit back to your heart, and this can lower the risk of heart attack. Interestingly, a test-tube study showed that when combined with green tea, another well recognized antioxidant, NAC appears to reduce damage from oxidized “bad” LDL cholesterol, another bigtime contributor to heart disease.

9. NAC and its ability to boost glutathione levels appears to increase immune function, boosting immune health. Research on certain diseases associated with NAC and glutathione deficiency suggests that immune function might be improved, and potentially even restored, by supplementing with NAC. 

This has been studied mostly in people with human immunodeficiency virus (HIV). In two studies, supplementing with NAC resulted in a significant increase in immune function, with an almost complete restoration of natural killer cells, the main patrol cells. High levels of NAC in the body may also suppress HIV-1 reproduction. A test-tube study indicated that in other immune-compromised situations, such as the flu, NAC may hamper the virus’s ability to replicate; this could potentially reduce the symptoms and lifespan of the associated viral illness. Other test-tube studies have similarly linked NAC to cancer cell death and blocked cancer cell replication. Great news, but more human studies are needed. 

This is a short blog, but that’s a good place to stop for this week. Next week, we’ll talk about how NAC may alleviate the symptoms of multiple psychiatric disorders, as well as reduce addictive behavior; and we’ll talk about some preliminary study findings as well. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

Learn More

Dark Side of OCD (Part 4)

The Dark Side of OCD

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

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

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

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

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

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

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

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

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

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

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

Thank you and be well people!

MGA

Learn More

OBSESSIVE COMPULSIVE DISORDER (Darker Subtypes)

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

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

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

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

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

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

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

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

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

Thank you and be well people!

MGA

Learn More

Dark Side of OCD

Dark Side of OCD

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

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

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

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

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

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

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

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

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

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

Thank you and be well people!

MGA

Learn More

OCD SUBTYPES PART 1

The Darker Side of OCD

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

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

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

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

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

Hyperawareness OCD

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

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

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

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

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

Thank you and be well people!

MGA

Learn More

Personality disorders Cluster C

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

Avoidant Personality Disorder

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

Signs and symptoms of AvPD may include:

-Anhedonia, lack of pleasure in activities

-Self-isolation

-Severe anxiety in social situations

-Avoiding conflict, being a “people-pleaser”

-Avoidance of social interaction despite a strong desire for intimacy

-Avoiding interaction in work settings or turning down promotions

-Avoiding making decisions

-Avoiding situations due to fear of rejection

-Easily hurt by criticism or disapproval

-Extreme self-consciousness, lack of assertiveness

-Fearful and tense demeanor, lack of trust in others

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

-Feeling inadequate, inferior, or unattractive

-Misinterpreting neutral situations as negative

-No close friends/lacking a social network

-Unwilling to take risks or try new things

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

Dependent Personality Disorder

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

Signs and symptoms of DPD may include:

-Difficulty making everyday decisions

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

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

-Submissive or clingy behavior

-Tendency for naiveté

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

-Instinctively agree with others for fear of disapproval

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

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

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

-Difficulty doing projects due to lack of confidence in abilities

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

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

having a family history of anxiety disorders.

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

Obsessive Compulsive Personality Disorder

Aka Anankastic Personality Disorder

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

Signs and symptoms of OCPD may include:

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

-Fixation on organization, detailed schedules, list making 

-An overwhelming need to be punctual

-Strict personal moral and ethical codes

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

-Often seen as ungenerous or frugal

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

-Significant rigidity and stubbornness

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

-Often feel righteous, indignant, and angry

-Socially isolated

-Stiff, formal, or rigid mannerisms

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

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

Personality Disorder not otherwise specified 

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

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

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

Thank you and be well people!

