Warning signs of Bipolar
Warning Signs of Bipolar
As a psychiatrist practicing in Palm Beach Florida, I come across a lot of bipolar patients. What are the warning signs of bipolar disorder? How can you recognize if someone you love or even yourself has bipolar disorder? You can’t get through an hour television program without at least 2 commercials for bipolar medications, so I thought it would be a good idea to talk about it.
First, what is bipolar? Bipolar disorder is a mental health disorder more commonly found in women that can cause dramatic changes in mood and energy levels. The term bipolar refers to the two poles of the disorder, the extremes of mood. Those two extremes of mood are mania and depression. The symptoms of bipolar can affect a person’s daily life severely as their mood can range from feelings of elation and high energy to depression. There are two types of bipolar, type 1 and type 2. Type 1 is more serious and disruptive than type 2, which can also be called hypomania.
Bipolar is sort of the Jekyl and Hyde of psychiatric disorders, with cycling of mania and depression. Manic episodes and depressive episodes have very specific signs and symptoms associated with them.
When someone is manic, they do not just feel very happy. They feel euphoric. Key features of mania include, but are not limited to:
– irritability
– having a lot of energy
– feeling able to achieve anything
– having difficulty sleeping
– using rapid speech that jumps between topics.
– inability to follow through with ideas or tasks
– feeling agitated, jumpy, or wired
– engaging in risky behaviors, such as reckless sex, spending a lot of money, dangerous driving, or unwise consumption of alcohol and other substances
– believing that they are more important than others or have important connections
– exhibiting anger, aggression, or violence if others challenge their views or behavior
– in severe cases, mania can involve psychosis, with hallucinations that can cause them to see, hear, or feel things that are not there.
People in a manic state may also have delusions and distorted thinking that cause them to believe that certain things are true when they are not. While I have many patients that get delusions of grandeur, I have one patient that comes to mind. Her name is Felicia. Felicia is a 32-year-old receptionist. She was diagnosed with bipolar type 1 when she was 25, which happens to be the typical age of diagnosis. Felicia is on two medications for her bipolar with mixed results. She still cycles occasionally to a manic state. Sometimes that’s a clue that she may not be compliant with her meds. Like many bipolar people, Felicia loves loves loves her manic state. When Felicia is manic, she is on top of the world. Her house is pristinely clean, the meals she makes for her family are total gourmet, and her appearance is perfect. Sounds great, right? You may be thinking ‘Where’s the downside, Dr. A?’ Well, in this manic state, Felicia absolutely positively believes that she is descended from “the true” royalty. She believes that the father of the current Queen of England, the previous King George VI, actually stole the monarchy and the crown from her father. As a result, she believes that she should be the rightful current monarch. In reality, her father is a semi-retired urban planner living just outside of Topeka Kansas. Regardless, when Felicia is super manic, she will relay this story with a voice full of indignation and a perfectly straight face. She will tell anyone this story, so people think she’s totally nuts.
A person in a manic state may not realize that their behavior is unusual, but others may notice a change in behavior. Some people may see the person’s outlook as eccentric or sociable and fun-loving, while others may find it unusual or bizarre. The individual may not realize that they are acting inappropriately or be aware of the potential consequences of their behavior. In some cases, they may need help in staying safe when they are completely out of touch with reality. Bipolar type 1 patients can be some of the most dangerous patients in my practice, as they can be violent, prone to rage and acting out on that rage. They are chaotic. If you have an untreated or ineffectively treated bipolar 1 person in the household, you will know. One big problem is that patients enjoy the manic state of their disorder. They feel such increased energy and euphoria that they are prone to stop taking their meds. Once that happens, all hell breaks loose.
But eventually, that mania will cycle into deep depression with all of the symptoms that go with it, and may end with suicidal thoughts or acts. Key features of depressive episodes may include, but are not limited to:
– feeling down or sad
– having very little energy
– having trouble sleeping or sleeping a lot more than usual
– thinking of death or suicide
– forgetting things
– feeling tired
– losing enjoyment in daily activities
– having a flatness of emotion that may show in the person’s facial expression
– In very severe cases, a person may experience psychosis or a catatonic depression, in which they are unable to move, talk, or take any action.
Bipolar type 2, also called hypomania, is a disorder which is sort of like type 1-light. It features episodes of depression and hypomania. Symptoms of hypomania are similar to those of mania, but the behaviors are less extreme, and people can often function well in their daily life. But if a person does not address the signs of hypomania, it can progress into the more severe form of the condition at a later time. I see type 2 patients more often in my practice, and I see them as generally being much calmer than type 1 patients. They do not get as violent, do not hear voices, do not have hallucinations, and are not disorganized in their speech or behavior. However, they are usually irritable. They talk quickly. They have trouble sleeping. They have trouble concentrating. They have trouble getting things done. They have relationship issues. They have trouble sleeping. These periods of hypomania can last anywhere between minutes to days to weeks.
So what can be done for a patient suffering from bipolar disorder, whether type 1 or 2? There are multiple drugs which can be used to balance the patient. I find my go-to drug would be lamotrigine, as it is minimal in its side effect profile, is mood stabilizing, does not put on weight, does not make you drowsy, and does not have many drug interactions. There are other drugs which can be used, oxcarbazepine and divalproex, which are antiseizure mood stabilizers. These have some effectiveness and have various side effect profiles. In some cases, antipsychotic drugs like lurasidone are useful. Many times I put patients on at least two drugs, one to treat mania and one to treat depression. I can prescribe all the drugs in the world, but they won’t do any good if patients are non-compliant in taking them. So the biggest and most important key feature in treating bipolar is having a relationship with the patient and making sure they are compliant with medicine, because the manic state is so enjoyable to them that they may choose non-compliance. That’s really the biggest barrier to treatment. I always explain to my manic patients that while they may like the mania, they will have to pay the piper, because guess what? Next they’ll be hopelessly depressed and unable to get out of bed.
In my practice, I see many female patients with mood disorders. The way I approach treatment is to find the best tolerated drug. This may not be the best drug on the market, but may be the best drug for that patient because it is better tolerated and has a better side effect profile for that patient. If the drugs cause weight gain, make them drowsy, or cause sexual dysfunction, they won’t take them. And who would blame them? So I work very hard to explore all available pharmaceutical treatment options for each patient as an individual. The goal is to have a drug regimen which is the least invasive in that person’s life and to combine that with psychotherapy. Because bipolar disorder is a lifelong disease, treatment should also be lifelong. If you suspect that you have bipolar or a loved one has bipolar, contact a physician for referral to a mental health professional like myself. For more information, check out my book, Tales from the Couch, available on Amazon.com
Learn MoreWhat Ever Happened To Dating
Whatever happened to dating? I’m part of a lot of talk on this particular topic. Day in and day out, patients tell me about their trials and tribulations in the dating world, and the dialog has definitely changed over the years. So, as an unofficial-official expert, I want to talk about dating. There are discrepancies as to who hit on the idea first, but computer-assisted dating sites came into play as personal computers gained popularity in homes everywhere. Remember the Tom Hanks movie You’ve Got Mail? That romanticized the idea of online dating and spawned sites like Match in the early 2000’s. The advent of Facebook kept people checking for “friends” as a hobby, linking people all over creation. However and whomever launched what doesn’t matter much anymore, dating sites and dating apps are here to stay. The list goes on and on and on, and now sites and apps are getting more specific. They target groups: SilverSingles, OurTime, JDate, BlackPeopleMeet, and Farmers Match…if you can be grouped into a subset, you will be. So what’s the impact of dating sites and apps? They’ve changed the game. If you listen to your grandparents tell their love story, it often includes a meeting of eyes, maybe across a crowded bar or restaurant, hence love at ‘first sight.” Now, if you manage to find love, it may be more like at “first site” or “first swipe.”
Whole movies are made of dating in the modern world. The process of meeting someone has now moved away from social contact, which is sort of oxymoronic in the age of ‘social’ media. The old rules don’t apply anymore. It used to be that to get a date, you got all gussied up to go out and attract a date. Now you can sit home on your couch in your boxers or fat pants and dangle an electronic lure to attract someone. Sadly, romance is now largely a thing of the past, replaced by an electronic algorithm. You have to be a wordsmith to get a date, not a romantic. Pickup lines aren’t spontaneous. Now someone trolling an app for a date can use a line that it took them a month to come up with, and they can use it over and over until the payoff, the date. Social media can also be very manipulative as well. When my patients tell me about failed dates arranged through social media, one of the most popular reasons they give me is that the person didn’t look like their picture. Blah blah blah… I hear that ALL the time. My only reply is usually “Duh!!! It took that guy / girl three hours to take that picture!” I marvel at how they’re shocked by not getting what they were expecting! And these sites and apps are too easy. Going out to attract a date used to require a little effort and forthought. Where am I going? What should I wear? How’s my hair? Is my breath okay? On sites and apps, it doesn’t matter. They’re a numbers game. Send a line out to enough people and you’re bound to hit on a date at some point. And what happens on that date? Social media has stripped away the art of conversation. It’s been reduced to memes, a series of easily textable phrases and lines. Those aren’t conducive toward building the foundation of a relationship. And there can be a darker side to the use of these sites and apps. Some people believe that participation on these dating sites and apps is essentially implied consent or positive acceptance of sexual advances. If you met someone In the real world, not all advances are welcome. The same is true with participation on an app or site. But the flip side of that coin are the apps where advanves are welcome. There are an increasing number of mobile apps that will let you know when a person of like mind is in the vicinity. Of like mind on these apps usually means down to hook up, which has inherant risks in and of itself. These transactional apps seeking sexual relations really take the human touch out of the whole equation. They’re all about the easy hookup, people as commodities. Phone on, date out. Social media has really changed the idea of participating with one’s community. Now you see young people with no interests beyond their phones. What’s going on in their electronic world takes precedent over what’s happening right in front of them. I discuss this at length in my book, Tales from the Couch. People miss so much of what’s going on around them because they’re buried in their phones. Human interaction goes by the wayside. Another consequence of social media is the downfall of commitment. With more relationships being non-committal, I’ve seen marriage rates among my patients go down. When I ask people about that, they essentially tell me that they’re not into commitment because why should they be? Why settle down and buy one cow when you can have all the milk from all the cows on the internet for free?
Some of these issues can be troubling. I especially wonder what happens to the people who don’t have profiles posted everywhere, who don’t want to swipe right or left to get dates and find companionship. Are they doomed to forever be single? Will they miss out on their happily ever after? Maybe.They may need to bite the bullet and throw a line into the electronic world of dating. For all it’s foibles and downfalls, social media doesn’t seem to be going anywhere anytime soon. Good, bad, or indifferent, that’s dating today. For more on the world of social media, check out my book Tales from the Couch, available on
Learn MoreThe Great Marijuana Debate
Given the legalization of marijuana in many states, I wanted to have an open discussion on the ramifications and repercussions of its legalization, and why choosing to use might not be the best choice for everyone.
Marijuana is so readily accepted everywhere now, in both legal and illegal states and in any and every social circle; regardless of its legal status, its use is suggested by so many people for everyone and everything under the sun…it’s a revolution that makes Woodstock look like a quilting circle. Grandmas and grandpas, CEO’s, lawyers, actors, the butcher, the baker, and the candlestick maker….everyone’s using marijuana, legal or not, and they’re not afraid to tell the world. And the marijuana of today ain’t yo mama’s marijuana…today many people prefer to smoke marijuana wax rather than the green herbacious stuff, because wax is a minimum of 90% pure THC, miles away from the 15% green stuff.
The legalization of marijuana has created a slippery slope. Now it’s basically off the radar for police, meaning that most officers will give a pass for possessing up to a certain amount of it, even in illegal states. The police officers have discretion in the field, and most just confiscate it and maybe write a fine ticket for it, or maybe not…it’s not worth the time or effort for them to fight it any further, even in illegal states. If they just wrote every possessor a fine ticket for marijuana possession, they’d be buried in tickets, so imagine the paperwork if they arrested them all. I watch a live police program on weekends, and the first question an officer asks the driver they’ve pulled over is if they have any weapons or drugs in the car. They then emphasize that “honesty goes a long way” when it comes to their decision-making process in drug possession. Sometimes they’ll employ a K-9 officer to find drugs, and I swear that at least 85% of the cars they pull over contain drugs of some sort. And most times (after the officer makes it clear that they can’t get in trouble for it) a driver will readily admit that they have smoked within the last hour or minutes before getting behind the wheel, or even just smoked while driving. This is apparently due to a general consensus that marijuana doesn’t cause impairment, which is debatable; more recent studies are suggesting otherwise.
Because marijuana has essentially vacated its spot in the illegal drug hierarchy, the next “least worse” drugs, meaning cocaine and methamphetamine, have moved up, becoming “less illegal” in a way. Now officers even have some discretion when it comes to the possession of cocaine and meth; if the possessor only has a small amount, they may not necessarily go to jail. As hard as it is to believe, I have seen it on the live police program, people issued a ticket for possessing a small amount of coke or meth. The only difference is the type of ticket issued: while a marijuana ticket is just for a steep monetary fine, the ticket for coke or meth possession is essentially an order to appear before a judge, who then decides if the offender goes to jail or gets off with just a steep monetary fine and/ or probation, community service, etc. I wonder if lawmakers ever imagined that the legalization of marijuana in some states would lead to the near decriminalization of even minute amounts of drugs like coke and meth, but it seems it has. Similar to marijuana, I think it’s likely due to the amount of time and effort it takes to haul every coke and/ or meth possessor to jail: small amounts are permissible when weighed in the face of 100% rule of law…it’s certainly faster, easier, and more profitable to fine someone through the nose (no pun intended) than to house them in our overcrowded and expensive jails.
Enough of the legal ramifications. Of course as a physician, I see the more personal, medical side of the legalization of marijuana. I am literally asked about it by patients every day, and I am a medical marijuana prescribing physician- I jumped through all of the state’s many hoops so that I can prescribe marijuana. I believe that used properly, marijuana has definite value as a drug. The key is for whom. I think it’s good for someone with cancer, with brain tumors, for AIDS, for neurologic disease like ALS (Amyotrophic Lateral Sclerosis), for Crohn’s disease, irritable bowel syndrome, for post-traumatic stress disorder, for specific types of chronic pain, and for certain seizure types. While I don’t prescribe marijuana willy-nilly, I definitely do prefer prescribing marijuana over other controlled drugs like opiates. But as I tell patients, just because it’s legal doesn’t mean it’s useful for everyone or even reasonable for everyone to use it. In fact, I think that for a subset of the population, up to age 30-ish, marijuana is counterproductive at best and damaging at worst. I call marijuana “the nothing drug.” If you give marijuana to a young developing mind, let’s say someone aged 14, the person belonging to that mind has their life course altered. From the day they start smoking marijuana, nothing happens. Their motivation drops off. They think a lot of good thoughts about what they can do or would like to do, but they do nothing. So nothing gets done. That’s what alters their life course. Dreams are great, but the key is to act on them. I tell my patients that when they use marijuana, nothing happens. Nothing bad, but nothing good. Nothing scary, but nothing awesome. Just nothing. Users do nothing, and if they continue to use habitually, they may amount to nothing. They may not fail, but they definitely will not excel. When you ask that marijuana-smoking 14-year-old what they’ve been up to, they’ll say ‘’nothing.’’ When you ask what they did in school that week, they’ll say ‘’nothing.’ When you ask them what they did over the weekend, they’ll say ‘’nothing.’ When you ask them what happened at the football game, they’ll say ‘’nothing.’’ When you ask them what they do when they get high, they’ll say ‘’nothing.’ Now you get the picture. Marijuana… The Nothing Drug. There’s a PSA campaign for ya’.
Using marijuana is mostly about being alone, being high, and being out of touch. You cause no problems. As a matter of fact, the last thing you want is conflict…it would harsh the mellow. My patients who smoke tell me that when they use it, they just want to keep using it, because it makes them feel so good. But there are qualities to marijuana that make people prone to isolation, where they don’t communicate with others as much. Think about it. When was the last time you went to a wild, raging party with people smoking only marijuana? Do you hear a lot of meeting and greeting, talking and laughing? Nope. But you do hear the sounds of lots of lighters striking and water bongs gurgling. And some muffled coughing- that wierd upper throat/ nasal cough that comes from people holding their breath and trying hard not to cough up the hit they just took. You may hear a woo-hoo or two, but that’ll come from the direction of the couch, which will be replete with reclining stoners. In my experience, people who smoke pot waste a lot of time doing so. It’s the kind of drug that can be used constantly, for hours and days on end, because there’s no concern of overdose. There’s a lot of time wasted, no pun intended, on thoughts not thought through and things left undone. When I warn patients about isolation, I often hear back from them that they do spend time with people, that in fact, they get high with people. I tell them that they may think they’re spending time with friends, getting high with their buddies, but that most of the time they’re getting high and playing video games or listlessly bobbing their heads to music and they just happen to all be in the same room. There’s no real interaction…it’s a very solitary pursuit, but in the presence of others, a mental masturbation marathon.
Obvi, I have many patients that complain that their lives aren’t going well, that they’re depressed and generally unhappy, and many of them smoke marijuana to “relax.” When I ask the marijuana users why they’re unhappy, they seem completely devoid of any insight as to what’s going on. I have a list of questions I ask, and it starts with “How much do you smoke?” I can probably count on one hand the number of people who tell me the truth, that they smoke a lot of marijuana; they always say they smoke “a little” marijuana. When I ask what form they use and how much “a little” is, some admit to using wax, and many tell me they use “only at night, never during the day” like that makes all the difference in the world, given that there are basically 12 hours of night in a 24 hour day.
The best “medicine” I can dispense to these marijuana-using patients is education. I have given a version of the same talk at least a thousand times, tailored to the patient’s age and condition. It basically goes something like this: “You’re unhappy because marijuana alters you. It makes it so you’re just going through the motions of life; when you’re directed to do something, you can do it, but you never do anything of your own volition. You have no original thoughts or ideas or insight into your life, because you don’t bother to examine it. You don’t have any meaningful interactions with other people. You spend your time playing video games and eating junk food. You never see the sun, unless you have to venture out in daylight for a marijuana-related errand. You’re lacking a creative outlet, because marijuana isn’t conducive to creativity. Marijuana is robbing you of motivation, memory, ambition, desire, and energy. It blunts your emotions so that you feel nothing, so you smoke more to feel high because that’s better than feeling nothing. It’s a vicious cycle. You’re just like a rat on a wheel in a cage.” These facts are why marijuana is most damaging for people up to about age 30, because by this time at the latest they should be expending great effort trying to establish themselves and their lives, deciding where they want to go and setting goals to get there. Instead, they use marijuana and all that goes out the window. For an 80-year-old woman with cancer or rheumatoid arthritis, marijuana isn’t going to affect her life nearly as much as a 20-something-year-old looking for a job or deciding what career path they want to take.
As an example to show that using marijuana is not exclusively for the young, take my patient Frederick, who is 68 years old. He started smoked marijuana at ten and basically smoked all day, every day since. Consequently, he did nothing his whole life, so 58 years. That’s 58 years completely wasted, again no pun intended. Somehow he got on disability years ago. As far as I could tell, his only disability was that he wanted to smoke all day, that he liked to be high. I have another patient, a 23- year-old named Skylar. He’s basically a trust fund baby, living in his parents’ Palm Beach mansion full time while they spend 48 weeks of the year living up in Massachusetts. Skylar’s “job” as caretaker of the mansion, supposedly overseeing a staff of six, has always left him with more than ample time to do, well, nothing…except smoke wax. And he was a hard case, because he was able to afford the strongest wax and he smoked a lot of it- one of the handful that admitted to doing so. I saw him in my office a couple of months ago, and he told me he had wasted enough time using marijuana, he wanted off, and would I help him? Once I recovered from the shock and picked myself up off the floor, I of course told him that I’d be glad to, and I explained the deal. Most people think there’s no withdrawl from marijuana, but that’s not true. There is about a ten day withdrawl period that typically includes insomnia, restlessness, and irritability. It then takes six weeks for green marijuana to eight weeks for wax for all traces of THC to leave the body. I use medications like clonidine and trazodone to minimize the effects of withdrawal, and they make it much easier. At the two-week mark, the four-week mark, the six-week mark and the eight-week mark, patients are amazed at how they feel clearer and clearer at each point. They’re able to see how impaired marijuana was actually making them- they were totally unaware of their impairment at the time, how slow they were, how dopey and lazy. Once it’s completely out of their systems, they tell me how they’re more active, how they’re getting up in the morning and showering and getting dressed, how they’re going outside and exercising, and how things are happening in their lives. I’m happy to report that Skylar was no exception. His withdrawl from marijuana wax was uneventful, and after eight weeks, he was shocked at how different he felt, describing it as like being awake after years of being asleep. For the first time in recent memory, he was thinking, he was weighing his options (now that he had some) and he was planning his future. When I asked his greatest revelations, he said, “I have to make things happen. I have to be proactive. I have to look for and seize opportunities. No one can do that for me.” I really couldn’t have said it better than that.
Re-reading this, I noticed that I said that marijuana is ‘robbing you’ of this and ‘taking away’ that, but really, marijuana doesn’t take things away from you, you give those things away when you choose to use. Marijuana has its place in treating certain illnesses and diseases; but remember that just because something is legal to use doesn’t make it reasonable to use it. If you’re faced with a choice to use, just think about Frederick, with 58 years wasted, no pun intended, and Skylar, who got a late start in adulting but has an unlimited future…now that he’s no longer letting marijuana limit his present.
For lots more entertaining stories and information about marijuana and other drugs, check out my book, Tales from the Couch, available on Amazon.com. It makes for a great read and an ever better gift!
Learn MoreThe Dark Side of OCD
The Dark Side of OCD
Hello, people… welcome back to the blog! We had some bigtime issues with our website, so we had to take a short blog break… but our IT guy got it sorted, so we’re finally back! Our last blog continued the discussion of OCD subtypes, and I went over Scrupulosity OCD, the obsession with morality and good versus evil, and Sexual Orientation OCD, the obsession with one’s “true” sexuality. This week, we’re wrapping up the OCD subtype series with a look at Relationship OCD, or ROCD, and an overview of Pure Obsessional OCD, aka Pure O.
In Relationship OCD, obsessions revolve around one’s feelings of attraction, attachment, and love for their partner. Recall again that OCD is a disorder of doubt, so ROCD presents as a preoccupation with doubting various aspects of the relationship. The person may wonder whether their person is really ‘the one,’ and about the level of sexual attraction or general compatibility; ‘Do they really love me?’ and ‘true love’ versus ‘just lust’ are other common themes. Whatever the doubts may be, they can become so pervasive and consuming that they can easily poison otherwise entirely healthy relationships… it can be exasperating to the person’s partner, and totally devastating to everyone involved. Imagine being married to someone for a number of years, maybe even having children with them, and then one day they tell you they’re not sure if you have sexual chemistry, or are compatible, and they don’t know if you belong together. Yikes! Scary stuff for everyone. It can even be a physical trait they’re unusually drawn to, and unsure if they can live with, or a common habit. Maybe you squeeze the toothpaste from the middle of the tube instead of rolling up the end. Jk on that last one people, though some folks, whether they have OCD or not, can be pretty particular about those kinds of things.
Sometimes people have a hard time understanding the difference between ROCD and more garden variety relationship doubts, and ROCD can even be misdiagnosed by mental health professionals if they misread the symptoms that way. Lots of people doubt their relationships from time to time, and there’s nothing wrong with taking a hard look at things and asking yourself some serious questions when choosing to settle down with a partner. We’re not talking about your usual commitment phobias here… make no mistake, people with ROCD are tortured continuously by their doubting thoughts. But the core issue with ROCD isn’t actually related to compatability or intimacy, once again, it’s about the doubt; specifically, the inability to tolerate that doubt. To draw the distinction, I’ll use a nerd word, people… ego-dystonic. For people with ROCD, the doubts they have are ego-dystonic, meaning that they are inconsistent with their actual feelings. They truly feel that they are attracted to, and compatible with, their partner, it’s just the ROCD causing them to constantly question it. Unfortunately, some clinicians and practitioners who aren’t familiar with ROCD may suggest to a person with it that “maybe you’re just not that into them” or that they “may not be right for you” or “not the one.” Worse yet, they might even tell them, “Well, maybe your gut is trying to tell you something… maybe those are your instincts, and perhaps you should pay attention to them” Alas, no. Telling someone with ROCD to listen to their doubts is the fastest way to send them into a tailspin of panic.
Aas ROCD obsessions center on doubt, the associated compulsions center on being absolutely sure that the relationship in question is right, on ascertaining the justification for entering into or remaining in it. For the person with ROCD, attempting to arrive at this level of certainty is agonizing, and it leads to an intense and endless cycle of anxiety, because it’s impossible to arrive at a definitive answer for any length of time. The doubt can usually be assuaged for a short time by performing various mental compulsions, but it always returns with a vengeance. It’s no picnic for the partner, either. They’re forced to think about what their significant other might be willing to do to reach that goal to be sure, especially the possibility of cheating, which is the usual form it takes. For them, this often leads to constant uncontrollable guilt, fear, and distressing thoughts of what will happen.
As with all forms of OCD, compulsions must be performed in an effort to reduce the anxiety related to the unwanted obsessional thoughts. Some examples of what ROCD might look like may be a married woman who has the obsessional thought, “What if I don’t really love my partner?” so she looks at old pictures and mentally recites her wedding vows until she feels she does. Or a husband who imagines cheating on his wife, and then obsessively fears that because he imagined it, he must secretly want to be with another woman, sso he may test the theory so to speak. Maybe a guy is drawn to his girlfriend’s nose, and obsesses about whether or not he finds her attractive enough to be with her, or if he should break up with her. Whichever way he leans- stay or break up- it causes him huge anxiety, so he compares his girlfriend to other girls he sees on the street to find evidence of sufficient feelings for her. Perhaps a man is attracted to a girl he notices on the street, and he begins to obsess that this must mean that he doesn’t love his girlfriend, so he must be in the wrong relationship. This causes him a lot of distress, because he actually believes he does love her and doesn’t really want to break up with her… but the doubt persists. How about a girl who’s living with her boyfriend, and confesses that sometimes she feels turned off by the thought of having sex with him. She believes that since she’s not 100% attracted to him 100% of the time, this is proof that she’s in the wrong relationship. So she mentally lists all the things she does and does not find aattractive about him in an effort to figure it out.
Notice that these compulsions aren’t very obvious… things like mentally reciting wedding vows and making mental lists and comparisons of people can clearly go unnoticed by others, as opposed to someone washing their hands over and over or unlocking and re-locking a deadbolt 20 times to check it. These are more of a mental obsession game. In fact, all of the subtypes we’ve been discussing in this series are similar in this way- sexual orientation OCD, pedophilia OCD, scrupulosity OCD, emotional contamination OCD, and hyperawareness or sensorimotor OCD- all of these are primarily cognitive in nature. As such, they are loosely categorized under Pure Obsessional OCD, aka primarily cognitive obsessive compulsive disorder, aka Pure O. Though not a true diagnosis found in the DSM-5, Pure O is considered a lesser known manifestation of OCD, and is thought of as one of the most distressing and challenging forms of OCD, as people with it have terribly disturbing and unwanted thoughts pop into their heads very frequently, totally unbidden; and once there, they tend to stick around.
In addition to the types we’ve discussed, some other common themes of Pure O thoughts and obsessions include:
-Responsibility type, which is marked by an excessive concern over someone else’s well-being, and hallmarked by guilt over believing they have harmed them, or might, either inadvertently or intentionally.
-Health type, which is essentially a contamination type, where they have constant fear of having or contracting a disease, generally through seemingly impossible means; for example, by touching an object that has just been touched by someone with a disease. This type can also include obsessive mistrust of the medical establishment and/ or diagnostic testing. It’s important to note that this is not the same as hypochondriasis, which is an illness whereby affected individuals falsely convince themselves they are physically ill, potentially to the point that they may even manifest physical symptoms. Maybe that’s a good topic for another blog.
-Existential type, which involves the persistent and obsessive questioning of the nature and meaning of self, life, reality, the universe, and other philosophical topics… all the deep stuff.
It’s important to distinguish Pure O from a singular fleeting thought. All humans experience unwanted thoughts. However, non-clinical people, or those who don’t have OCD, are able to easily dismiss the thoughts as uncomfortable, weird, or just something their brain does. What distinguishes Pure O from a fleeting unwanted thought is the anxiety that becomes affixed to the thought, which then creates a significant amount of distress to the sufferer. As you’ve probably noticed throughout this series, the nature and type of Pure O obsessions vary greatly, but the central theme is the emergence of a disturbing, intrusive thought or question, an unwanted or inappropriate mental image, or a frightening impulse that causes the person extreme anxiety, because it’s typically oppositional to their religious beliefs, morals, or societal norms. The fears associated with Pure O tend to be far more personal and terrifying for the sufferer than those of someone with traditional OCD… scenarios that they feel would ruin their life or the lives of those around them, the stuff of nightmares. Not to minimize the fears associated with stereotypical OCD, but to illustrate the difference, think about being overly concerned about security or cleanliness, and then imagine being terrified that you’ve undergone a radical change in your sexuality, or that you want to molest your baby nephew, or stab your father. You might be a murderer, you might cause some harm to a loved one, or an innocent person, or to yourself… or maybe you are, or will go, insane. You don’t actually want to do these things, but your brain makes you doubt that, makes you think you might want to. You have to think about it all the time, just to be absolutely sure that you won’t. That’s the pure hell of Pure O.
People with Pure O understand that these fears are probably unfounded, that it’s highly improbable, or even impossible, that they would ever hurt anyone or themselves, but the anxiety they feel will make the obsession seem very meaningful and real. While people wwithout Pure O will usually instinctively dismiss any bizarre, intrusive thoughts as insignificant impulses that are part of the normal variance of the human mind, just doing its thing, someone with Pure O will respond with alarm, followed by a desperate attempt to neutralize the thought and banish it… anything to try to avoid ever having it again. Even though they usually realize that their fear is irrational, a fact which just causes even more distress btw, they’ll constantly ask themselves, “Am I really capable of something like that?” or “Could that really happen?” and they’ll continuously put tremendous effort into resolving or somehow escaping the unwanted thought. It ends up in a vicious cycle, as they mentally search for reassurance, while trying to get a definitive answer to the question(s). This is generally through creating specific mental rituals they must accomplish in order to reassure themselves their intrusive thoughts are untrue, or that they aren’t a bad person. They may repeat specific words, recite special prayers or mantras in their head, or mentally review certain images each time there’s a negative thought, in an effort to neutralize it.
People with Pure O often report that it’s these thoughts that make them incredibly anxious, that they can’t get out of their head. This is an important point: what ignites the symptoms of Pure O isn’t having the experience of intrusive thoughts, but actually the reaction to them. The more they hate the experience of the intrusive thoughts and try to repress, control, or fight them, the greater the frequency of intrusive thoughts they’ll experience. It’s the very act of trying to not have the thought(s) that guarantees they’ll resurface agaain and again. This is because Pure O is rooted in the faulty assumption that as humans, we have control over our thoughts, when in fact, not so much. The human brain has evolved to be constantly searching and seeking, aware and alert, to find interesting problems to solve, and to search for threats to safety and existence. In addition, the brain is hardwired to be particularly interested in thoughts that contain uncertainty, and OCD thoughts are the epitome of uncertainty. When the brain of someone with Pure O lands on a thought or question that’s unacceptable or fearful to the person having the thought, the fear network of the brain is alerted that something is wrong, and that something must be done about it IMMEDIATELY. It comes down to the fight or flight response, and it’s this fight or flight experience that causes the sufferer a great deal of distress.
Remember when I talked about perfectionism being a little unusual because it’s really a subtype of its own, but also a common feature of stereotypical OCD as well as the other OCD subtypes? Many people with Pure O also experience comorbid features of perfectionism. They tend to maintain a high overall standard for what their brain “should” be thinking, and the level of control they “should” have over their thoughts. Individuals living with Pure O will commonly berate themselves, saying things like “I shouldn’t be thinking this,” “These thoughts are wrong or bad,” and “I should be able to control these thoughts.” They spend a great deal of time analyzing why they’re having them, with negative self talk about what the thoughts say about them as a person. Sadly, for many sufferers of Pure O, failing to meet this self-imposed standard of control over their own brain will lead them to conclude that they are a bad person, when the truth is that they are not… their brain may be “disordered,” but this is not, and should not be, a reflection on them as a person. They’re typically their own worst enemy, and they need and deserve our empathy and understanding.
Now you know more about the dark side of OCD- that it’s not all cleaning, straightening, and arranging- and that brings us to the end of this series. Next week, new topic… I’ll surprise you… as soon as I figure out what I’m writing about.
I hope you enjoyed this week’s 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 MoreObesity:What Causes It and How to Combat it.
Obesity: What Causes it and How to Combat it
We’re nearly six weeks into the new year, and this is right about the time that most people toss their new year’s resolutions out the window. Many of them had resolved to lose weight: surveys have shown that, of the people who make new year’s resolutions, an average of 45% of them resolve to lose weight and get in better shape. So that means that nearly half of resolution-makers are overweight at least. That number seems high, but given that obesity has reached epidemic status, I guess it’s not that surprising.
Obesity is broadly defined as the state of being well above one’s normal weight. Obesity often results from taking in more calories than are burned by exercise and normal daily activities, aka ‘eating too much and moving too little.’ A person has traditionally been considered to be obese if they are more than 20% over their ideal weight. That ideal weight must take into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (NIH) by utilizing a person’s BMI, body mass index. The BMI is a key index for relating body weight to height, and it is formulaic. The imperial BMI formula is weight (in pounds) multiplied by 703, then divided by height (in inches²). If you don’t feel like dealing with the math, you can google a BMI calculator. Having a BMI of 30 and above is considered obesity. Over 70 million adults (35 million men and 35 million women) in the U.S. are obese, while 99 million (45 million women and 54 million men) are overweight and at risk for becoming obese.
What are the causes of obesity? Obesity can be complex, going beyond eating too much and moving too little. Following are some other factors that cause or contribute to obesity.
Genetics
Obesity has a strong genetic component. Genetic predisposition means that children of obese parents are much more likely to become obese than are children of lean parents. Genetics also affect the rate at which the body uses energy (burns calories) when at rest, which is called the basal metabolic rate. People with higher basal metabolic rates naturally burn more calories than other people, so they are less likely to gain weight. The opposite is also true: people with lower basal metabolic rates burn fewer calories, so they are more likely to gain weight. But these facts don’t mean that obesity is completely predetermined, that there’s no way to change it. What you eat can have a major effect on which genes are expressed and which are not. This is demonstrated when people of non-industrialized societies come to the U.S., begin a western diet, and then rapidly become obese. Obviously, their genes didn’t change, but their diet did; that changed the signals they sent to their genes, which then changed the expression of the genes. Changing the expression of the genes resulted in obesity. The bottom line is that genetics do play a key role in determining susceptibility to gaining weight and obesity, but that is only one factor of many; it is not all genetically predetermined.
Diet: What and How You Eat
Obviously, eating an unhealthy diet is a major contributing factor in obesity. Overeating at meals and snacking throughout the day can also lead to obesity. An unhealthy diet would be high in complex carbohydrates, bad fats, and sugar, and low in fresh fruits, vegetables, and high protein lean meats. There are social factors that affect diet and therefore weight. If you spend a lot of time with overweight friends and family who eat too much of an unhealthy diet, the odds are that you’ll be overweight as well. Economic factors also play a role in obesity. If you can only afford cheap, ready-made packaged foods or fast foods from the dollar menu, you are much more likely to be obese. Economics may force you to eat a diet high in complex carbs like pastas, breads, potatoes and rice just to fill yourself up, because that is all you can afford. That type of diet greatly increases the risk of obesity. Unfortunately, eating unhealthy foods and overeating are easy in our culture today. Many things influence eating behavior, including time with family and friends, the low cost of unhealthy but filling foods, and the access to and expense of healthy foods.
Lifestyle
If you have a lifestyle that centers on eating and/ or drinking, this can contribute to excess weight. A chef, bartender, or baker, something that requires tasting various dishes and trying new recipes for example. Also, someone who travels a lot for their job so always eats at restaurants, which are notorious for hidden calories and fat; they are more likely to be overweight and at risk for obesity. A sedentary lifestyle, where there is little to no activity or exercise is a huge contributing factor in being overweight or obese. Our modern conveniences- elevators, cars, remote controls- have cut activity out of our lives. The problem is that the less you move, the less active you are, the more likely you are to be obese. Being active helps you stay fit. And when you’re fit, you burn more calories, even when you’re resting, so you’re less likely to be overweight or at risk for obesity.
Medical Conditions
There are a host of medical issues that can cause or contribute to significant weight gain. Some examples are hypothyroidism, diabetes, Cushing syndrome, polycystic ovarian syndrome (PCOS), menopause, depression, and endocrine dysfunction. Some medical issues don’t cause weight gain in and of themselves, but make weight gain more likely because they limit the person’s activity. Some examples would include conditions like osteoarthritis, uncontrolled rheumatoid arthritis, and chronic pain syndromes.
Medications
The list of medications that can cause weight gain is a long one. Everyday medications like corticosteroids (Prednisone, Celestone), diphenhydramine (Benadryl), hormone replacements/ birth control, and even insulin are among the culprits. Sometimes it’s not the drug itself causing weight gain, it’s a side-effect from the drug. Some drugs stimulate your appetite, and as a result, you eat more. Others may affect how your body absorbs and stores glucose, which can lead to fat deposits in your body. Some cause calories to be burned more slowly by altering your body’s metabolism. Others cause shortness of breath and fatigue, making it difficult to exercise, while some drugs cause you to retain water, which adds weight but not necessarily fat. Some medications don’t cause you to gain weight outright, they just make it more difficult to lose excess weight you may already carry. A lot of psychiatric medicines cause weight gain. The worst offenders generally include mirtazapine (Remeron), paroxetine (Paxil), risperidone (Risperdal), aripiprazole (Abilify), and quetiapine (Seroquel). With the exception of Wellbutrin, essentially all classes of psychiatric meds can be associated with serious weight gain. As a psychiatrist, I have to prescribe meds that may cause an unwanted side effect like weight gain. I have to weigh the cost to benefit with each patient. Unfortunately, I have patients who are trapped; they must take certain medicines to remain stable, so they have to severely alter their food intake and diet every day of their lives in an effort to avoid weight gain if possible. That’s the cost to benefit ratio- they pay the cost of a severe diet in order to get the benefit of being stable psychologically.
Why should you care about your weight? What health issues does being overweight cause? The answer is many. Obesity leads to type 2 diabetes. It causes high blood pressure, which can cause strokes. Obesity can increase cholesterol levels and cause coronary artery disease, which is where deposits line the blood vessels that feed the heart and partially or totally block them, so the heart does not get adequate blood supply; this results in a heart attack, aka a “coronary” and this can easily be fatal. Being overweight puts excess weight on the human body, and this commonly causes osteoarthritis of major joints like the knees, the hips, and the ankles. All parts of the body are stressed and strained because they are not designed to carry around that much weight, and this limits the range of motion, mobility, and ability to walk. Obesity increases the risk of cancer to several organs and body parts: the breast, colon, gallbladder, pancreas, kidney, prostate, uterus, cervix, endometrium, and ovaries. Another common medical issue from being overweight is sleep apnea. All the weight on the chest and throat causes you to temporarily stop breathing when sleeping, until you finally noisily gasp for air. Sleep apnea is serious, and very disturbing for anyone that you share your bed with. Obesity causes a fatty liver, which then leads to liver disease and the potential to cause the liver to shut down. Obesity can cause gallstones as well as kidney disease, which can cause your kidneys to stop functioning. Obesity can also cause fertility problems in both men and women. As a psychiatrist, I get obese patients referred to me because obesity can directly cause, or indirectly lead to, various syndromes and other issues, including chronic pain syndromes, depression syndromes, isolation syndromes, social problems, self esteem issues, and difficulty dating. People who develop obesity, especially when it is the result of something beyond their control, like from a medical issue such as hypothyroidism, have all sorts of social interaction issues and work problems, and I can treat them and help walk them through it with psychotherapy.
We defined obesity, discussed the risk factors and what can cause it, and then the issues it can cause. Now let’s discuss how we can lose weight and prevent obesity.
Food Diary
To offset weight gain or to help work off excess weight, consider keeping a food diary tracking what you eat and when you eat. Becoming a mindful and aware eater is a great first step to managing weight.
Eat Slowly
Another factor which helps with weight loss is eating slowly. It takes some time for your stomach to tell your brain that you’ve had enough to eat. If you mindlessly shovel huge amounts of food into your mouth, you’ll miss your cue and overeat, and that obvi will cause you to put on weight and increase the risk of obesity. Eating slowly also has the added benefit of reducing the chances of having indigestion.
Get Physical
Become more active whenever possible. Instead of meeting someone for coffee or a movie, meet them at a park, beach, or green space and go for a walk. Ideally, you want aerobic activity; that means getting your heart rate up, when it’s harder to breathe. Aerobic activities mean constant motion, like running, biking, swimming, soccer, basketball, anything where you’re moving constantly. Constant activity is aerobic activity, and daily aerobic activity will raise your basal metabolic rate and you’ll burn more calories, even when you’re at rest.
Resist It
Resistance training is good for targeting fatty areas on the body. Resistance training involves moving a specific muscle against resistance, either using your own body weight or using standard weights. Other activities like lifting weights, doing push-ups, and doing squats are good for reducing body fat.
READ LABELS!
…and make sure you understand them. If you don’t understand them, do some research, get a library book on nutrition, ask a friend if they understand, or ask your doctor what the values all mean and how much of the various components should be included in a healthy balanced diet or when dieting in an effort to lose weight. Pay close attention to calorie count, fat grams, protein grams, sugar grams, and carbohydrate count. Just because something says “light” doesn’t mean it should be included in your diet. So many people are ignorant about nutrition information on food packaging. Be sure to know what those values mean and how much you should have of each every day.