MGA

Learn More

Personality Disorders

Personality Disorders

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

Borderline Personality Disorder

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

BPD signs and symptoms may include:

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

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

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

-Unstable and intense relationships

-Suicidal behavior or threats of self-injury

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

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

-Ongoing feelings of emptiness

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

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

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

Histrionic Personality Disorder

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

HPD signs and symptoms may include:

-Constantly seeking attention

-Into instant gratification

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

-Excessive concern with physical appearance

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

-Makes rash decisions

-Easily influenced by others

-Shallow, rapidly changing emotions

-Believes relationships with others are closer than they really are

-Gullible and easily influenced by others

-Excessively sensitive to criticism or disapproval

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

-Self-centered, rarely showing concern for others

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

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

Narcissistic Personality Disorder

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

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

NPD signs and symptoms may include:

-Fantasies about power, success, and attractiveness

-Entitled, conceited, snobby

-Exaggeration of achievements or talents

-Expectation of constant praise and admiration

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

-React negatively to criticism

-Show great charm but quickly become irritated or angry

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

-Show aggression when faced with a threat to their ego

-Resent the successes of other people

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

-Perceived superiority that covers a deep seated insecurity

-Unreasonable expectations of favors and advantages

-Envy of others accompanies belief that others envy them

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

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

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

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

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

Thank you and be well people!

MGA

Learn More

Personality Disorders

Personality Disorders

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

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

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

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

ASPD signs and symptoms may include:

-Disregard for right and wrong

-Persistent lying or deceit to exploit others

-Callous, cynical, and disrespectful of others

-Criminal behavior

-Applying charm or wit to manipulate others for personal pleasure

-Arrogance, a sense of superiority, extremely opinionated

-Lack of compassion and empathy for others

-Unremorseful when confronted with wrongdoing

-Inability to admit mistakes

-Bullying demeanor, use threats to deal with personal conflict

-Impulsiveness or failure to plan ahead

-Unnecessary risk-taking or dangerous behavior 

-No regard for the safety of self or others

-Instability when it comes to work and home life

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

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

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

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

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

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

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

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

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

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

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

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

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

Thank you and be well people!

MGA

Learn More

Personality Disorder Part 3

Personality Disorders, part 3

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

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

Cluster A Personality Disorders

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

Paranoid Personality Disorder

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

Common PPD symptoms include:

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

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

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

-Becoming detached or socially isolated 

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

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

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

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

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

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

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

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

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

Schizoid Personality Disorder

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

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

Common Schizoid PD symptoms include:

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

-Limited range of emotional expression

-Inability to take pleasure in most activities

-Inability to pick up normal social cues

-Difficulty relating to others

-Appearance of being cold or indifferent to others

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

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

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

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

Schizotypal Personality Disorder

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

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

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

-Limited or inappropriate emotional responses, “flat emotions”

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

-Very uncomfortable with intimacy

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

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

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

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

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

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

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

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

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

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

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

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

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

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

Thank you and be well people!

MGA

Learn More

Personality Disorders part 2

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

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

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

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

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

Diagnosing Personality Disorders

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

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

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

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

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

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

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

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

Thank you and be well people!

MGA

Learn More

The Cult of Personality…Disorders

The Cult of Personality… Disorders

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

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

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

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

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

Personality Disorders: Ten Types

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

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

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

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

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

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

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

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

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

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

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

Thank you and be well people!

MGA

Learn More

Treating Thyroid Disease

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

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

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

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

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

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

Hyperthyroidism Treatment

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

Radioactive Iodine 

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

Antithyroid Medications 

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

Beta Blockers

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

Surgical Thyroidectomy

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

Hypothyroidism Treatment

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

Levothyroxine

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

Thyroid Disease: Prognosis 

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

Thyroid Disease: Complications

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

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

Hyperthyroidism: Complications

Heart problems

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

Brittle bones

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

Eye problems

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

Red, swollen skin

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

Thyroid Storm

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

Hypothyroidism Complications

Goiter

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

Heart problems

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

Mental health issues

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

Peripheral neuropathy

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

Joint pain

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

Infertility 

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

Myxedema

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

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

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

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

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

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

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

Thank you and be well people!

MGA

Learn More

Thyroid 2

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

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

Thyroid Disease by the Numbers

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

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

Hyperthyroidism Causes and Conditions

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

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

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

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

Hypothyroidism Causes and Conditions

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

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

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

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

Thyroid Disease Risk Factors

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

Thyroid Disease Symptoms 

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

Symptoms of Hyperthyroidism

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

Symptoms of Hypothyroidism

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

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

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

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

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

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

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

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

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

Thank you and be well people!

MGA

Learn More