Know the Fats
Trans fats- Bad fats!
Historically, trans fats are an evil on par with Satan himself, to be avoided at all costs. The worst type of dietary fat, trans fat is a byproduct of the industrial process of hydrogenation, which turns healthy oils into solids to prevent them from becoming rancid. Eating foods rich in trans fats increases the amount of harmful LDL cholesterol in the bloodstream while reducing the amount of beneficial HDL cholesterol. Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions. They contribute to insulin resistance, which increases the risk of developing type 2 diabetes. Even small amounts of trans fats can harm health: for every 2% of calories from trans fat consumed daily, the risk of heart disease rises by 23%. Mind blowing. Though they have no known health benefits, trans fats were found in most pre-packaged garbage foods and were the main component in margarine type spreads. I say ‘were’ because recent science found there is no safe level of consumption of trans fats, and as a result, trans fats have been officially banned in the United States and several other countries.
Monounsaturated fat- Good fats!
Evidence has shown that consuming monounsaturated fats has several health benefits, including reducing general inflammation in the body. Studies have also shown that a high intake of monounsaturated fats can reduce triglycerides, decrease the risk of heart disease, and lower bad LDL blood cholesterol while increasing good HDL cholesterol. A diet with moderate-to-high amounts of monounsaturated fats can also help with weight loss, as long as you aren’t eating more calories than you’re burning. These fats are liquid at room temperature. Good sources of monounsaturated fat include avocados, almonds, cashews, peanuts, cooking oils made from plants or seeds like canola, olive, peanut, soybean, rice bran, sesame, and high oleic safflower and sunflower oils.
Polyunsaturated fat- Good fats!
The two types of polyunsaturated fats (omega-3 and omega-6) are essential fats, meaning they’re required for normal bodily functions, but your body can’t make them, so you must get them from food.
Omega-3 fats are a type of polyunsaturated fat that, like other dietary polyunsaturated fats, can help to reduce your risk of heart disease. Omega-3s can lower heart rate and improve heart rhythm, decrease the risk of clotting, lower triglycerides, reduce blood pressure, improve blood vessel function and delay the build-up of plaque in coronary arteries.
Omega-6 is a polyunsaturated fat that lowers bad LDL cholesterol. Eating foods with unsaturated fat, including omega-6, instead of foods high in saturated fats helps to get the right balance for your blood cholesterol (ie lower bad LDL and increase good HDL). Sources of polyunsaturated fats include oily fish (like salmon, mackerel, sardines), tahini (a sesame seed spread),
linseed (flaxseed) and chia seeds,
soybean, sunflower, safflower, and canola oil, margarine spreads made from those oils, pine nuts, walnuts, and Brazil nuts.
Follow these easy ideas for getting the balance of blood cholesterol (LDL and HDL) right.
– Go nuts! Nuts are an important part of a heart-healthy eating pattern. They’re a good source of healthier fats, and regular consumption of nuts is linked to lower levels of bad (LDL) and total blood cholesterol. So, include a handful (30g) every day! Add them to salads, yogurt, or your morning cereal. Choose unsalted, dry roasted or raw varieties.
– Go fish! Include fish or seafood in your family meals 2 – 3 times a week. Fish are great sources of the good omega-3 fats. If you don’t eat fish, you can take an omega-3 supplement.
– Use healthier oils! Choose a healthier oil for cooking. For salad dressings and low temperature cooking, choose olive, peanut, canola, safflower, sunflower, avocado or sesame oils. For high temperature cooking, especially frying, choose olive oil or high oleic canola oil, as they are more stable at high temperatures. Store oils away from direct light and heat and don’t ever re-use oils that have been heated before.
Eating polyunsaturated fats in place of saturated fats or highly refined carbohydrates reduces blood pressure, raises good HDL cholesterol, reduces harmful LDL cholesterol, lowers triglycerides, and may even help prevent lethal heart rhythms.
Saturated fat- OK in strict moderation
Saturated fats are common in the American diet, and they are solid at room temperature- think along the lines of cooled bacon grease. Common sources of saturated fat include red meat, whole milk and other whole-milk dairy foods, cheese, coconut oil, and many commercially prepared baked goods and other foods. A diet rich in saturated fats can drive up total cholesterol and tip the balance toward more harmful LDL cholesterol, which can prompt heart disease from blockages formed in arteries in the heart and elsewhere in the body. For that reason, most nutrition experts recommend limiting saturated fat to under 10% of calories a day. Replacing excess saturated fat with polyunsaturated fats like vegetable oils or high-fiber carbohydrates is the best bet for reducing the risk of heart disease.
Diet Do’s
– Eat plenty of fiber. Fiber fights belly fat. When ingested, fiber goes into your system, binds to and then forms a sort of gel with the food, which slows down the absorption of food in the gut.
– Eat a high-protein diet. Eggs are eggsellent…high in protein and low in fat. Avoid red meat. All meats should be lean and high in protein, like chicken or turkey. Nuts are also good for a protein snack.
– Eat fish, as often as 2-3 times per week for good omega-3’s. As discussed above, oily fish like salmon, mackerel, and sardines are high in omega-3’s which are good for the brain, help to decrease weight, and have numerous other health benefits. If you don’t eat fish, take a good omega-3 supplement.
– Drink green tea; there are reports that it helps with weight loss, and it’s generally just good for you.
Diet Don’ts
– Don’t eat sugary foods or anything with sugar in it: sodas, candies, cakes, cookies, doughnuts; those are the main culprits. It’s a major bummer, but to avoid weight gain in your life, much less to try to lose weight if you’re already overweight, you must avoid sugar like the plague. Wah wah wah…
– Cut out the carbs! To lose weight or just to avoid putting weight on, anything with white flour must go, so say syonara to pasta and most breads. You have to cut way down on starches, if you’re allowed them at all, so there goes rice and potatoes. And while most people consider corn a vegetable, you must count it as a starch when dieting.
– Get on the wagon! If you drink alcohol, you won’t lose weight and keep it off. Won’t happen. When you consume booze of any sort- beer, wine, liquor- the alcohol is immediately converted to sugar, and if you’ve forgotten, see Diet Don’t 1 above. There’s no point in restricting calories, fats, etc by following a diet and also drinking alcohol at the same time, even a small amount.
Go to Bed!
Sleep is critical if you want to lose weight, so aim to sleep at least 7-8 hours each night. If you do not get proper sleep, it will be very difficult (if not impossible) to lose weight, and you will likely gain weight. This is all thanks to brain chemistry and hormones, which get all fouled up with sleep deprivation.
Stress Less!
You have to reduce stress if you want to lose weight. When you are stressed, your body produces the stress hormone cortisol, and cortisol increases appetite and increases belly fat by selectively placing fat deposits around the stomach and middle of the body.
A Fast Fast
We’ve always been told that starving ourselves will not result in weight loss, and that it will even result in weight gain because the body goes into ‘starvation mode.’ Well, there are some recent studies out there that conclude that intermittent fasting, 24 hours without eating, once or twice a week, actually helps with weight loss. Very interesting.
So that’s all about obesity: what causes it, what it causes, and how to combat it. We are a fat society, and the number of cases of obesity goes up every day. It’s disturbing because it’s essentially a preventable issue.
For more information and interesting stories on other diagnoses, check out my book, Tales from the Couch, available in my office and on Amazon.com.
Learn MoreHow to Improve Social Skills
Through the years I’ve had lots of patients ask me how to interact with people and how to be social, the mechanics of it, so I want to give some rules of the road, social skills 101 if you will. First, let’s talk about why social skills are important. Social skills are the foundation for positive relationships with other people: friends, partners, co-workers, bosses, neighbors, on and on. Social skills allow you to connect with other people on a level that is important in life, a level that allows you to have more in-depth relationships with others rather than meaningless surface relationships that have no benefit to anyone. Once you understand the value of having good social skills, you need to want them for yourself and commit to working on them, because that may mean doing new things that may be uncomfortable at first. So, how would you start to improve social skills? Well, socialization is an interaction, so you need at least one other person to socialize with. So the first step is to put yourself among other people. Basically, you have to suit up and show up to socialize. You might feel wierd or shy at first, but don’t let anxiety stop you. If you’re not around other people to socialize with, you’re obviously not going to improve your social skills. So take a breath and dive in.
Step number two, put down the electronics. If you’ve put yourself in a social situation, you may be tempted to fiddle with your phone to avoid the awkwardness of just standing there, but when you’re around people, turn the phone off. You shouldn’t be disrupted, you can’t be distracted, and you can’t be checking email, messages, notifications, etc. Those things will get you to exactly nowhere. When you’re distracted, you won’t pay proper attention to the social setting you’re in, and since that’s kind of the whole point, put it away and keep it there.
So you’re in a room with plenty of folks to socialize with, your phone is tucked away, so what’s next? Well, if you want to interact with people, socialize with people, you have to look like it. You can’t put yourself in a corner with your arms crossed and a disinterested look on your face. Step three is to demonstrate an open, friendly posture. You need to be inviting to others who may want to talk to you. Put on a friendly face – you’ll be surprised at how many people approach you when you look approachable.
As they say, the eyes are the entries to the mind. Step four is to always maintain good eye contact. This is hugely important when conversing, but fleeting eye contact also comes in handy when you’re just circulating in a room or looking for someone to strike up a conversation with. Eyes can entirely change a facial expression and easily convey mood and interest. Without eye contact, there is limited communication, and social skills are compromised without appropriate eye contact. Eye contact is so integral to communication that some people say they can tell if someone they’re talking to is being honest or lying by their eye contact, or the lack thereof.
To communicate well, you must pay attention to your equipment…your speech. So step five is remember your speech: the tone, the pitch, the volume, the tempo, the accent. Right or wrong, people will judge and label you by your voice. A man’s voice that’s too loud is a turnoff, he comes off as a blowhard. A woman’s voice that’s too soft is annoying because people have to try too hard to hear her, and people may say she’s a sexpot, a la Marilyn Monroe. If she speaks at too high a pitch, she’s a bimbo. To some, a southern accent means you’re dumb and a northern accent means you’re a hustler. Speaking too slowly or too fast is annoying, too monotone and you’ll put people to sleep. On the flip side, a singer or actor with perfect pitch or an especially unusual or dulcet tone can build a legacy based just on their voice, a voice that will be instantly recognized for all time. When it comes to the way you speak, be aware and make alterations to be distinct and easily understood. Remember voice inflection, because monotone is a tune-out and turnoff. Speech should be like a story, with highs and lows, ups and downs to hold people’s interest.
After reading step five above, you might think that developing good social skills hinges on everything you say, but that leaves out a key factor…listening. Step six on the path to developing good social skills is to be a good listener. Just listen. Eazy peazy lemon squeazy. Now, if you’ve ever in your entire life enjoyed speaking to someone who clearly wasn’t listening to anything you said, raise your hand. Any takers? Anyone? I thought not. It is annoying AF when it’s so obvious that someone’s not listening to you speak. And you don’t want to be annoying AF, do you? I thought not. Social skills aren’t just about what comes out of a person’s mouth, so listen.
A great way to deal with nerves that may accompany you when you put yourself in a social situation and talk to people is to find commonality, so this is step seven. When you first meet someone, a sense of commonality is a great way to establish a quick rapport with them. Commonality is something you share. It could be something as simple as going to the same school, a shared interest in sports, same places where you’ve lived or hobbies in common. Step seven is to find commonality with someone; something simple to break the ice and establish a conversation.
Once you’ve begun a conversation with someone and you want to further it, you need to go beyond just commonalities. You need to relate to the person on a deeper level. How do you do that? Through step eight, empathy. Empathy is the ability to relate to someone by putting yourself in their position in order to understand them better. If someone has a dying parent, has just lost their job, if someone is lonely, has ended a relationship, didn’t get a promotion, or experiences anything that elicits an emotional response, being empathetic is the ultimate understanding of their pain, their sorrow, or their disappointment. Step eight in improving social skills is the ability to put yourself in someone else’s shoes in order to have genuine empathy for that person. A key word here is genuine. As a general rule, good social skills are genuine. Lip service is not part of good social skills.
Step nine is a pretty simple concept, though not so much in practice. Respect. In order to learn good social skills (and have anyone to practice them on) you must respect what other people say. I did not say agree. You can completely disagree with their opinion, but step nine is that you must respect their right to have it and include it in the conversation.
While in theory you have the right to say anything you want in your social circle, you should watch what you say. Step ten is to consider the content of your conversation. There are certain things that shouldn’t be brought up in some situations. As they say, religion and politics are big no no’s for sure. Gossiping is also on the no list, because it’s really toxic to a conversation and leaves people scratching their heads. If you’re talking about Mary to Connie, Connie’s bound to wonder what you say about her when you’re speaking to Shelly. So it’s best to just not talk about people. But I think it was First Lady Dolly Madison who said “If you don’t have anything nice to say, sit next to me” Some people do like gossip, the jucier the better. But you have to be prepared to pay the piper. A conversation can be like a minefield, with certain subjects as the mines. You have to navigate through the whole conversation without blowing yourself to smithereens.
In order to have appropriate social skills, you must consider the non-conversational parts of social interaction. If you’re so drunk that you can’t speak or no one can understand what you’re saying, obviously you can’t use good social skills. Same goes for drugs. If you take a Xanax to calm your nerves before the company mixer, you will not have appropriate social skills. You may not think people can tell, but you’d be wrong. Step eleven is about intoxicants like alcohol, marijuana, benzodiazepines, and Adderall… they all make you act weird and affect your social interactions, and people pick it up right away. They may not know what drug you’re on, but they’ll know you’re on something for sure, because your social interactions will be inappropriate. Rule eleven: you cannot interact appropriately when using drugs or alcohol, so cut both out if you want to have good social skills.
If you follow these steps, you’ll definitely learn better social skills. And a breath mint wouldn’t hurt. Like with anything else, practice makes perfect when it comes to social graces. Be positive, open, honest, empathetic, clear, respectful and sober, and you’ll never be at a loss for people to talk to. You’ll navigate the waters of conversation deftly with give and take, and all included will come out feeling positive about the interaction.
Learn MoreCOUPLES AND CONFLICT
Couples and Conflict
One of my foremost jobs as a psychotherapist is to be a listener. All day, every day people come to me to talk about their problems. As you can imagine, many times patients want to talk about their spouses, specifically how they fight with them. So I want to talk a little bit about couples and fighting. Whether it’s about money, children, career, housework, all couples fight. Nobody gets along 100% of the time without some conflict. It’s all a matter of how you resolve that conflict. I had a patient named Roxanne come in for her session yesterday, and she told me that she and her husband Bill fight all the time. One yells at the other and the other yells back louder until it reaches a terrible crescendo and both storm off in opposite directions. She said she had no choice in this, he just made her so angry and they just didn’t get along. I told her that the first thing that had to happen for the relationship to move forward was to decide that it wasn’t his fault and wasn’t her fault, it was both of them. She immediately recoiled and told me I was dead wrong. That it was all Bill’s fault. He was never home, he didn’t want to be a part of the family, he this, he that, ad nauseum. I asked her about how they fight, her yelling and screaming…was it working? Was it resolving anything? She launched in again, saying it wasn’t her fault, it was his fault because he made her yell. He antagonized her. I told her that she didn’t have to go to every fight he invited her to, she had the choice. This is a point that I think a lot of couples miss. Just because your spouse may be baiting you, looking for a fight, it doesn’t mean you have to give them what they’re looking for. You don’t have to respond at all. You have a choice in how you behave.
I explained to Roxanne that the only way to start to resolve an issue is to not yell and scream, not raise a voice. Once you express anger, you’ve made the situation worse. I suggested to her that the only way to make the situation better when Bill is yelling and screaming is to fall silent. Until the yelling stops, nothing productive can be accomplished. A conflict cannot be resolved through warfare. Once people raise their voice, no interaction happens. For instance, if you raise your voice at a child, they shut down. They will hear nothing you say. The same happens in couples. If one raises their voice at the other, from that moment forward, nothing constructive happens. So, if you’re married or in a relationship and you find you are having problems or there is fighting, and yelling, you are responsible for your response, and your response should be to not yell back, fall back. All yelling does is put fuel on the fire. If you fall silent, eventually they will stop yelling, and once the yelling stops, resolution can start. You can begin a conversation by discussing what the problem is, why you keep arguing, and what you can each do to make things better. That’s the only way these things will really be resolved. But you have to be willing to change how you respond to conflict and how you fight. Learn to fall back if baited. Talk should replace screaming matches.
I hear so often in my office “it’s not me, it’s him, it’s her, they’ll never change, we tried that” blah, blah, blah, blah. If you really want to effect change in your relationship, change your own behavior and then the reaction you get back from your spouse or partner will change. Stop yelling and start conversing. Focus on what you can each do to make the relationship better. To resolve conflict, cooler heads should always prevail over heated emotions.
Learn MoreThe Thyroid
The Thyroid
Hello people! Last week was a light one on dark chocolate (ha ha?) but as promised, today marks the start of a new series on thyroid disease. If you’re wondering why I, a shrink, would care about the thyroid, the answer’s simple: because when it’s a problem, it’s a real problem, because it can affect nearly every aspect of your life, including your mental health. But when it comes to the thyroid, you’re about to find out that that’s where the simplicity ends.
Before we can talk about how the thyroid can affect you, first we have to talk about what it is. The thyroid is a butterfly-shaped endocrine gland that’s found in the forward aspect of the middle of the neck, just below the larynx, or voice box. Its two lobes, left and right, lie on either side of the windpipe, and are each about the size of a halved plum. These lobes are analagous to the wings of the butterfly, and they are joined by a small bridge of thyroid tissue called the isthmus.
Notice I said it was an endocrine gland? The endocrine system is made up of glands that make hormones, which are the body’s chemical messengers- they carry information and instructions from one set of cells, glands, and organs to others. In doing so, the endocrine system influences almost every cell, gland, organ, and function of the body. That’s what makes the thyroid so important- because it’s a big part of the endocrine system, along with the other major glands, including the hypothalamus, pituitary, parathyroid, adrenal, pineal, and the ovaries and testes.
The hormones made by the various glands of the endocrine system are released into the bloodstream, and they travel to cells in other glands and organs where they help control organ function, mood, growth and development, metabolism, and reproduction. The amounts of hormones produced and released is highly regulated, and depends on levels of other hormones already in the blood, other minerals like calcium in the blood, the blance of water and other fluids in the body, and external factors such as stress and infection, just to name a few. Because hormone production and levels are all interlinked- one dependent upon another- it’s important that these levels remain normal. Too much or too little of any one hormone affects production and release of multiple others, so it can affect several organ systems, and cause nearly endless physical and emotional symptoms. This can make you feel very ill, a little “off,” or anything in between.
The Pituitary Gland
Even though this series is on the thyroid, I can’t rightly talk about it, or the endocrine system, without mentioning the pituitary gland. The pituitary is a pea sized gland located at the base of the brain, but don’t let its size fool you, because mighty things can come in small packages. In fact, the pituitary is often called the “master gland,” because the hormones it makes control many of the other endocrine glands. The pituitary also happens to be one of my faves- and it should be one of yours too- because it secretes endorphins, the body’s natural feel good chemicals, the ones that act on the nervous system to produce feelings of pleasure and reduce feelings of pain.
The pituitary gland makes many other hormones, including growth hormone, which stimulates the growth of bone and other body tissues; prolactin, which activates milk production in breastfeeding women; corticotropin, which stimulates the adrenal gland; antidiuretic hormone, which helps control the balance of body water through its effect on the kidneys; and oxytocin, which triggers uterine contractions during labor. But the pituitary hormone that’s most germaine to today’s topic is thyrotropin, more commonly known as thyroid-stimulating hormone, or TSH. Once secreted by the pituitary, TSH, as its name suggests, stimulates the thyroid to synthesize and release thyroid hormones.
In response, the thyroid produces thyroxine and triiodothyronine, more commonly known as T3 and T4, respectively. These hormones control the rate at which cells burn fuels from food to make energy. They basically regulate the body’s metabolism- the rate at which the cells of the body use and store energy. I’ll get into that in a moment, but because they control such a basic function, you can clearly see that thyroid hormones are essential for all the cells in your body to work normally. If that weren’t enough, they also play a role in bone growth and development, as well as that of the brain and nervous system. Just to add another level of complexity, there are also four other tiny glands attached to the thyroid gland called the parathyroids. They release parathyroid hormone, which, along with help from another thyroid hormone called calcitonin, controls the level of calcium in the blood. And if you remember, calcium is one of those minerals in the blood that controls the production and release of other hormones. Yikes!
Believe it or not, this is as simplified as the endocrine system- and the thyroid- really gets, people, so if you’re thinking all of this is super complicated, you cannot even imagine if you just go by this! As a matter of fact, there’s an entire (underappreciated) specialty medical field devoted to this alone… so thank you endocrinologists!
Thyroid Function: Metabolism
As I mentioned before, thyroid hormones regulate the body’s metabolism. Many people think that just means how many calories you burn, but metabolism is a complicated process, one that’s happening 24/7, no matter what you’re doing. That’s even reflected in its literal meaning, which is “a state of change.” Your body relies on metabolism to carry out all of its functions, whether it’s storing or burning fat, regulating sugar levels, or keeping your neurons firing; so metabolism has a huge impact on your health. The three main purposes of metabolism are: the conversion of food to energy to run cellular processes, the conversion of food/ fuel to the body’s building blocks, and the elimination of metabolic wastes.
Thyroid Imbalance
This intricate involvement with such an important, universal bodily process is why diseases of the thyroid have such an extreme and varied impact on human health. But (thankfully) all of it boils down to two basic conditions: having too much thyroid hormone results in a condition called hyperthyroidism, while having too little thyroid hormone is called hypothyroidism. Generally speaking, in hyperthyroidism, when there is too much thyroid hormone, your body processes speed up, and the body uses energy very quickly. And in hypothyroidism, when you don’t have enough thyroid hormone, your body processes slow down, and the body uses less energy.
That’s probably a good place to stop for this week. It’s been a while since I’ve had to write an endocrine overview, people! Next week, we’ll start getting into the meat and potatoes when it comes to thyroid imbalance- how it can affect you. Something to look forward to.
I hope you enjoyed today’s blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
Please feel free to share the love! Share blogs and YouTube videos with family and friends.
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And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
MGA
Learn MorePersonality 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 MoreThe Dark Side Of OCD
The Dark Side of OCD
Hello, people… hope everyone had an awesome weekend! Was it perfect? Because last week, we talked about POCD, perfectionism OCD. This subtype is pretty self explanatory; it’s the obsession with being perfect. Perfectionism is a little unusual, as it can exist outside of OCD, underlie many OCD subtypes, and be a subtype all on its own. In people with stereotypical OCD, perfectionism contributes to the need to do a ritual perfectly, or have things arranged just right. But when it’s extreme, when it’s rooted in obsession(s), followed by compulsion(s), and causes dysfunction in the person’s life, perfectionism can really be thought of as its own OCD subtype. Perfectionists rigidly adhere to the belief that things must be done in a certain way- perfectly- or not at all. It’s a tough way to live, and the pressure to constantly achieve this standard often becomes so great, at times it’s far easier for them to give up on doing something altogether. This week, we’ll be talking about Scrupulosity OCD, which involves obsessions with morality, being good or evil, or sinning; and Sexual Orientation OCD, obsessions involving one’s sexuality.
I love the word scruples… it’s fun to say. Scruupullzzz. Scruples are the moral principles or beliefs that make you unwilling to do something that seems wrong. Having scruples is kind of like having a conscience… when you’re considering doing something shady, that little knot in the pit of your stomach is brought to you courtesy of your scruples. Fun fact, a scruple is also a unit of weight in old school pharmacy- equal to 20 grains- so sometimes “a scruple” means a minute amount. I drink my tea with a scruple of honey. Okay, sometimes maybe a little more.
Scrupulosity OCD is usually thought of as an obsession with sinning or offending God- common concerns include devil worship, blasphemy, and hell- but it’s not always focused on religion. Secular or moral scrupulosity is more about right and wrong, and being a “good” or “bad” person. While research shows it’s common in orthodox Jews and Catholics, up to 25 percent of people with scrupulosity OCD say that they have no religious affiliation at all. It runs the gamut; I’ve seen very pious, religious people with scrupulosity OCD, as well as people who’ve never even gone to a church service.
I recall a patient who was not raised in the church, who thought he was never going to find God. This internal doubt turned into obsession, requiring various rituals he had to complete. It started with conquering fears to prove that he was worthy; he had to challenge himself to conquer any fear that came up in his daily life. Then, he started to worry that he had already done something horribly wrong, something unforgivable, and as a result, God would never reveal Himself to him. To fix it, he had to do everything correctly, to be a good person, if he had any hope of finding Him. He was always scared that he was off “the path” and constantly tried to find ways to prove that he was on the path. He got totally obsessed with it, and every little decision that he made became monumentally important for how to do the right thing and be on the right path. He became so obsessed with getting on, staying on, and proving he was on the right path, his life deteriorated. He couldn’t get his homework done, couldn’t complete tasks or chores, or go out with friends. Eventually, his scrupulosity led to complete avoidance; he stayed away from people, avoided churches like the plague, and would even get scared whenever anyone would mention the devil or say the word ‘Satan.’ Until he started treatment, his thoughts only intensified, and he was sure that he was going to go to hell.
Some other patients I recall include a woman obsessed about whether or not she felt enough empathy for people she saw suffering in fundraising specials on TV. She also obsessed about not recycling every single scrap of recyclable material, thinking it made her a bad world citizen, someone who didn’t care about the greater good. I remember another woman had to imagine the people she loved with a protective halo surrounding them at all times, to prevent them from being harmed. She was convinced that if she imagined them without it, a horrible fate would befall them.
OCD has a knack for latching onto whatever matters to the person, and that’s why scrupulosity can often strike people whose religion matters a great deal to them. And this can also make it hard to design exposures for therapy. The goal isn’t to make someone violate their true religious beliefs; you don’t want to force a kosher person to eat something unkosher. Instead, you challenge them with feelings of doubt; give them something kosher, but don’t allow them to triple check that it is. Or challenge a secular scrupulosity OCD patient from seeking reassurance that they’re not going to hell, or that they’re a good person.
In my research, I read about an exposure for one scrupulosity patient that was interesting to say the least… he had to go into a church, put up his middle finger and say “F@*k you, God.” Clearly, the idea was to do very blasphemous things, completely contrary to everything he was taught as a kid, in order to show him that God wasn’t going to smite him. In the interview, he said that it was extremely difficult for him to do at the time, but it made him realize that the less he let scrupulosity take over, the more faithful he felt. His therapist told him, “Every ritual resisted is an act of faith,” and those are the words he went by to help stop his compulsions. He decided that listening to the therapist, rather than listening to his OCD, was going to better demonstrate the faith that he was brought up with, as opposed to doing his various rituals. He was at a point where he was willing to do whatever it took, and he amazed himself when he lived through the anxiety. Thankfully, now he notices his thoughts, but doesn’t have to act on them. He can let them go, not dwell on the devil or hell, without reacting compulsively to fix the anxiety. Pretty powerful stuff.
Sexual Orientation OCD
SO-OCD is characterized by obsessions and intrusive thoughts revolving around a person’s “true” sexual orientation. It has been referred to as homosexual OCD or H-OCD, but this term is somewhat misleading, and is increasingly discouraged due to its lack of sensitivity. In reality, SO-OCD can happen to people of any sexuality, about any other sexuality. It goes beyond just questioning your sexuality; because sexual desire is such a fundamental issue, and sexual orientation is such a big part of a person’s identity, SO-OCD often causes a great deal of internal distress, and sadly, shame. The truth is that though we’ve come leaps and bounds as far as acceptance goes, we’ve still got some ground to cover there. Constantly questioning, while simultaneously hiding the questioning, of something so fundamental causes a great deal of internal strife and anxiety. Keep in mind that OCD has that penchant for latching on to what a person values, so with SO-OCD, it can feel like there’s nearly endless fuel for these obsessive thoughts and anxieties.
Someone with SO-OCD may experience fears about being perceived or labelled as having a certain sexual orientation, such as gay or straight. Or they might wonder if they’re actually of an orientation other than the one they thought; they may fear they’re in denial of their “true” sexual orientation. Or, they might fear that their sexual orientation could abruptly change, that they could “turn” gay or straight, and worry what this change will mean for their life. For example, will they have to leave their family? Will their relationship end when their partner discovers they’re not who they think they are?
They often constantly assess or question their behaviors and attraction levels to potentially nearly every person encountered, and can be excessively concerned with whether their behaviors align them with a particular sexual orientation. Asking things like: “I was attracted to that guy back there. This must mean I’m gay.” or “He’s attractive. Was I really into that last girl when we dated… or am I more into guys?” or “What if I’m actually straight and I’m not really in love with my partner?” These thoughts can really take hold of a person’s mind, and they won’t let go until they’ve found sufficient proof that their fears are unfounded. But as with all types of OCD, any relief they may find is only temporary, it’s only a matter of time before the cycle begins again. The most common compulsions to quell these anxieties often involve looking at pictures of women or men to see if you’re attracted to them, repeatedly asking people if you seem straight to them, and/ or avoiding people of the same sex altogether to avoid any confusion or complications.
These intrusive thoughts and compulsions can be extremely distressing, and interfere with a person’s relationships bigtime. And we mentioned religion in our discussion of scrupulosity OCD, and it often plays a role in SO-OCD… it’s fairly common for people to fear going against a religion they were raised in or that their family believes in. Remember in the first blog of this series, I explained that OCD is a disorder of doubt? Well, SO-OCD isn’t so much about their actual sexual identity or orientation, it’s about the doubt that’s common among all subtypes of OCD. It’s really the same uncertainty that exists for everyone, that’s part of human nature… multiplied many fold by confusion and divided by doubt. It’s a tough equation. Nearly every SO-OCD patient I’ve treated has been unconcerned with which orientation fits them, they just want to know with 100% certainty what their sexual orientation is, just as everyone else does. This is how and why people of any orientation can have SO-OCD. Because sexual orientation plays such a big part of a person’s life and identity, and because OCD tends to latch on to what an individual values, it can feel like there is endless fuel for the intrusive thoughts and the anxiety that accompanies them. Altogether, it can make for a debilitating and life altering disorder.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
MGA
Learn MoreThe Deal on Vitamin D
The Deal on D
Hello, people! Last week, we finished our series on personality disorders. Now that everyone has “properly diagnosed” their coworkers, friends, neighbors, and family, we’ll be having a quickie two part piece on vitamin D before starting a new series.
Chances are, your parental units always told you “Drink your milk!” Why? Because it contains vitamin D, which is essential, along with calcium, to maintain healthy bones and teeth, just like they said… but vitamin D does a whole lot more than that. More on that in a few. First, let’s talk about what it is.
Adolf Windausin was awarded the Nobel Prize in 1928 for his role in the discovery of vitamin D. Everyone thank Adolf… Thanks for that Adolf, good job! But despite its name, vitamin D isn’t actually a vitamin, it’s really a neuroactive steroid. It’s a hormone, just like testosterone, estrogen, corticosteroids, and our thyroid hormone friends we talked about in a series several weeks ago. Vitamin D is required to absorb and metabolize calcium, but it’s about more than just bones and teeth. Almost every cell in your body has a receptor for vitamin D, and it’s essential to many processes. Vitamin D is a transcriptional regulator for a large number of genes important for brain function, meaning it influences their expression, and is required for normal brain development. It’s involved in homeostasis, and it regulates melatonin production, the hormone involved in the human circadian rhythm and sleep patterns. It supports good lung function and cardiovascular health, and is involved in regulating insulin levels. And it happens to be responsible for stimulation of the most important antioxidant in the brain, the neuroprotectant glutathione, or GSH. Antioxidants like GSH help to counteract free radicals, the nasties that contribute to aging and some diseases, possibly even cancer. As it increases GSH production, vitamin D helps protect the body from their damaging effects.
Generally speaking, vitamins are nutrients that the body cannot create on its own, so a person must consume them in their diet, or boost intake through supplements. However, vitamin D is a little unusual, in that the body can produce it as a response to sun exposure… as long as you’re not wearing sunscreen or are covered by clothing head to toe, mind you. Sensible sun exposure on bare skin for 5 to 10 minutes, two or three times per week, allows most healthy people to produce sufficient amounts of vitamin D. Even though it’s easy to get a dose of D, many healthy people are D-ficient ha ha. Depending on the reference, anywhere from between 42 and 64 percent of the American adult population has low levels, but hypovitaminosis D has been shown to be even more common among older adults, with some references indicating it affects up to 90 percent of the elderly population. Deficiency is fairly common across the board, but is of special concern in pregnant women, as the fetus relies completely on maternal stores. More on the potential effects during pregnancy will be discussed in a moment. Studies have demonstrated that deficiencies play a role in a wide range of diseases and disorders, including autoimmune/ inflammatory, cardiovascular, neuropsychiatric, and more. Supplemental vitamin D has been shown to be beneficial as part of a treatment regimen for some of these conditions. On that note, I should mention that two forms of vitamin D exist, D2 and D3. D3, or cholecalciferol, is the more powerful of the two types, and this is the supplemental form that’s naturally present in the human body.
Where and How Much?
Getting sufficient sunlight is the best way to help the body produce enough vitamin D. Otherwise, it’s always best to get nutrients from natural dietary sources, but good D3 supplements are inexpensive, and that may be the way to go if levels are low. Plentiful food sources of vitamin D include fatty fish, such as salmon, mackerel, and tuna; egg yolks, cheese, beef liver, mushrooms, fortified milk, and fortified cereals and juices. How much vitamin D you need depends on many factors, including age, ethnicity, latitude, season, and amount of sun exposure. Dosage is measured in micrograms (mcg) or international units (IU). One microgram of vitamin D is equal to 40 IU. The National Institutes of Health (NIH) recommends an average daily intake of 400 – 800 IU, or 10 – 20 micrograms, but some studies indicate that the daily intake needs to be higher if you’re a couch potato, aren’t exposed to the sun, or have darker skin tones. Please note that everyone processes and absorbs substances differently, and your levels can be checked in an annual physical, or sooner if you suspect you’re low. Home test kits are undoubtedly available on the interwebs. Don’t forget the kids when it comes to supplements. Children younger than 12 months old need 400 IU each day, while children 12 to 24 months old need 600 IU. Drops are available for ease of dosing.
Depending on who you ask, blood levels above 20 ng/ml or 30 ng/ml are considered as “sufficient.” One study of healthy adults showed that a daily intake of 1,120 – 1,680 IU was needed to maintain sufficient blood levels, but the same study showed that deficient individuals needed 5,000 IU each day to reach the same level. It’s all relative, people. Studies in postmenopausal women with vitamin D levels below 20 ng/ml found that ingesting 800 – 2,000 IU raised blood levels above 20 ng/ml. However, proportionally higher doses were needed to reach the 30 ng/ml level. People who are overweight or have obesity may also require higher amounts. All things considered, a daily vitamin D intake of 1,000 – 4,000 IU, or 25 – 100 micrograms, should be enough to ensure optimal blood levels in most people.
For people with vitamin D deficiency, it may be appropriate to use up to 50,000 IUs weekly for up to three months, or until levels become normal, and then switch to a maintenance dose, usually between 2,000 and 5,000 IU daily. But Captain Obvious says that needs to be documented and handled by a physician. If you don’t have a deficiency and you take that much, you might be sorry. According to the NIH, the safe upper limit is 4,000 IU. Make sure not to take more than that without consulting with a healthcare professional. Excessive consumption of vitamin D supplements can lead to over calcification of bones, and the hardening of blood vessels, as well as kidney, lung, and heart tissues. The most common symptoms of excessive vitamin D include headache and nausea, but it can also cause loss of appetite, dry mouth, a metallic taste, constipation, and diarrhea.
D-ficiency
Although the body can create vitamin D, a deficiency can occur for many reasons. Darker skin, sunscreen use, and the time of year reduce the body’s ability to absorb the ultraviolet radiation B (UVB) rays from the sun, and this is critical to produce vitamin D. Deficiency during pregnancy is especially concerning, as it may lead to a greater risk of mom developing gestational diabetes, preeclampsia, and having preterm birth.
Recent evidence in clinical literature suggests that the development of autism spectrum disorders may be attributable to maternal vitamin D deficiency. In addition, vitamin D is a critical contributor to immune function during pregnancy, and the placenta contains the considerable amount necessary for fetal development. Vitamin D deficiency can also increase risks of inflammatory and infectious diseases given its role in innate and autoimmunity. There are receptors for vitamin D throughout the entire central nervous system and in the hippocampus of the brain. It activates and deactivates enzymes that are involved in neurotransmitter synthesis and nerve growth. Studies suggest it protects neurons and reduces inflammation, and deficiency is associated with several medical conditions, including Alzheimer’s disease, dementia, Parkinson’s disease, autism, OCD, sleep impairment, infectious/ inflammatory diseases, and autoimmune disorders such as diabetes and rheumatoid arthritis. Symptoms of vitamin D deficiency may include regular sickness or infection, fatigue, bone and back pain, low mood, impaired wound healing, hair loss, and muscle pain. If vitamin D deficiency continues for long periods of time, it may result in serious illness, including cardiovascular conditions, autoimmune problems, neurological diseases, infections, pregnancy complications, and certain cancers, especially breast, prostate, and colon.
Illnesses Linked to D-ficiency
Skeletal/ Bone Health Issues
Vitamin D deficiency in children can cause rickets, a disease which leads to a severely bowlegged appearance due to the softening of the bones. In adults, vitamin D deficiency manifests as osteomalacia, or softening of the bones, a condition that results in poor bone density and muscular weakness. One of vitamin D’s primary roles is to maintain skeletal health through a synergy with calcium, and low levels of vitamin D decrease calcium absorption, lead to low bone calcium stores, and increase the risk of fractures. Ultimately, vitamin D deficiency can lead to osteoporosis, which over 53 million people in the United States either seek treatment or face an increased risk for. Osteoporosis occurs when new bone doesn’t generate at the same pace as the loss of old bone, it’s lost faster than it can be replaced. Bones then become brittle and more prone to fracture.
Neuropsychiatric Disorders
Over the past several years, vitamin D deficiency has been associated with an increased risk of brain-related disorders. Vitamin D alters cholinergic, dopaminergic, and noradrenergic neurotransmitters systems, and abnormalities in these neurotransmitters have been implicated in various neuropsychiatric diseases. These include schizophrenia, autism, depression, Parkinson’s disease, dementia/ Alzheimer’s disease, and, most compellingly, multiple sclerosis, MS. As I mentioned in the intro, depending on what reference you believe, a large percentage of people fall short of the 30 ng/mL sufficient threshold of vitamin D, but these numbers skyrocket among people with brain disorders. An estimated 80 percent of people with multiple sclerosis (MS) and 90 percent of people with dementia have vitamin D levels of less than 20 ng/mL. Researchers suspect that people with Parkinson’s or Alzheimer’s disease and the elderly are similarly deficient. Why are the aged so deficient? Aging reduces skin thickness, which inhibits the body’s ability to make vitamin D from sun exposure. When this is coupled with reduced dietary intake of vitamin D and the impaired intestinal absorption that also accompanies aging, deficiency is almost inevitable. More research is needed to elucidate the mechanisms involved, the how and why. Unfortunately, a simple vitamin D supplement isn’t the answer to these neurodegenerative diseases. Someday we’ll get it figured out.
Next week, I’ll continue with illnesses of D-ficiency. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
MGA
Learn MoreThyroid Disease and Mental Health
Thyroid Disease and Mental Health
Hello, people! Welcome back to the blog. We’re continuing with our look at thyroid disease, and this week will be focused on its links with mental health conditions.
Thyroid hormones regulate metabolism in every organ of the body, including of course the brain, which contains one of the highest concentrations of thyroid hormone receptors of any organ. These hormones are essential for brain development and maturation, as well as for function throughout life. Neurons are more sensitive to thyroid abnormalities than other cells, so it comes as no surprise that thyroid disease commonly results in various clinical manifestations affecting mental health/ function. In fact, the majority of people with thyroid dysfunction will develop cognitive, mood, and/ or emotional symptoms, it’s mainly a matter of degree. If that’s the case, where do thyroid symptoms end and psych symptoms begin? In recent years, we’ve learned they’re more connected than we once thought.
People with an overactive thyroid, hyperthyroidism, can suddenly feel tense and anxious. They may experience bouts of impatience or overactivity, panic attacks, and extreme sensitivity to noise. Are these symptoms of their thyroid disease? That sounds a bit like anxiety. People with an underactive thyroid, hypothyroidism, may feel overwhelmed, disinterested, and tearful. They can experience a progressive loss of memory and appetite, a dulling of personality, difficulty concentrating, and a lack of interest and mental alertness. Sounds a whole lot like depression. People with both thyroid disorders commonly suffer from mood swings, short temper, and difficulties in sleeping. And generally speaking, the more severe the thyroid disease, the more severe the mood changes. They can be the result of abnormal or rapidly changing thyroid levels, or it can even be a side effect of treatment. For example, if you have hyperthyroidism and take beta blockers to slow down your heart rate, this can make some people feel less mentally alert, depressed, and fatigued.
A review of the literature estimates that up to 60 percent of people diagnosed with hyperthyroidism also have clinical anxiety, and up to 69 percent of people diagnosed with hypothyroidism are also clinically depressed. As you can imagine, misdiagnosis can become a problem. When thyroid conditions are misdiagnosed as mental health conditions, that can leave you with symptoms that may improve, but a disease that still needs to be treated.
There can be a lot of overlap in symptoms. Thyroid disease is often at the top of my list of differential diagnoses with many new patients, especially women of menopausal age. It can be a confounding riddle, especially in times of crisis, if patients are unaware that they may have either condition. I’ve seen patients in emergency rooms for new onset of severe psychotic symptoms- auditory and visual hallucinations- and it turns out to be severe hypothyroidism. It’s usually a woman in her 50’s who’s been suffering through various symptoms for years, but assumed it was associated with menopause. In years past, even physicians would take a wait and see approach before doing labs. Today we’re better understanding the progression of illness and the links that exist between conditions.
Common Symptoms
Hyperthyroidism and Clinical Anxiety
Hyperthyroidism and Bipolar Disorder
Insomnia, anxiety, elevated heart rate, high blood pressure, mood swings, irritability
Hyperthyroidism can produce symptoms similar to those seen in cases of clinical anxiety. It can also produce symptoms of mania that are more or less identical to the mania symptoms found in people with bipolar disorder. We also know that people with bipolar disorder have increased risk for developing hyperthyroidism. And lithium, a drug used to treat bipolar disorder, can aggravate or trigger hyperthyroidism. Good to know.
Common Symptoms
Hypothyroidism and Depression
Hypothyroidism and Cognitive Dysfunction
Bloating, weight gain, memory loss, difficulty processing information, fatigue
Hypothyroidism symptoms have a lot in common with those of clinical depression as well as cognitive dysfunction- meaning memory loss and difficulty organizing thoughts. In fact, there’s fairly recent evidence that thyroid hormone replacement medication may be helpful for treating depressed patients, even those with normal thyroid function. German researchers found that high doses of thyroxine improved the symptoms of 17 depressed patients who had not responded to multiple antidepressant drugs. Half of them recovered, and only one failed to improve.
Autoimmune Thyroiditis (AIT)
aka Hashimoto’s Hypothyroidism or Disease
Hashimoto’s disease is the most common cause of hypothyroidism, and affects about 10 percent of the population. It primarily affects middle aged women, but can also occur in men and women of any age, and in children as well. AIT means the person’s immune system is creating antibodies that mistakenly attack their own thyroid, leading to chronic inflammation, which interferes with hormone production. This leads to a potentially severe drop in thyroid hormone levels, and the person feels exhaustion and tension, and all the symptoms of hypothyroidism, up to psychosis- myxedema madness.
AIT often goes undiagnosed because symptoms are attributed to menopause, as women aged 30 to 50 are the most common sufferers, or to depression and anxiety. If you have AIT and seek psych treatment, make sure your psych provider knows you have AIT, you can receive more effective treatment by being able to choose antidepressants that are less likely to cause weight gain. And you should also know how your antidepressant effects selenium levels, which can help with inflammation. Patients with depression and anxiety disorders should consider having a full thyroid panel with antibodies to test for AIT. And for patients with AIT, a screening for psych symptoms is recommended. Early administration of appropriate treatment- antidepressants and hormone replacement- provides a distinct advantage to patients.
Recent studies have quantified links between AIT and depression, anxiety, and bipolar disorder. If you have AIT, you’re 3.5 times as likely to suffer from depression and 2.3 times as likely to suffer from anxiety. Inversely, more than 40 percent of people diagnosed with depression also suffer from AIT, and the same is true for 30 percent of people diagnosed with anxiety. And AIT is an endophenotype of bipolar disorder, meaning that both conditions have the same genetic origin.
The main message today is that if you have thyroid disease or a mental health diagnosis, be sure to inform all of your physicians, be aware of the links between the two conditions, keep an eye on your symptoms, and consider screening for the linked condition as early as possible to initiate treatment if needed.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
Please feel free to share the love! Share blogs and YouTube videos with family and friends.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
MGA
Learn MoreThe Thyroid, Part Trois
The Thyroid, Partie Trois
Hello, people- welcome back to the thyroid blog! Last week, we took a deep dive into all of the causes and symptoms of hypothyroidism and hyperthyroidism, and today I’ll get into diagnosis and testing. Before I do, I just want to highlight some key points from last week and squeeze in a couple of other little facts, or “factlets” if you will. As I mentioned last week, hypothyroidism- underactive thyroid causing low hormone levels- is far more common than hyperthyroidism, with its overactivity and elevated hormone levels, but about 60 percent of people are unaware of their diagnosis at all. Thyroid disease can occur in anyone at any time, but it’s more common in women, and risk increases with age. In the United States, prevalence is generally highest in Caucasians, followed by Mexican Americans, then African Americans.
About 95 percent of cases of hypothyroidism are due to a problem in the thyroid gland itself, so they’re called primary hypothyroidism. However, certain medications and diseases can also decrease thyroid function, and this is called secondary hypothyroidism. An example of this may be when there’s a problem with the pituitary gland- the endocrine gland that controls the thyroid- and that results in decreased production of TSH, thyroid stimulating hormone, and as a result, the thyroid produces less hormone. Another example of secondary hypothyroidism that’s important to note actually involves hyperthyroidism- specifically after medical treatment for hyperthyroidism. When you have treatment for hyperthyroidism that includes surgical removal of the thyroid, called thyroidectomy, or even radioactive iodine treatment to destroy thyroid tissue and reduce hormone levels, you can then develop a secondary issue related to these decreased thyroid hormones, and this would be considered secondary hypothyroidism. And sometimes, a condition of tertiary hypothyroidism can occur. This happens when an underactive thyroid results from a problem with the hypothalamus. The hypothalamus is the endocrine gland responsible for stimulating the pituitary, which in turn is responsible for stimulating the thyroid. In cases of tertiary hypothyroidism, the problem with the hypothalamus stops up the works- the pituitary isn’t properly stimulated, so the thyroid isn’t properly stimulated, and as a result, it doesn’t produce enough thyroid hormone. Hence tertiary hypothyroidism.
Thyroid Regulation
The system by which the thyroid gland is regulated is what’s called a negative feedback loop. The thyroid regulation loop includes the two aforementioned endocrine glands- the hypothalamus and pituitary- in addition to the thyroid. Here’s how thyroid regulation works: the hypothalamus secretes its hormone called TRH, thyrotropin-releasing hormone. TRH stimulates the pituitary gland to produce TSH, thyroid-stimulating hormone. TSH, in turn, stimulates the thyroid gland to secrete its hormones T3 and T4. When the level of these thyroid hormones is high enough, the hormones holler back to stop the hypothalamus from secreting TRH, and that stops the pituitary from secreting TSH, which then prevents the thyroid from secreting more hormones. So when T3/ T4 get high enough, they holler back ‘No! Stop!’ – that’s the negative bit- and that stops the loop. Clearly they don’t actually holler back, they “feedback” to stop the loop, which is why it’s called a negative feedback loop. When that feedback happens, without the stimulation of TSH, the thyroid gland stops secreting its hormones T3 and T4, and the level of thyroid hormone starts to fall.
When all three glands are functioning normally, thyroid production is regulated to maintain relatively stable levels of thyroid hormones in the blood. But if the thyroid gland is underactive- doesn’t produce sufficient T4/ T3- either due to thyroid issues or to pituitary issues/ insufficient TSH, then the affected person experiences symptoms of hypothyroidism, such as weight gain, dry skin, cold intolerance, irregular menstruation, and fatigue, etc. If the thyroid gland is overactive- produces too much T4/ T3- the affected person experiences symptoms associated with hyperthyroidism, such as rapid heart rate, anxiety, weight loss, difficulty sleeping, tremors, and eye issues, etc. I gave a much more complete list of symptoms last week so check that out if you need to refresh your memory.
Thyroid Disease: Diagnosis and Testing
Thyroid disease can be difficult to diagnose, because the symptoms are easily confused with those of other conditions. Fortunately, there are specific tests that can determine if your symptoms are being caused by a thyroid issue. These include lab tests, imaging, and physical exams.
Thyroid Lab Tests
One of the most definitive ways to diagnose a thyroid problem is through blood tests. These give an indication of how your thyroid gland is functioning, by measuring the amount of thyroid hormones in your blood. I imagine some of you have seen ads on the interwebs for home thyroid screening kits. You get it, lance your finger, send it in, and five days later, you get the results. I’m sure they’re pretty limited, and it’s probably better just to see your primary, but if you have symptoms and you can’t do that for some reason- say a no insurance sitch- and you don’t want to spend a small fortune on bloodwork to satisfy a hunch, then a home kit probably wouldn’t be the worst idea- definitely better than ignoring it.
No matter how you get labs, measuring hormone levels sounds pretty straightforward, but this is the endocrine system we’re talking about here people, so it’s not that simple… There are multiple tests to measure function, but I’m going to simplify it as much as possible and only talk about three: TSH, T4 and T3. During thyroid diagnostics, there are so many tests that can be done, but these three, singly or in combination, are always among them. They offer the best snapshot of thyroid function, even post diagnosis, for monitoring treatment efficacy.
TSH Test
Arguably the most useful thyroid test, a TSH test measures the levels of thyroid stimulating hormone made by the pituitary gland. Looking at TSH is often the best way to initially test thyroid function, and changes can even serve as an early warning system, because they often occur before the actual level of thyroid hormone in the body becomes too high or too low and starts causing major symptoms.
Doctors generally consider TSH levels to be within a normal range if they are between 0.4 and 4.0 milliunits per liter (mU/l). I should note that this normal range can vary based on a person’s age, as ranges tend to increase as a person gets older. It can also vary in pregnant women. That said, research hasn’t shown a consistent difference in TSH levels between males and females. Some studies suggest higher levels in males, while others suggest the same in females, but any such difference appears quite small, and it’s unlikely to be clinically relevant.
Most labs use the following reference values for TSH levels for what is considered normal vs low, indicating hyperthyroidism vs high, indicating hypothyroidism:
Low TSH: 0 to 0.4 = Hyperthyroidism
Normal TSH: 0.4 to 4 = Normal
Elevated (mild) TSH: 4 to 10 = Mild hypo
High TSH: >10 = Hypothyroidism
These are the commonly accepted values, but there is some debate about the ranges- some studies suggest that normal levels are more likely to fall between 0.5 and 2.5 milliunits per liter (mU/l) so I suspect far more people would qualify as hypothyroid.
A low TSH level indicates that the thyroid is producing too much thyroid hormone, meaning hyperthyroidism. It may seem counterintuitive at first glance, how a low level of one thing could cause overactivity of another, but low TSH levels being indicative of overactive thyroid makes sense in terms of the negative feedback mechanism: when the thyroid gland is secreting high levels of hormones, the pituitary gland is told to stop producing TSH, so TSH would be expected to be low.
On the flip side, a high TSH level indicates that the thyroid is not secreting enough thyroid hormone, meaning hypothyroidism. In this case, not only won’t the pituitary gland be told to stop making TSH, it will actually produce more TSH to try to compensate, to make the thyroid secrete more hormone.
T4
A T4 test measures the blood level of thyroxine, the main hormone that accounts for about 95% of all thyroid hormone circulating in the blood at any given time. A typical normal range is generally about 4.5 to 11.2 mcg/dL, micrograms per deciliter, though I’ve also seen 5.0 to 12, it varies among different laboratories. Just so you’re aware, T4 exists in the body in two forms- bound and free- and there are a few different types of T4 tests, but I’m applying the KISS principle, and that’s too complex for our purposes today. But check it out if you’re interested.
High levels in any T4 test generally indicate an overactive thyroid, or hyperthyroidism, while low levels in any T4 test generally indicate an underactive thyroid, or hypothyroidism.
It’s important to note that T4 levels are affected by several medications and medical conditions. Estrogen, oral contraceptives, methadone, amiodarone, pregnancy, liver disease, and hepatitis C can cause a high T4 level. Testosterone or androgens, anabolic steroids, lithium, phenytoin, propranolol, interferon alpha, and interleukin-2 can cause a low T4 level.
The T4 test and the TSH test are the two most common thyroid function tests, and they’re usually ordered together. When their results are looked at together, they can offer a snapshot of overall function, as well as potentially suggest a cause for an abnormality. In fact, these are the tests I mentioned last week that are routinely performed on newborn babies to identify a low-functioning thyroid gland- a condition called congenital hypothyroidism- which, if left untreated, can lead to those severe developmental disabilities.
As a practical example of how looking at T4 and TSH together can give you an idea of the cause of an abnormality, consider this hypothetical: say lab results show low T4, indicating hypothyroidism. If TSH testing shows an elevated or high TSH, this would indicate that the problem is with the thyroid gland itself, because the pituitary is doing its job properly- you’d expect TSH to be high when hormones are low. So this would be like 95% of cases, primary hypothyroidism. Contrast that same low T4 with a TSH test that shows low TSH. That would indicate that the pituitary gland is the likely cause, because TSH should be high, and it’s not, so this would be considered a case of secondary hypothyroidism.
T3 Test
A T3 test measures the level of the thyroid hormone triiodothyronine, which normally accounts for about 5% of thyroid hormone circulating in the blood at any given time. Like T4, T3 also exists in two forms. If T4 tests and TSH tests suggest hyperthyroidism, a T3 test is usually ordered to support the diagnosis, and T3 testing is especially useful in helping determine the severity of the hyperthyroidism present. It may also be ordered if you’re showing symptoms of an overactive thyroid gland, but your T4 and TSH aren’t elevated. In hypothyroidism, T3 testing is rarely helpful, because it’s generally the last hormone to become abnormal. Many factors influence T3 levels, including age, sex, and some health conditions, such as liver disease, and of course pregnancy. As such, an abnormal T3 level doesn’t always mean that a person has a thyroid condition.
A normal T3 level might be somewhere between 100 to 200 nanograms per deciliter. A high T3 level is indicative of overactive thyroid, or hyperthyroidism, and a low T3 level is indicative of underactive thyroid, or hypothyroidism. That said, patients can be severely hypothyroid- with a low T4 and high TSH- but still have a normal T3 level. That’s why it’s not super helpful in many hypothyroid patients.
T4 vs T3
In some individuals with hyperthyroidism and low TSH, only the T3 is elevated and the T4 is normal, and vice versa. In some specific types of thyroid diseases, the levels and proportions of T3 and T4 in the blood change, and in doing so can actually provide diagnostic information. For example, a pattern of increased T3 vs T4 is characteristic of the autoimmune condition called Graves’ disease, the most common cause of hyperthyroidism in the US. On the other hand, severe illness and medications- like steroids and amiodarone- can decrease the amount of thyroid hormone the body converts from T4 to T3, resulting in a lower proportion of T3. As a result, depending on the individual and the type of disease, generally the best way to get an accurate depiction of thyroid function is to look at blood levels of all three of these hormones: TSH, T4, and T3.
In addition to these most common hormone level tests, there are several thyroid antibody tests that can be run, especially during an initial diagnostic workup, to help identify and confirm different types of autoimmune thyroid conditions, such as Hashimoto’s Thyroiditis and Graves’ Disease. There’s also antibody testing; microsomal antibodies called TPO, thyroglobulin antibodies, aka TG abs, and stimulating immunoglobulins and blocking immunoglobulins. So many other components that can be part of thyroid disease. As part of a diagnostic workup, a physician may also look at calcitonin and thyroglobulins to look for potential hyperplastic, or cancerous and/ or inflammatory processes.
One last note on thyroid labs, triglyceride levels may also be tested, because these can be an indicator of metabolic rate, and that’s what the thyroid controls. For instance, having very low triglycerides can be a sign of an elevated metabolic rate, so could support or suggest a diagnosis of hyperthyroidism.
Imaging Tests
If your blood work suggests that your thyroid gland is overactive or underactive, your doctor may order imaging tests to assist in diagnosis. Ultrasound can be used to examine and measure the size of the entire thyroid gland- as well as any masses that may be present within it- and then determine if a mass is solid or cystic. A thyroid uptake scan can be used to see if the thyroid is overactive; specifically, it can reveal whether the entire thyroid or just a single area of the gland is causing the overactivity. Based on these findings, a physician may want to sample tissue from the thyroid to check for cancer. Other imaging tests like CT or MRI can be used to look for things like pituitary tumor that could be causing the condition.
Physical Exam
Another way to quickly check the thyroid is with a physical exam in your healthcare provider’s office. This is a very simple and painless test where your provider feels your neck for any growths or enlargement of the thyroid. There are plenty of resources on the great interwebs that claim to make you an expert in self exam to determine thyroid health, but I think that’s a pretty dubious claim. If you think you might have a thyroid issue, see your primary. Or at the very least, order a home screening kit, lance your finger, and send it in.
Next week, I’ll start with treatment for hyper and hypothyroidism; I’ll cover meds and modalities, as well as how diet and nutrition can be used to help manage or possibly prevent thyroid dysfunction.
hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
Please feel free to share the love! Share blogs and YouTube videos with family and friends.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
MGA
Learn MoreThe Thyroid
The Thyroid
Hello people! Last week was a light one on dark chocolate (ha ha?) but as promised, today marks the start of a new series on thyroid disease. If you’re wondering why I, a shrink, would care about the thyroid, the answer’s simple: because when it’s a problem, it’s a real problem, because it can affect nearly every aspect of your life, including your mental health. But when it comes to the thyroid, you’re about to find out that that’s where the simplicity ends.
Before we can talk about how the thyroid can affect you, first we have to talk about what it is. The thyroid is a butterfly-shaped endocrine gland that’s found in the forward aspect of the middle of the neck, just below the larynx, or voice box. Its two lobes, left and right, lie on either side of the windpipe, and are each about the size of a halved plum. These lobes are analagous to the wings of the butterfly, and they are joined by a small bridge of thyroid tissue called the isthmus.
Notice I said it was an endocrine gland? The endocrine system is made up of glands that make hormones, which are the body’s chemical messengers- they carry information and instructions from one set of cells, glands, and organs to others. In doing so, the endocrine system influences almost every cell, gland, organ, and function of the body. That’s what makes the thyroid so important- because it’s a big part of the endocrine system, along with the other major glands, including the hypothalamus, pituitary, parathyroid, adrenal, pineal, and the ovaries and testes.
The hormones made by the various glands of the endocrine system are released into the bloodstream, and they travel to cells in other glands and organs where they help control organ function, mood, growth and development, metabolism, and reproduction. The amounts of hormones produced and released is highly regulated, and depends on levels of other hormones already in the blood, other minerals like calcium in the blood, the blance of water and other fluids in the body, and external factors such as stress and infection, just to name a few. Because hormone production and levels are all interlinked- one dependent upon another- it’s important that these levels remain normal. Too much or too little of any one hormone affects production and release of multiple others, so it can affect several organ systems, and cause nearly endless physical and emotional symptoms. This can make you feel very ill, a little “off,” or anything in between.
The Pituitary Gland
Even though this series is on the thyroid, I can’t rightly talk about it, or the endocrine system, without mentioning the pituitary gland. The pituitary is a pea sized gland located at the base of the brain, but don’t let its size fool you, because mighty things can come in small packages. In fact, the pituitary is often called the “master gland,” because the hormones it makes control many of the other endocrine glands. The pituitary also happens to be one of my faves- and it should be one of yours too- because it secretes endorphins, the body’s natural feel good chemicals, the ones that act on the nervous system to produce feelings of pleasure and reduce feelings of pain.
The pituitary gland makes many other hormones, including growth hormone, which stimulates the growth of bone and other body tissues; prolactin, which activates milk production in breastfeeding women; corticotropin, which stimulates the adrenal gland; antidiuretic hormone, which helps control the balance of body water through its effect on the kidneys; and oxytocin, which triggers uterine contractions during labor. But the pituitary hormone that’s most germaine to today’s topic is thyrotropin, more commonly known as thyroid-stimulating hormone, or TSH. Once secreted by the pituitary, TSH, as its name suggests, stimulates the thyroid to synthesize and release thyroid hormones.
In response, the thyroid produces thyroxine and triiodothyronine, more commonly known as T3 and T4, respectively. These hormones control the rate at which cells burn fuels from food to make energy. They basically regulate the body’s metabolism- the rate at which the cells of the body use and store energy. I’ll get into that in a moment, but because they control such a basic function, you can clearly see that thyroid hormones are essential for all the cells in your body to work normally. If that weren’t enough, they also play a role in bone growth and development, as well as that of the brain and nervous system. Just to add another level of complexity, there are also four other tiny glands attached to the thyroid gland called the parathyroids. They release parathyroid hormone, which, along with help from another thyroid hormone called calcitonin, controls the level of calcium in the blood. And if you remember, calcium is one of those minerals in the blood that controls the production and release of other hormones. Yikes!
Believe it or not, this is as simplified as the endocrine system- and the thyroid- really gets, people, so if you’re thinking all of this is super complicated, you cannot even imagine if you just go by this! As a matter of fact, there’s an entire (underappreciated) specialty medical field devoted to this alone… so thank you endocrinologists!
Thyroid Function: Metabolism
As I mentioned before, thyroid hormones regulate the body’s metabolism. Many people think that just means how many calories you burn, but metabolism is a complicated process, one that’s happening 24/7, no matter what you’re doing. That’s even reflected in its literal meaning, which is “a state of change.” Your body relies on metabolism to carry out all of its functions, whether it’s storing or burning fat, regulating sugar levels, or keeping your neurons firing; so metabolism has a huge impact on your health. The three main purposes of metabolism are: the conversion of food to energy to run cellular processes, the conversion of food/ fuel to the body’s building blocks, and the elimination of metabolic wastes.
Thyroid Imbalance
This intricate involvement with such an important, universal bodily process is why diseases of the thyroid have such an extreme and varied impact on human health. But (thankfully) all of it boils down to two basic conditions: having too much thyroid hormone results in a condition called hyperthyroidism, while having too little thyroid hormone is called hypothyroidism. Generally speaking, in hyperthyroidism, when there is too much thyroid hormone, your body processes speed up, and the body uses energy very quickly. And in hypothyroidism, when you don’t have enough thyroid hormone, your body processes slow down, and the body uses less energy.
That’s probably a good place to stop for this week. It’s been a while since I’ve had to write an endocrine overview, people! Next week, we’ll start getting into the meat and potatoes when it comes to thyroid imbalance- how it can affect you. Something to look forward to.
I hope you enjoyed today’s blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
Please feel free to share the love! Share blogs and YouTube videos with family and friends.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
MGA
Learn MorePhenylethylamine (The Love Molecule)
Phenylethylamine
We’ll be starting a new series next week, so this week I thought we’d just keep it light this week- have some fun. Believe it or not, this week’s topic, phenylethylamine, is a good time. Before I tell you why and how, let’s go over how to say it. Phenyl is pronounced just like the green herb fennel. Ethyl is exactly like it sounds- like Lucy’s sidekick. And amine is pronounced with a long a, like Canada, ehh… plus mean, as in “what do you meanphenylethylamine is a good time, Dr. A?” Fennel-Ethyl-ehh-mean. While it’s fun to say, science nerds, myself included, call it PEA to make life easier. I’m all about that, so that’s what I’ll be using hereafter.
So, what is PEA? It’s a naturally produced alkaloid, which is basically a biologically active chemical, with similar pharmacological properties to amphetamine. In the human brain, it functions as a neuromodulator, sort of an influencer of the happy hormones, the endorphins like dopamine and serotonin. While it’s produced naturally in the body, PEA is also found in nature, most notably in a particular strain of blue green algae called Aphanizomenon flos-aquae or AFA. It’s also found in many common foods, and can be easily synthesized in the lab as well.
There is evidence demonstrating PEA’s efficacy as an antidepressant and for ADHD, and it’s also responsible for the brain chemicals involved with “runner’s high” and even love and monogamy. In fact, PEA is commonly referred to as the “Love Molecule.”
That’s my best Barry White voice: luuuvvv mol-e-quuullle.
People who don’t make enough PEA naturally may be helped by taking it as a supplement. That’s where that blue green algae called AFA comes in- it’s loaded with PEA, and commonly taken as a supplemental source. In addition to helping stave off depression, and to improve mood and attention, some people also use PEA for athletic performance and weight loss, because it’s properties are so similar to amphetamine. But for that same reason, taking too much of it can induce side effects that are similar to amphetamine as well.
As I said, it’s found in many foods, but most popularly, it’s found in chocolate. Yum! It’s actually believed to be the component responsible for producing chocolate’s positive effects on mood. One UK study I read looked at over 13,000 people, and found that individuals who reported eating any dark chocolate within two 24-hour periods were 70 percent less likely to report “clinically-relevant depressive symptoms,” as compared to those who ate no chocolate at all. In other words, eating dark chocolate made them feel happier. This is not only because chocolate contains PEA, which induces those happy hormone endorphins, but also because chocolate contains a higher concentration of antioxidants that reduce inflammation, which is directly linked to the onset of depression.
There have been a number of studies that show other health benefits of dark chocolate. Daily consumption of dark chocolate can reduce LDL, the “bad cholesterol” levels we’ve all heard about. By doing so, dark chocolate can help reduce the risk of heart disease by as much as 30 percent. It’s also been shown to reduce the risk of dying from a stroke by nearly 50 percent. Studies even show that eating dark chocolate at least once per week can also improve cognitive functioning.
So is dark chocolate a superfood? Maybe so- especially when you consider that on top of all of the health benefits, it also acts like an aphrodisiac, because it stimulates the production of those endorphins, and they’re the chemicals in the brain that create feelings of pleasure. After all, PEA has earned its reputation as the luuuvvv mol-e-quuullle. But before you reach for a candy bar, there is a small catch- literally. All you need to produce those happy-happy effects is half an ounce of chocolate per day. There’s also a big catch- literally. If you’re watching your weight, even a small amount of chocolate has a big calorie impact. A half-ounce of dark chocolate typically contains between 70 and 80 calories, depending on the percentage of cacao solids- that’s pronounced like Batman’s ka-pow! That’s the paste that results from fermenting, roasting, and crushing the cocoa beans that make it. This cacao then gets mixed with milk and sugar, and tah-dah: chocolate!
Dark chocolate is called dark because it contains more cacoa and less milk and sugar than milk chocolate. While dark chocolate can contain as little as 45 to 50 percent cacao solids, research shows the greatest benefits come from dark chocolates that contain at least 60 percent cacao solids. Some dark chocolates contain as much as 85 percent cacao solids, so if you venture to the darker side, will that make you even happier? Well, that’s the last catch- but this one’s a good one. The evidence suggests that the mood benefits only happen if you enjoy the chocolate you eat. Since that suggests that the experience of eating the chocolate is also an important factor, it’s vital to choose what you like. But keep in mind that white “chocolate” doesn’t count, because it doesn’t contain any cacao solids- it’s not actually chocolate… wah wah wahhh.
The chemical ingredients in the chocolate clearly make an impact, but it’s very interesting to me that the taste matters as well- definitely indicative of a stronger correlation between dark chocolate and mood, so future studies may tell more of the tale. Until then, I’ll happily gather anecdotal evidence. But remember that second catch, people- the big one. If you like dark chocolate, a half-ounce clearly won’t kill you, but it might kill your diet- or at least inflict some damage.
Luckily, I have a simple solution. Enjoy your half-ounce, then take a fifteen or twenty minute walk, preferably with someone you like- a loved one or friend. That way, you’ll burn off the calories while strengthening your relationship, and you’ll be quadruple dipping on the benefits of eating chocolate: you’ll get the enjoyment of eating it, its mood lifting and cognitive benefits, its general health benefits, and all the benefits of exercise. Not to mention how all of those things work together synergistically, because walking positively impacts mood and cognitive ability as well, as does positive interaction with someone you care about.
It’s a win-win-win-win. And win.
Next week, I’m starting a new series on the thyroid. I’ll tell you all about how it impacts just about every aspect of your life, and maybe especially your mental state.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like and subscribe.
Please feel free to share the love- share my blogs and YouTube videos with family and friends!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
MGA
Learn MoreAlprazolam
Alprazolam
Welcome to a brand new blog, people! Last week we talked about mindfulness, so I hope everyone has been trying to practice that in at least some small ways everyday, especially when stressed. If not, the topic of the new series I’m introducing today may be a bit of foreshadowing, as you might need it. Trust me when I tell you that it’s far easier, not to mention more rewarding, just to live a more mindful life. The new topic is alprazolam, which you might better recognize as Xanax, a drug used nearly solely for anxiety, at least when used as intended, but we’ll get to that.
Today as an introduction, I’ll give you an overview on what you should know about alprazolam if you’re thinking about taking it. But my advice? Don’t, because while it works, it can be so sneakily addictive, in a way that seems almost sinister. Insidious. It took me a second to get there, people. My point is, it will creep in and take over anyone’s life if given the smallest opportunity to do so. We’ll talk more about that later. For now, suffice it to say that it’s so abused by so many people, it’s literally become a threat to public health. I hear stories everyday about how it ruins the lives of good people with only the best of intentions. For that reason, plus more that I’ll get into, everyone should really know the basics about alprazolam.
Alprazolam belongs to a group of medications called benzodiazepines, aka benzos. Other meds in this group include Valium, Klonopin, and Librium. You may have seen my YouTube video on benzodiazepines, barbiturates, and alcohol. If not, I’ll put the link at the bottom so you can check it out. Alprazolam, aka Xanax, has a lot of slang names as well, mostly referring to its shape and color. Bricks, zanny bars, blue footballs, and z-bars are the ones that come to mind right now, but there are others used on the street. Speaking of, alprazolam is pretty cheap in the pharmacy. On the street, it’s pretty damn expensive when you consider it can easily cost you your life, but it usually goes for around $3 to $5 per bar or pill, depending on strength. What a bargain.
Alprazolam, like other benzos, is most commonly prescribed for people with anxiety disorders or panic disorder. Sometimes it’s also used short term for treating severe insomnia, alcohol withdrawal, and prolonged seizures. I myself prescribe it for these indications- very short term and as low dose as possible- because it works well and it’s so fast acting. For anxiety and panic attacks, I almost universally try other meds and methods first, because of its aforementioned insidiousness, but occasionally I might use it as a bridge while the other meds and methods start to work.
How Alprazolam Works
Like all other benzodiazepines, alprazolam works by binding to specific receptors in the CNS called GABA (gamma-aminobutyric acid) receptors. GABA is an inhibitory neurotransmitter, meaning it works to decrease nerve activity. The simplified pharmacological mechanism looks like this: when alprazolam binds to the GABA receptors, it enhances GABA’s inhibitory activity. This pumps up the GABA, which greatly reduces neural stimulation. This decreased neural activity produces general CNS depression, and elicits the anti-anxiety and sedative-hypnotic effect that’s felt by the person ingesting it. It’s important to note that alprazolam doesn’t affect everyone in the same way. There can be other factors involved, including the person’s mental state at the time the drug is taken, the dose taken, the person’s age, weight, and individual variances in the metabolism of the drug.
How Alprazolam Feels
Captain Obvious says that this depends on the dose, which I’ll get into next, but when taken as prescribed for anxiety or panic disorders, the idea is that you should feel “normal” after your first dose. The sedative effect should help alleviate the symptoms of anxiety, and calm your body’s response to the anxiety or the stressor. If you take it recreationally, aka without a prescription, the effects you feel would still be dose dependent, and if you take a small dose, in theory you would have the same effects. I say in theory because that would depend greatly on where you get it. If you buy it on the street, you’re probably not taking actual alprazolam. Fake alprazolam is a huge, lethal problem, and I’ll be dedicating an entire blog to that topic in this series. You’ll be shocked. Hint: if you want to live, don’t buy Xanax on the streets! Unlike stimulant drugs like cocaine, which produce a euphoric “high” feeling, recreational alprazolam users describe feeling more relaxed, quiet, and tired, often to the point of passing out for several hours at a time. Some people have memory lapses or amnesia or black out periods, where they can’t remember anything that happened for several hours, even if they’re awake at the time. Equally important is what you should not feel when you take alprazolam, and I’ll cover that below, when I talk about side effects.
Alprazolam Dosing
Alprazolam is available in multiple milligram strengths, 0.25 mg, 0.5 mg, 1 mg, and 2 mg.
The effects become more significant as the dose increases, so first-time alprazolam users should absolutely start with the lowest possible dose and let your prescribing physician know exactly how it affects you to determine if the dose needs to be adjusted. You don’t ever get to play doctor here, people. Don’t increase the dose on your own, even if you’re an experienced user. This is because higher doses can be fatal for everyone- from first-time users all the way up to people who’ve used it as prescribed for many months or years. Again… don’t take a higher dose than what’s prescribed by your doctor.
In addition to instant death, high doses are associated with a counterintuitive complication known as the “Rambo effect.” This unusual side effect can happen out of the clear blue sky in anyone taking alprazolam, prescribed or not and experienced or not, and generally presents as the user beginning to display behaviors that are very unlike them. These might include aggression, theft, or promiscuity, but can really be any unusual legal or illegal behavior- the key is that it’s very atypical and seems to occur suddenly. It’s not clear why some people react this way, or how to predict who it will happen to, so it adds a very unwelcome guest to the alprazolam party.
Alprazolam Metabolism
How alprazolam is broken down and affects you also depends on those aforementioned factors of age, weight, and individual variances in metabolism, but can also be impacted by the presence of other substances and/ or medications you may be taking. When taken by mouth, alprazolam is absorbed quickly by the bloodstream, so it’s very fast acting. Some people can begin to feel its effects within 5 to 10 minutes of taking the pill, but almost everyone will feel the effects within an hour. One of the reasons why it’s so effective for treating panic attacks and anxiety is that the peak impact from the dose comes so quickly. But, fast acting meds wear off fast too, so the effects are brief. Most people will feel the strongest impacts from the drug for two to four hours, though lingering effects or “fuzzy feelings” may stretch out beyond that for several more hours. Some people even report a hangover type effect as well.
The length of time that alprazolam stays in the body before being excreted also varies person to person by those aforementioned factors. The half-life of alprazolam in a healthy adult averages about 11 hours, meaning that it takes the average healthy person 11 hours to eliminate half of the dose from the bloodstream. Typically speaking, that time would generally be a little shorter for younger people, and longer for older people. It’s important to recognize that you will stop feeling the effects of the alprazolam long before you reach half life.
It is possible, even likely, to build up a tolerance to alprazolam, and this can happen very quickly. If that happens, you may begin to notice it takes longer to feel the sedative effects of the drug, and that feeling will wear off more quickly. As alprazolam wears off, most people will stop feeling the calm, relaxed, lethargic sensations that the drug is associated with. If you take this medication to relieve symptoms of anxiety, like a racing heart, those symptoms will begin to return long before it’s half-life. If you don’t have these symptoms, you’ll begin to return to feeling “normal.” However, some people who take alprazolam for reasons other than anxiety may find they actually begin to experience feelings of depression and/ or anxiety, even if they’ve never had an issue with these conditions, as the chemicals in their brain adjust to the lack of the drug. This rebound anxiety or depression is usually temporary, but will often happen each time it’s taken. I have a Huntington’s patient who never had any anxiety or depression until his specialist put him on alprazolam for severe muscle spasm, and now it’s a real problem. Sometimes it’s hard to tell what’s worse, the disease or the “cure.”
Alprazolam Side Effects
Captain Obvious says that being aware of potential side effects is very important when considering taking any drug. He also says that should you experience any of these, stop taking it and contact your prescribing physician immediately, or seek emergency medical attention if appropriate. Possible side effects of alprazolam include sleepiness, dizziness, headache, confusion, muscle cramps, decreased appetite, weight loss or weight gain, diarrhea, nausea or vomiting, manic symptoms, difficulty walking, dry mouth, irregular heartbeat, low blood pressure, and blurry vision.
How it Shouldn’t Feel
When taken properly at prescribed doses, the effects of alprazolam should be mild, but detectable, and the symptoms for which it is prescribed should be decreased. If the drug appears to be having a significant negative impact, seek emergency medical attention and then contact the prescribing physician later. It should go without saying, but don’t take it again. Symptoms to watch for include extreme drowsiness, muscle weakness, confusion, fainting, loss of balance, and/ or feeling lightheaded. You should also seek emergency medical attention if you experience signs of an allergic reaction. Signs may include swelling of the face, lips, throat, and tongue, and difficulty breathing.
Alprazolam Special Considerations
Some people should avoid alprazolam entirely because they may be more sensitive to its side effects, or it could potentially harm them in some other way. This includes pregnant women, older patients, children and teenagers, people with a history of alcohol or drug abuse, and people with certain medical conditions such as respiratory illnesses.
Alprazolam Tolerance, Abuse, Dependence
I cannot overstate the potential for misuse, abuse, dependence, and addiction associated with alprazolam. And it doesn’t “just happen to junkies” people. Some folks without any reason take it recreationally just because they like the way it makes them feel. Others have undiagnosed anxiety disorder, so they start buying it or taking it. Others are prescribed it for anxiety, insomnia, seizures, or severe muscle spasm, but begin to need higher or more frequent doses of it to achieve the same effect; this is known as tolerance.
Though the routes to get there vary widely, without any intervention, all of these situations usually lead to the same place: dependence and addiction. This happens when the body begins to rely on alprazolam to function normally. Over time, we’ve collected scientific data and anecdotal reports to determine that certain people/ groups are at greater risk for abuse, tolerance, and dependence on alprazolam. These include non-hispanic whites, young adults 18 to 35 years old, people with a current psychiatric disorder, and people with a personal or family history of substance abuse. For these people, taking alprazolam is like playing with fire. If you’re one of them, don’t risk getting burned.
Alprazolam: Synergistic Interactions
A synergistic interaction occurs when the combined effect of two drugs or substances is greater than the sum of the individual activity of each. As a CNS depressant, alprazolam has synergistic interactions with other CNS depressants, and there are lots of those out there. The biggest example is also the most commonly overlooked one: alcohol. Good ole EtOH. Other examples include: other benzos (duh), opioid analgesics ie OxyContin, Vicodin, morphine etc, barbiturates ie Seconal and Nembutal, hypnotic drugs ie Ambien, heroin, methadone, neuroactive steroids ie estrogen and testosterone, and intravenous and inhalational anesthetics. If you take alprazolam and any of these substances, the alprazolam intensifies the effects of that substance and vice versa, so when taken together, they literally become exponentially more potent than if you used either of them on their own.
This is because all of these substances also increase neurotransmitter GABA activity in the CNS, slowing the activity of the nervous system, causing the sedative effect. When alprazolam is mixed with any of these substances, because the effects are synergistic and exponentially more potent than just the two combined, you’re at risk of excessive sedation, extreme confusion, prolonged memory loss, seizure, loss of consciousness, respiratory depression, cardiac problems, dangerous accidents from increased clumsiness and sedation, and unintentional death. Please note that these synergistic interactions occur whenever the substances are mixed- even if it is at prescribed doses.
However, there are some drugs that cannot be combined with alprazolam that you wouldn’t even think about. This includes some oral contraceptives, antifungals, antidepressants, antibiotics, and heartburn drugs. These drugs can affect the pathway that’s responsible for eliminating alprazolam from the body, so that the alprazolam isn’t removed as quickly as it should be. Over time, this can lead to a toxic buildup of the drug, and eventually an overdose. Always speak with your doctor to review meds and discuss potential interactions. In addition, your pharmacist is an excellent resource for any questions about med interactions. Some specific meds that may interact with alprazolam include cimetidine (Tagamet), fluvoxamine (Luvox), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), carbamazepine (Tegretol), diltiazem (Cardizem), isoniazid (Laniazid, Rimifon, Hyzyd, Stanozide, Nydrazid), and cyclosporine (Sandimmune).
Also, not a medication, but important to remember is… grapefruit juice! Grapefruit juice can block the action of CYP3A4, which is a critical enzyme in the body. Mainly found in the liver and the intestine, it oxidizes small foreign organic molecules, like toxins and drugs, so that they can be removed from the body. When CYP3A4 is blocked, instead of being metabolized, more of the drug enters the blood, and stays in the body longer. The result is too much drug in the body. I should add that there is some controversy surrounding this. The FDA says grapefruit juice does slow alprazolam metabolism, but some studies have published results that indicate it is “unlikely to affect the pharmacokinetics or pharmacodynamics of alprazolam, due to its high bioavailability.” Translating this geek speak to plain english, they’re saying their studies found that grapefruit juice had no effect on how alprazolam was metabolized and cleared from the body, because so much alprazolam is absorbed and available for biological activity in the cells and tissues where it’s metabolized. I say err on the side of caution and avoid alprazolam, or grapefruit juice if you just can’t. I should add that CYP3A4 is involved in the metabolism of other meds as well, so if you drink grapefruit juice, keep that in mind- tell your docs and pharmacist.
Stopping Alprazolam
I touched on the dependence issue associated with alprazolam, but I’m going to discuss that and withdrawal in more detail in next week’s blog. Regardless, even if you have only taken alprazolam exactly as prescribed, and you’re sure you’re not dependent on it- if you want to stop using it, you must do so with the guidance of your prescribing physician or another healthcare provider, because stopping alprazolam abruptly can lead to serious, medically dangerous withdrawal symptoms and rebound anxiety. Don’t stop alprazolam on your own! Depending on how long you’ve been on it and how much you take, your physician will need to taper your dose, meaning step you down on the dosage until you stop it altogether. This is the only way to go. Withdrawal is no picnic, but stepping down makes it so much easier, and it eliminates the dangers associated with cold turkey. Rebound anxiety from abrupt alprazolam withdrawal is no joke- people who experience rebound anxiety report that their anxiety symptoms are at least at the same level, but usually worse, than they were before starting alprazolam- so not only are they not better, they’re worse. You want to avoid this if at all possible, so don’t stop alprazolam abruptly.
Speaking of stopping abruptly, that’s it for this week. Next week I’ll talk in depth about alprazolam addiction and withdrawal. And we may have a guest blogger situation. We’ll see.
I promised you a link to my YouTube video that covers a lot of this information, so here that is. Lots of other vids to check out there too.
Benzodiazepines, Barbiturates, and Alcohol
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
Please feel free to share the love! Share blogs and YouTube videos with family and friends.
Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too!
And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them!
As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
MGA
Learn MoreWorking Remotely,Part Trois
Working Remotely, Part Trois
Hello, people! The last couple of weeks we’ve been discussing working remotely. I was prompted to do this series after noting the ways some of my patients evolved, or devolved, after working remotely in a ‘rona world. When I did some research, I read studies and reports from years BR, before ‘rona, and saw that remote workers regularly reported higher stress levels than their office worker counterparts. According to a 2017 United Nations study involving 15 countries, 41 percent of “highly mobile” employees (defined as those who “most often,” or “more often…worked from home” as opposed to “in office” or “onsite”) rated themselves “highly stressed,” as compared to only 25 percent of the office and onsite cohort. This was of obvious interest to me, given what I’d been seeing in my patients, so I thought it warranted further investigation and discussion. And a baby blog was born. Awww…
Captain Obvious says that mental health and work are intertwined, because work is such an integral part of our lives. Remote work has a somewhat unique ability to get to people, even the mentally healthiest of individuals, because when you work from home, you may feel like you live at work. The work-home and work-life lines can blur, especially if the switch is abrupt and unavoidable. Thank you, ‘rona. Last week I talked about some of the issues that can come along with this type of remote arrangement, and the fact that they generally present as some level of SADness, so you may find you feel stressed, anxious, and even depressed as a result. You may feel these impacts within a widely variable range as well as pattern; acutely, chronically, or as more of a cumulative or building phenomenon. Just to make it more complicated, you can also have a pink cloud situation as well. After making a switch, the novelty of the setting can alter how you value certain associated factors. You may find that any negative impacts you feel from one issue are offset by the positive impacts of another. But this can be a little insidious if you’re not careful, because it’s a transient phenomenon. Once the novelty wears off, that pink cloud goes **poof-bye bye** and suddenly, the equation is altered again! It’s not really worth it anymore, and that can make you SAD.
Sometimes the effects can be so low level, you might just generally feel blah, or ‘some kind of way,’ as the kids say, but you can’t seem to put your finger on why. There are nearly innumerable ways that stress can manifest, regardless of where you work, and it usually doesn’t just affect your work. It often seeps over into your private life as well, but this is especially true when you’re working from home, because of those annoying blurred lines.
So if you’re a remote worker and feeling some kind of way, how would you know that it might be your remote work at the heart of it? Clearly it’s difficult to pinpoint it exactly in a generalized blog setting, because each person is different; but there are some ways stress can manifest in both your personal and professional life, some things you may start to notice. The most common things can include: insomnia and poor sleep patterns, an inability to ‘switch off’ from work, headache, feeling disconnected from other people, an increase or decrease in appetite, having difficulty concentrating, having difficulty becoming and/ or staying motivated, having difficulty prioritizing workload and daily tasks, and feeling insecure or unsure of standing or spread too thin/ pulled in too many directions in your work and/ or personal life.
Last week I likened work, and life, to an equation. Everything has a value, and you decide what’s worth what, give and take, in order to decide what works for you. Last week I focused on the negative side of said equation, so this week will focus on the more positive side. Today will be about addressing issues I brought up last week, presenting some additional factors, and suggesting some steps you can take if you think that working remotely is having a negative impact on your life. Clearly, you don’t have to wait for that to happen, and everyone knows what they say about an ounce of prevention, people. When we’re talking about stress, it all comes down to minimization and mitigatation. I’ll try to address each issue in the same order I did last week, and make some strategic suggestions for solutions. Some of these may have been mentioned in the first blog of this series, so people that might’ve missed it can still follow along. If you didn’t miss it, please bear with me.
Awesome Office
I’ve joked about how many patients I’ve seen in bed during facetime appointments, but I think far too many people are both working and sleeping there. Seems like a lot of people’s morning routine is just rolling over to grab the laptop. But there are good reasons why this is concerning to me. Humans need sleep, and studies show that working from home, just in and of itself, can already interfere with sleep. But this is especially true for people who find it difficult to switch off from work. Working from your bed, or even bedroom, makes it very difficult to do just that. Not only does it encourage the late night blue light exposure that has been shown to interfere with sleep, but it also makes your brain associate that place with being alert, awake, and switched on. And that’s not the association you want- your bedroom should be the place you rest and recharge.
If you find yourself working remotely full time, you want the best possible experience. You’ll certainly be more comfortable and productive, not to mention a lot happier, if you create a dedicated space to work. Preferably, a separate room with a door you can close for privacy, and to minimize distractions and physically separate your work from your home life. If you just don’t have a separate room, find a corner or nook in your house that you can commandeer, and transform it into your home office. The goal is to make it feel detached from the rest of your house, so if it’s a small space, consider a room divider, or think about using just an area rug as a means of creating a division. Once you have “the office” location, be it a separate room or just a corner, set yourself up for success. Buy new- or check out used shops or thrift- for a desk that’s wide enough to support your wrists, arms, and elbows to keep carpal tunnel at bay while you’re tapping away at your keyboard. Better yet, go tetherless and get a wireless mouse and keyboard. Also look for a comfortable, ergonomic chair that supports your lumbar back, neck, and spine. Few paychecks are worth an orthopedic problem. Big bonus points if you can kit out your space with a sound system and other creature comforts. Try to also get some life into the space. Consider some plants and maybe even a little fish tank if you have room- they’re very soothing. If you’re only working remotely temporarily, and you just don’t have the space at home for an office, even going to a local library or cafe to work may be better than just converting your bed to one. When you have a clearly defined working space and time, it’s far easier to finish your tasks for the day, and leave work at “the office.” That way home remains home, and you avoid being “on” all the time.
Tech No!
Once you’ve done what you can to create a dedicated work space, make sure to do what you can in the way of technological assistance. If you need a new laptop, smartphone, wi-fi, or cell booster, communicate that with your employer, if appropriate. If they provide the equipment, or some sort of assistance in purchasing it, then score! If not, investing in tech that will save you time and aggravation is always a good move, so do that as soon as is feasible. If you’re all set up and ready to roll and find you’re still having technical difficulties, most definitely communicate that with your company’s IT department, if that’s not you, to fix the issue. If that is you, take the time to deal with it as efficiently as possible, call a “geek” to come out for a diagnosis. The sooner your systems are running smoothly, the fewer the tech migraines you’ll have later.
Coming at this from a different direction, once you’re properly setup, working from home can give you an opportunity to be proactive, learn something useful, and make friends with technology. There are apps out there that do all sorts of cool things that can be helpful in a remote work environment. You can set timers and reminders for break activities, track your social media usage, like if you need some help to use it less, remind yourself to get back to work when you become distracted for too long, and you can create to-do lists and schedules galore to help stay on top of things, simplify tasks, avoid frustrations, and be more productive. There’s nothing more encouraging than getting your mundane tasks done as quickly and efficiently as possible, so check out all the options available and learn to use tools like these to your advantage.
And just as the expansion of the internet has made remote work possible from nearly all corners of the globe, novel programs and platforms have also been developed specifically for remote workers. If you work for an organization, they may offer access to automated online courses that will allow you to keep honing your skills, so contact human resources and make some inquiries. If those opportunities don’t exist, you can always look for other free or paid online courses for virtual and remote workers. When I searched it, the number of them available was impressive. There are courses designed to give you the skills necessary to start a new career, or to grow an existing one. Remember that any time you work to broaden your horizons, you further your personal identity and make yourself more valuable in every professional application.
Management
A significant issue revolving around working remotely involves its management. How do you adequately supervise- and support- multiple employees, when they’re potentially thousands of miles away? Both managers and employees face a different set of challenges when working remotely. From what I hear from remote worker patients, the decreased feedback from managers and supervisors boils down to making some employees feel insecure. As I mentioned last week, it makes them feel mistrusted, and as though they have to prove that they’re actually working from home and not goofing off. I think the remoteness gives them no benchmark to judge their own progress, and that leads to increased anxiety and concerns about being up to standards. In short, they may not be getting the attaboys they did in the office, and that makes them wonder if they’re doing a good enough job. Obviously, employees need to adequately document the hours they work, and maintain regular communication with supervisors to keep them up to date on what they’re working on. More on communication later.
On the supervisory side, I think the solutions to these issues requires an open mind. Remote companies need to start thinking about how they can ensure that employees aren’t overworked, and also utilize management courses for remote team leaders to help train them for this new working environment. They should set aside more traditional ideas that no longer work, in favor of developing more flexible policies that better correspond with a more modern arrangement. Maybe implement the concept of management by objectives accomplished instead of by time. I can tell you from years of listening to people that helicopter monitoring- actually helicopter anything- and micromanagement won’t work. Management should consider allowing some employee input into the creation of novel management methods as well. Employee happiness and engagement increases productivity by 31 percent, so getting them involved in making suggestions benefits everyone.
Some other simple steps that management can take include encouraging employees to communicate amongst themselves, to take PTO days, to stay out of their “office” after hours, and to enjoy a hobby that does not involve a computer screen or technology of any kind. Also, performing technology and work station audits to confirm reasonable working conditions, and giving regular updates regarding organization standards and plans for future work performance will help alleviate a great deal of employee insecurity. Management also needs to be proactive in helping remote employees avoid undue stress, and allow them to feel comfortable reporting stress without worrying about repercussions. Two psychologists created the Yerkes-Dodson Law, which points out that stress can be productive up to a point, and then it results in reduced productivity. Being overly stressed without the ability to report it is detrimental, as pressure will eventually outweigh an individual’s ability to cope over time. Contrast that with the findings of one recent study, which reported that colleagues who spend just 15 minutes socializing and sharing their feelings of stress had a 20 percent increase in performance. Clearly, this demonstrates how it behooves management to implement measures for employee stress sharing and reporting.
Given the negative impact of stress in a remote work environment, management should also avail themselves of training to learn the warning signs that signal that remote employees are feeling workplace stress. Opening up a line of communication is a good first step, so that when they are starting to experience burnout, they’ll be comfortable discussing how they feel. Management should learn to ask questions about how they’re feeling and listen closely to the answers. Do they mention having a difficult time concentrating? How about their interests in things they used to like? Are they experiencing any feelings of frustration, irritability, or hopelessness? These would all be indicators of stress that management needs to catch before employees reach a breaking point. An increase in negative language is another indicator. The use of phrases such as: “there are no options,” “I can’t do anything,” or “this is impossible” are examples of catastrophizing, and should be red flag indicators of employees having more workplace stress than they know how to deal with. There are other signs as well. Make sure to speak with employees that are starting to make mistakes, missing deadlines, or getting sloppy, as they are often the first signs of struggle. And instead of cracking down on staff that’s having a hard time, organizations must offer support through stress management initiatives in the workplace. In my opinion, management and employees making all of these efforts would result in big strides on the road toward improving the remote work experience for everyone.
Isolation and Loneliness
The solitude of working remotely can be a double-edged sword. It can be easier to focus when you’re in your own home, with no annoying coworkers randomly stopping by your desk, or your boss breathing down your neck. Aah…sweet freedom! But when there’s no social interaction during a full workday, that also means there’s no one there to ask a work related question to, or bounce an idea off of, or un-stick you at a crucial point. Social isolation was another factor associated with increased stress levels mentioned in the UN study. In addition, without personal communication, more emphasis is placed on deadlines and routine information, so remote workers can feel like a cog in a machine, rather than an essential part of a team. This just adds to the sense of isolation that naturally comes with working remotely, and the two together can make it difficult to have as much energy to be productive. In addition, it can be very unpleasant, if not impossible, to sustain this for the life of a career. A top priority should be to maintain relationships with coworkers and managers, especially if you are one who is energized by these relationships. It is critical not only to work performance, but to emotional and mental wellness.
Technology can serve as an assist, and there are plenty of platforms like Slack, Zoom, and even good ole facetime to facilitate this. Lots of companies have established ‘virtual coffee breaks’ and even ‘watercooler’ channels to encourage break-time chatter during work hours, to foster collaboration and create a more comfortable work environment. If your company has outlets like these, take advantage of them. If they don’t, then maintaining connections is essentially up to each individual. Because everyday encounters with colleagues don’t spontaneously happen when working from home, you need to be proactive to maintain positive relationships. Think about scheduling a few minutes for informal banter at the start and end of video calls to emulate the normal casual talks you would have with coworkers when walking by their desks, or in the kitchen at the office. It may not seem productive, but it helps build internal relationships and boost morale. These connections will help you feel less isolated, reduce stress levels, and stay productive.
You can always facetime, Zoom, message, and email people, but that’s not the same as having face-to-face interactions with them. So make it a point to meet with coworkers or friends for lunch, coffee, or drinks a couple of times a week. If you find you’re still feeling isolated and lonely while working remotely, consider meeting other digital nomads at a coworking space, or work together from one of your home offices twice a week, or more often if it’s helpful. But remember what all work and no play did to little Johnny. Make social commitments with friends and get outside of the house at least once a week. Ultimately, if you work from home and feel isolated or lonely, it’s important that you take responsibility for your own social interactions. The key is to make an effort and be proactive to do things to decrease the isolation that can come from the remote work setting.
Burnout
One of the biggest challenges in working remotely is finding a healthy work-life balance to avoid blurring those lines I mentioned earlier. Surveys show that 51 percent of employees report stress and burnout as a result of working at home. Just as an interesting aside, the most often cited reasons for burnout are, surprisingly, the very things that made remote work seem attractive to most people. The dressing! Or not. The surveys indicated that when people dress in sweats because they are not seeing anyone, they then find that comfort makes it difficult to fully engage. Their clothing signals fun chill time, while their tasks are anything but. And while remote work seemed liberating, many employees relied on supervision and structure to manage their workday. Without it, many people fing it hard to be as productive, and are stressed about not completing tasks in a timely manner, and these cause them to overwork and risk burnout.
Not all people can achieve proper work-life balance when they work from home, and in fact, the UN study also noted that this is one of the many negative impacts of the remote work arrangement. For some, working from home feels like a special privilege that’s been granted to them, so they feel like they should work harder, and that’s how stress and burnout are escalated. I’ve noted that some patients, who definitely seemed to have a solid, healthy work-life balance when they worked in an office, suddenly started to become work obsessed after going remote. They work ridiculous hours at home, unable to even define the end of a day, much less switch off at it. I’ve seen it happen- watched it happen- to people who had a previously healthy balance, so imagine what happens to someone with workaholic tendencies when they go remote. From what I’ve observed, working remotely is to workaholism what bar hopping is to alcoholism. If you’re in a place that facilitates a bad habit, that’s a bad place to be. In other words, workaholics probably need not- or should not- apply for a remote position.
When working in an office environment, there are often clear signs and symptoms if somebody is burning out. These commonly manifest as increased emotional reactions to situations, a general lack of motivation, and the appearance of small, seemingly minor mistakes. There are also some visible physical signs, such as bags under the eyes and even weight loss, that can be seen. When working from home, there isn’t anybody to notice these telltale signs, apart from family members or friends. But if that person lives alone or is isolating themselves, then they’re not even there to see them. So remote workers have to be able to police themselves to avoid burnout.
Flexibility is a double edged sword. It can be liberating to set your own times as to when you need to get up, when you go to bed, when you need to start work, and when you need to stop. But this feeling of freedom can gradually morph into a feeling of being out of control, especially if you don’t expect it. It sounds great to eliminate a structured office setting, but once that structure is gone, where it might have felt stifling before, it can start to feel like the scaffolding on which your whole life was built. When there’s no one there to monitor or guide you, and structure has to be self-imposed, it can be difficult to create. It can also be more challenging to function as efficiently without it.
The solution is to set a schedule and put it on a calendar. Look at it as an opportunity to exercise the flexibility that is a prime benefit of working remotely. It can be vital to not only save you from burnout, but also from distractions that will swallow up your time. More on that in a bit. There are several useful tricks for creating a schedule, and you can always use an app to help you to make one in a format that suits you. If you are free to set your own hours, meaning it doesn’t matter when you work, then decide when you work best. Many people find that working in the morning when they feel rested can provide a more productive experience than beginning work halfway through the day after cleaning the house and doing other non-work-related activities. This isn’t true in all cases, so feel free to experiment if this advice doesn’t seem to ring true for you. If it were me, I would not only start work first thing in the morning, but I would also prioritize the most challenging tasks first. Rather than letting unpleasant or difficult tasks hang over your head and create stress when you think about them, pushing yourself to get the most difficult jobs done first will give you a sense of accomplishment and increased energy to get you through the day.
To be productive and avoid burnout, you not only have to set a schedule for balance, but you have to stick to it. Make sure to maintain reasonable office hours. As I mentioned last week, your home is now your office, so you’re not technically ‘leaving’ work unless you turn off all communication platforms. Sign out of your email, close the laptop, put the phone down at the end of the day, then leave “the office.” Make sure to include time to step away from your desk to take a lunch break, and eat something sensible to avoid being distracted by hunger later. If you have children or family at home, this is a good opportunity to spend some time with them. Since you probably spend a lot of time indoors, try to have lunch outside.
In addition to a lunch break, schedule short breaks during the day. Scheduled breaks are better than just working until you lose focus, then randomly giving in to distractions. Everyone is different, so the length and number of breaks can vary slightly, but within reason. Some people would do better taking 15 minutes mid-morning, and then again mid-afternoon, while others would rather two shorter breaks in place of one longer one. During these breaks, try to step away from your desk to disconnect for a few minutes; this is a very effective method for avoiding/ managing stress. Go outside to get some fresh air, maybe take the dog out to get the mail. The idea is to use these times to clear your head to help you focus on work when you come back.
When you take time off, take it completely off. If you’re guilty of working on PTO days or of bringing your laptop on vacation, you’re missing the point and need to disconnect more fully. It might seem like bringing work with you means you’ll have less to catch up on, and therefore less stress, when you get back, but in reality, you aren’t allowing yourself to recharge. This goes for weekends too. Keep the laptop closed, resist the urge to check emails, and concentrate on the life part of the work-life balance during your time off.
Focus, Motivation, Distraction
Creating structure and setting boundaries are critical in a remote work setting, not only to avoid blurring the lines between work life and home life, but also those between productivity and leisure time, and socializing time and working time, in order to avoid distractions. But this can be more challenging than many people expect. If you live with family, setting boundaries with others can be difficult when people expect that you should have time to talk when they do. You may feel pulled between competing loyalties and overwhelmed by the responsibilities of your various roles. Not only is it difficult to set and communicate boundaries, but in some situations, such as when there are children in the home, those boundaries may also be constantly challenged. If you live with other people, especially children, make sure to have set office hours and communicate them to everyone. You can even show small children your schedule, and explain that you have break times and lunch time scheduled, and you’ll see them during those times. Also clearly communicate what circumstances warrant an interruption of work time in order to avoid random needless interruptions. Apparently some companies actually provide employees with do not disturb signs to hang on their office doors in order to remind others you’re actually working. It’s not the worst idea ever. I say if you have kids, and your company doesn’t provide you with one, get out the markers, glue, and glitter and them involved- ask them to create a sign for you. If they make it, they’ll be more lilely to respect it when they see it hanging on the door.
Setting and sticking to boundaries with yourself may be even more difficult than with others, especially when you are feeling a lack of motivation. Without other coworkers around to hold you accountable, you may have a little tougher time motivating yourself, but resist random distractions in favor of taking your scheduled breaks. In addition to sticking to your schedule, you can avoid distractions by not taking personal calls during the middle of the day and avoiding the endless rabbit hole of social media. Turn off notifications and/ or mute your devices while you’re working. Just don’t go on social media if you don’t want to be Alice. It’s easy to lose sight of tasks and deadlines, especially when your superiors can’t physically see you, but you can monitor your own productivity by planning ahead of time and using time management techniques. At the end of each day, make a list of tasks to be done for the following day. On the next day, review your priorities and tackle high-value tasks first. By following this, you’ll stay organized by keeping your schedule and calendar straight, and learn how to prioritize to get your work done. It should also help you learn one of the golden rules to working remotely: don’t procrastinate! If you need more help with time management techniques, google it. There are methodologies available on the interwebs to help maintain your focus throughout the day, and I’m sure there are apps for that, as well. Aren’t there for everything?
To keep your motivation up, it’s a good idea to break big tasks down into smaller, workable goals. You can also setup project milestones, working with a manager to establish objectives when needed. Sometimes communicating those goals out loud to others can help to motivate you, so consider sharing those goals with coworkers or family members, because sometimes making public commitments to others about what you will accomplish that day helps hold you accountable. If you need to really pump up the motivation factor, you can always reward yourself for accomplishing goals as well. But this doesn’t mean a food reward, people. Maybe schedule a massage, a special lunch with a friend, or an ice cream with the kids. Okay, I guess that’s technically a food reward… so make it a yogurt if you’re trying to be healthy. At any rate, put planned rewards on the calendar so you can see it as a motivator. It doesn’t even have to be a real reward that costs anything. Sometimes it’s rewarding enough to imagine something you’re working toward, and reward yourself by taking whatever the next step is in attaining it. Maybe you want a new kitchen; you can go to the tile store and get different samples to bring home and mull over. The point is that it’s up to you to be productive, while also making your work experience pleasant. Try to keep yourself feeling appreciated, even if you yourself are the only one who appreciates you.
Freelancing
If you’re freelancer, your monthly workload and income can be unreliable and constantly changing. This is an obvious source of anxiety and stress, as sometimes you may be swamped with too much work, while at others, not have enough; it can be very difficult to find that middle ground. And because jobs aren’t usually long-term, you need to spend much of your time searching for new opportunities, while simultaneously completing the work you have. Not only are these conditions stressful, but freelancers are independent contractors that usually have to handle everything, so switching hats from sales to service to invoicing and bookkeeping adds to the stress. Not every personality is well suited for this variability. While researching this blog, I found a lot of resources available- job boards, apps, communities, and blogs for freelancers that look like they would make their lives quite a bit easier. One blog I came across had a list of various applications with descriptions of exactly what they do, along with links to everything. If anyone is interested, the blog was called skillcrush, and can be found here: https://skillcrush.com/blog/useful-resources-for-freelancers/
Communication
Communication can be very sensitive territory, and learning how to navigate it is an essential skill to avoid misunderstandings and misinterpretations in every work situation, but especially in a remote work setting. With electronic communication methods that don’t allow for visible body language, it’s difficult to convey the true meanings of messages, leaving them open to individual interpretation. Misunderstandings can lead to hurt feelings, decreased productivity, and issues with your corporate culture. For these reasons, it’s best to have an assortment of communication and collaboration tools at your disposal for use in different circumstances. Email and instant messaging are convenient, but more complicated communications should always take place using some sort of video interface, such as Zoom or Skype, as it allows people to interact with each other in a format that provides body language and non-verbal cues that other forms of correspondence don’t express.
When communicating with a group, make sure that any messages you share are very easy to understand. On that note, if you receive a message that isn’t understood, don’t be shy about asking for clarification. For collaboration to work properly, the right information needs to be passed along efficiently and comprehensively, so this makes proofreading especially important.
Keep in mind that etiquette matters in all communication. Jokes and sarcasm have their place, but that is not in professional group applications. Also, remember to check your tone. Without that face-to-face connection, tone is important, so take the time to double check your phrasing before hitting send. Spending a few extra seconds to go over what you’ve written to make sure that there aren’t mistakes, omissions, or other factors to get in the way of what you’re trying to say helps keep you from having to backtrack and explain things again later. This can also keep incorrect presumptions from influencing the results of your efforts. Given that your coworkers could be located anywhere around the world these days, try to be extra aware of time zones, and remember that waking up to 20 Slack notifications/ instant messages is stressful! Try to be respectful of the different time zones that your team are working from, and keep communication to those hours whenever possible.
Conduct regularly scheduled video chat meetings to maintain good communication with your colleagues and managers. This is the best way to keep lines open and make sure everyone is on the same page about whatever projects you’re currently working on. Make sure the video chat platform includes features such as file sharing, screen share, and multiple user interfaces in one chat. Be sure to always “show up” to your organization’s online meetings and be heard. If you need to communicate with your manager about sensitive topics, such as evaluations, progress reports, or even workplace stress levels, always do it over a video conferencing platform. It’s much easier to connect and fully emote how you’re feeling when your manager can see you.
Stressbuster Tip: Mobile Devices
Probably the biggest overall culprit common to all remote workers in causing stress is device use, especially smartphones. I’ve been yelling about this forever. While all of the sources of stress I’ve mentioned are significant, the UN study that prompted this blog found that frequent use of mobile devices appeared to be a “significant source” of added stress. Part of the reason has to do with blue light exposure from device use late at night, which remote workers are more prone to, and the serious impact it has on sleep schedule. In fact, this study found that it was linked with frequent waking at night: 42 percent of those who work from home report frequent night waking, while only 29 percent of office workers reported the same. This is especially important because poor sleep can add a significant amount of stress throughout the day.
Research has also connected higher levels of stress to the habit of constantly checking one’s phone. Remote workers certainly check their phones often, but what else might make people constantly check their phones? Hello, social media. Not only that, but surprise, social media use itself can also lead to stress, because of increased social comparison. I’m sure I’ve mentioned that before. Ultimately, the increased use of devices, and the constant checking of devices- whether for work or social media silliness- is absolutely associated with higher stress levels, insomnia, and ironically, social isolation. Okay, rant over. The solution for this one is pretty simple: limit the number of times you check your phone for non-work reasons, ie social media, each day, make it a point to put the devices down at the end of the work day, and declare a minimum 90 minute moratorium on all device and screen use, for any reason, before bed.
Stressbuster Tip: Make it Routine
Just as you create a schedule to keep you on track at work, design a morning and evening routine unrelated to your work, to tell your brain when it’s time to work, and when work is over for the day. This will help your brain create a distinction between work and home, which helps you switch off and decompress. Yet another good reason to get dressed for work, even though no one will see you- it helps you create that division. If you have young children at home, seeing you “dressed for work” will also help them to understand the distinction. Be sure to use time spent away from work for yourself, for family time, exercise, and self care.
Stressbuster Tip: Get Comfortable Saying No
Working from home, you’ll be faced with many requests, many of which you may need to refuse if you want to have enough time to get everything done. It can be surprisingly difficult to say no to people you don’t really owe your time to, simply because most of us can find reasons why a “yes” is a perfectly reasonable answer. We may think of their needs and see ourselves as a great answer for them, and not realize that saying yes to them means saying no to ourselves. We may also have our egos involved in having a solution for them. Whatever the challenge, realize that saying no to the time drains you didn’t plan for often means saying yes to the healthy life you truly want and need. For freelancers, learning to say no is an especially important skill. You may want to take on as much work as you can, but there’s only so much you can complete in a day. Know your limitations, set boundaries based on your schedule and workload, and don’t extend yourself beyond them. Be assertive, yet courteous, and your clients will still respect you.
Stressbuster Tip: Protect Your Sleep
A good night’s sleep rejuvenates the body so you can tackle the day ahead and can help lower the effects of stress during your workday. Because healthy sleep is vital for your productivity, do what you need to do to get it. It may sound like kindergarten time, but this includes setting a bedtime for yourself and sticking to it. Believe it or not, keeping a sleep schedule is one of the hardest things for most of my patients, even the ones I lecture to about it. In any case, when you do it for a while and feel the effects of getting adequate sleep, you’ll see that it’s well worth the effort. You already know that this is a no-no, but it bears repeating, as so many people blow it off: using screens and devices late at night alters your sleep patterns; it makes it very difficult to not only get to sleep, but to stay asleep at night, because it elicits brain patterns of wakefulness. So skip the screens before bed for a minimum of 90 minutes.
Stressbuster Tip: Accentuate the Positive
Another cause of work-related stress is focusing on the negative, and all of the things going on that are beyond our control. The best cure for stress is to concentrate on what is going right and the progress that is being made. I’m sure I’ve mentioned in various blogs that laughing and smiling lowers stress hormones like cortisol, epinephrine, and adrenaline, and can act sort of like a natural antidepressant that releases healthy hormones. When you’re working remotely, learn to take a few minutes to concentrate on positive things, and do what makes you feel calm and happy, even if these things may not be so productive and useful all the time, you’ll find you’re less stressed.
Stressbuster Tip: Slow Down
Life can come at us way too fast at times, and while you can’t just stop, you have to learn to pace yourself if you want to be a great remote worker. Slow down and remember that the best decisions are never made in a rush, and rushing is never the best decision. When you’re stressed, take a few minutes to breathe and clear your head. Try inhaling for five seconds, holding five seconds, and exhaling with another five. Do this a few times in succession if necessary. This will help you stay calm and focus, like a 90-minute yoga class, but in three minutes or less.
Stressbuster Tip: Eat Right
Diet does matter. Eating poorly will stress your body out, while eating right will restore balance and reduce pressure. Sometimes working remotely can be a recipe for a snack attack when you get distracted or don’t eat properly, so that’s double trouble. When you work remotely, make sure to eat three decent, well balanced meals each day.
Stressbuster Tip: Share Stress
Remember the two kinds of stress, good and bad, how they work for and against you, and the Yerkes-Dodson Law. Share your stress with coworkers to lighten everyone’s load. I’m not saying concentrate on it, just spend a few minutes each day releasing it, and then keep it moving.
Stressbuster: Keep it Moving
Speaking of which, you should absolutely be doing something to move your body everyday, so incorporate exercise into your non-work routine. I personally exercise every morning, first thing, to get my blood pumping; and I also use that time to think about what I have coming up in my day. You don’t have to spend two hours at the gym, even just 30 minutes of walking per day can help boost your mood and reduce stress levels, and you can do that on a treadmill if you have one, or just in your neighborhood if you don’t. That way you also get some fresh air and kill two birds with one stone. In addition, a pre- or post-work workout will help enforce those divisions in your brain to keep your work life separate from your home life, and prevent those lines from blurring.
Mental Health Benefits of Flexible Work
Yes, remote work can cause and exacerbate mental health issues, but it can also act as a support mechanism. I read a survey of over 3,000 professionals conducted in 2018 on flexible work options, which includes remote work, flexible hours, and reduced schedules; and the results were interesting. It demonstrated that flexible work options have a lot to offer in supporting mental health at work, and in life in general. In fact, the impact that work flexibility can have is so great that 97 percent of people surveyed said that having a more flexible job would have a “great,” “positive” impact on their quality of life. That same survey also found that work-life balance and commute-related stress are two of the top factors that make people want a job with flexible options. For people with mental health concerns, caregivers, and professionals at large, flexible work options appear to support efforts to improve the mental health of everyone. It should be noted that this study included people who self-identified as living with a chronic physical or mental illness, making up 16 percent of those surveyed; and also included people who were caregivers of someone with a physical or mental health issue, making up 10 percent of those surveyed.
There other notable way flexible work can positively affect mental health is directly related to commute-related stress. Even if a person loves their job, sometimes what they have to go through to get there is so stressful that it can negate that positive impact and result in added stress. The average commute time in the U.S. is approximately 26 minutes each way. But according to this survey, people who are most interested in flexible work options have even longer commutes, with 73 percent of respondents reporting commutes exceeding one hour. And 71 percent said they’d like to work from home just to eliminate commute-related stress, so this is clearly a huge factor in the appeal of remote work.
Other interesting findings from the survey on specifically how remote work could help respondents “reduce stress and improve productivity” included: 75 percent indicated by generally reducing distractions during the work day; 74 percent indicated by eliminating interruptions from colleagues, 65 percent indicated by keeping them out of office politics, 60 percent indicated by allowing for a quieter work environment, 52 percent indicated by giving them a more comfortable work environment, and 46 percent indicated by a giving them a more personalized work environment.
Remote work also provides more job opportunities in economically disadvantaged areas. Living through the decline of an industry or long-term high unemployment can negatively affect mental health. High rates of depression and anxiety are found in rural areas, especially among older adults who have often had their lives greatly affected by their community’s economic decline. Those living in rural or economically struggling areas may miss a key piece of the human experience: engaging in the workforce in a meaningful, long-term way. Remote work may be an solution to all of these issues by providing options to people in economically disadvantaged areas that may have mental health issues. It shows huge promise in bringing people in these situations back into the workforce, and there are partnering programs established to help spread the awareness of these opportunities.
Another population that would reap great benefit from flexible work options are neurodivergent individuals. For example, employees on the autism spectrum and people with mental disorders like OCD can benefit from more time working from home, as loud noises, distractions, and pressure to appear “neurotypical” in front of colleagues and coworkers takes an emotional toll and impacts performance. By working remotely, they can benefit greatly, both professionally and personally.
All professionals put a huge amount of time, energy, and focus toward work each day. By offering flexible work options, companies are signaling to their employees that they can, and should, devote more time to health and wellness. And that’s never a bad thing.
The other top factors that make people want a flexible job, in addition to better work-life balance and eliminating commute related stress, were family time savings. The constant pull that people feel between time spent with family versus time spent at work can negatively affect mental health, and flexible work options allow those priorities to coexist more peacefully. But this isn’t just a benefit for employees, because companies also benefit when their workers are healthier. Multiple studies have demonstrated that employees in unhealthy workplaces are likely to experience higher stress levels and lower engagement, and that these feelings actually spread throughout the workplace, negatively affecting productivity and corporate culture. Companies that give employees more control over when, where, and how they work by offering flexible work options, are supporting the health and wellness of their workers and enhancing the company’s culture and productivity, all at the same time.
The only demonstrable good thing ‘rona did was to reveal the opportunities that working from home poses for many companies that may not have considered it an option otherwise. Maybe it helped them realize how important health, both physical and mental, is as well. Nothing like a pandemic to set your priorities straight. Ultimately, mental health at work must remain a priority for employers, regardless of whether that takes place at the office, or at the employee’s home.
The news that remote work can actually be as stressful as working from an office, if not more so, may have come as a shock to many people who considered a work-from-home lifestyle to be one that’s less stressful just because it offers more personal freedom and eliminates a commute. Part of the stress experienced by remote workers may be due to the fact that those who work from home face a host of challenges that are unique to this particular setup. While there are certainly pitfalls, there are also a number of benefits. As remote working becomes more popular, it’s very important that companies adapt and put the right policies in place to ensure their employees don’t experience any undue stress or burnout, and still feel like a valued part of a team. The right kind of communication is key to overcoming the challenges, as is being proactive about using it. Everyone involved in the remote work equation, top to bottom, needs to think about what makes them productive, happy, and successful in everyday life, and try to replicate those things in a remote setting. When you implement ways to mitigate and manage the stress associated with working remotely, then you’re free to enjoy all of the many benes.
Hopefully now that you know how common some of these stressors are, you may feel less isolated in what you face, and more energized in tackling these challenges in the remote work environment. While employers should make the mental health of their employees an important priority, remember that ultimately, we’re all responsible for monitoring our own mental health, so if the simple exercises and routine changes I’ve suggested here are not enough, and workplace stress becomes too much for you to handle, it’s important to talk to somebody about it, so please seek professional help if that’s the case.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
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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 MoreMigraines;Strategies to Treat It and Bear It
Migraine: Strategies to Treat It and Beat It
Last week, I talked all about migraine. What do I hope were the takeaways? Well, there are roughly 10,000 known human diseases under the sun… of allll those diseases, I hope you learned that migraine is a very unique beast, thanks to a very unusual constellation of facts surrounding it: its striking capacity to debilitate (ranked first in neuro and sixth overall) and staggering prevalence (ranked third overall) despite a frighteningly high (60%-70%) rate of misdiagnosis really make it a beast of a neurological disease.
This week, the focus will be on how to manage and/ or prevent migraine. I’m going to cover some basic suggestions and nonprescription ways to avoid or prevent migraine, and I’m also going to discuss some prescription medications and procedures to treat migraine when it occurs. Spoiler alert: one of the very new migraine meds has been like a miracle in my life people. So read on to find out how you might be able to avoid getting a migraine as well as some ways to deal with it once it rears its ugly head.
First, a few more takeaways from part 1:
– Migraine is more than a bad headache.
– Proper and early diagnosis by a specialist physician with specific neuro symptoms is very important.
– Episodic migraine occurs once or twice a month while chronic daily migraine is minimum 15 days per month.
– There are several migraine types classified mainly by presence or absence of neurological aura.
– Migraineurs often have identified triggers that will cause attack.
– All migraines suck, but some more so than others (hello cluster, rebound, and status migrainosus) because of the extreme pain, but also because of the extreme neurological disturbances that come along for the ride.
– Exact cause of migraines still unknown, but thought related to a combination of genetics, neurotransmitters, and/ or hormones.
– There are medications to prevent, abort, and rescue from migraine.
Why isn’t there an obvious known way to prevent and treat migraine?
When people find out I have cluster headaches or when I’m asked by a fellow migraineur or a patient why we don’t already have a foolproof way to prevent and treat migraine, the answer is intensely unsatisfying, especially considering that migraine affects zillions of people, and has done so for a looong time. For the love of Pete, why haven’t we figured it all out by now? Well, even though it is the world’s most common cause of neurological disability, researchers are only just beginning to understand what really causes migraine. I say ‘really’ because unfortunately, the common and long accepted vascular explanation for migraine had to be thrown out relatively recently. The vascular theory was proposed in 1938 and claimed that pressure changes in the vascular system near the brain, and in the brain, caused migraine. More specifically, that vasospasm and vasoconstriction narrowed the blood vessels, slowing and restricting blood supply in and around the brain and causing visual aura and other neuro symptoms; then vasodilation occurred, and those vessels rebounded and widened, allowing too much blood to course through too quickly and causing pain. Eventually, the vessels came back to their normal size and state and the migraine ended…until the next time. This vascular explanation had considerable intuitive appeal because alteration in blood flow seemed to fit the pulsating pain quality that migraine headaches often possess. But now after extensive testing, this theory no longer has any validity. We now know for sure that migraine is a gene-related neurological disease, not a vascular one. So we lost a lot of valuable time looking at the wrong culprit and screwing around with the vascular theory.
Current research shows that a variety of genetic mutations are at least partly responsible for migraine, with the TRESK gene being identified as one such genetic mutation site. The TRESK gene provides the blueprints for a potassium ion pump channel that is believed to help nerve cells rest. When mutations occur in this gene, they may cause nerve cells to become overexcited, making them more responsive to a smaller pain stimulus or less pain. Personally, I would call that over-reactive rather than overexcited, but that’s just me. Either way you get the idea. Even though genetic mutations tell part of the story, migraine initiation is enormously complicated. It relies on several processes which either result in a visibly changed brain structure or are caused by these changes in structure. In fact, it seems that most scientists believe as I do, that there isn’t just a single cause. In my thinking, there can’t be- there are so many different systems and senses affected that there have to be multiple causes in play. Obviously, lots of research is still needed before we know the whole story.
Treating Migraine: Natural Remedies
When a migraine does strike, you’ll do almost anything to make it go away. There are ten natural remedies and at-home treatments that may help prevent migraines, or at least help reduce their severity and duration.
1. Know and avoid triggers, esp in diet
Diet plays a vital role in preventing migraines. Many foods and beverages are known migraine triggers, such as:
-Foods with nitrates, including hot
dogs, deli meats, bacon, and sausage
-Chocolate
-Naturally-occurring tyramine compound, such as blue, feta, cheddar, Parmesan,
and Swiss cheese
-Alcohol, especially red wine
-Foods that contain the flavor enhancer monosodium glutamate (MSG)
-Foods that are very cold such as ice
cream or iced drinks
-Processed foods
-Pickled foods
-Beans
-Dried fruits
-Cultured dairy products such as
-Buttermilk, sour cream, and yogurt
-Caffeine: a small amount of caffeine may ease migraine pain in some people, and a small amount of caffeine is found in some migraine medications. But too much caffeine may also cause a migraine and/ or may also lead to a severe caffeine withdrawal headache.
**Track yourself! As Migraine Warriors, we tend to think of the occasions when attacks occur and the major symptoms that go along with them. Always keep a diary or list of things that act as warning signs or triggers of an oncoming migraine, including foods or environmental triggers, how much sleep have you had, what the weather is like, what you ate and when, etc. To figure out for the first time which foods or beverages may trigger your migraines, keep a daily food diary. Record everything you eat and note how you feel afterward. All information may be very important and will likely help you to avoid future attacks.
2. Apply lavender oil
Inhaling lavender essential oil may ease migraine pain. According to a 2012 study, people who inhaled lavender oil for 15 minutes during a migraine attack experienced faster relief than those who inhaled a placebo. Lavender oil may be inhaled directly or diluted and applied to the temples.
3. Try acupressure or acupuncture
Acupressure is the practice of applying pressure with the fingers and hands to specific points on the body to relieve pain and other symptoms. While there are no recent scientific studies, according to some sources, acupressure is a credible alternative therapy for people in pain from chronic migraine and other conditions, and may also help relieve migraine-associated nausea. And although there may not be any definitive scientific studies on acupuncture, some migraines may respond well to acupuncture, the Chinese method of inserting needles into specific body locations to reduce or stop pain. Because the results are so variable, some doctors do not recommend this treatment. But because some patients report headache relief, it is another treatment method to consider.
4. Look for feverfew
Feverfew is a flowering herb that looks like a daisy, and according to some, is a folk remedy for migraines. According to some sources, there’s not enough evidence that feverfew prevents migraines, but many people still claim it helps their migraine symptoms without side effects.
5. Apply peppermint oil
The menthol in peppermint oil may stop a migraine from coming on. A 2010 study found that applying a menthol solution to the forehead and temples was more effective than placebo for the pain, nausea, and light sensitivity associated with migraine.
6. Go for ginger
Ginger is known to ease nausea caused by many conditions, including migraines, and it may also have other migraine benefits. One study claimed that ginger powder decreased migraine severity and duration as well as the prescription drug sumatriptan, and with fewer side effects.
7. Sign up for yoga
Yoga uses breathing, meditation, and body postures to promote health and well-being and may relieve the frequency, duration, and intensity of migraines. It’s thought to improve anxiety, release tension in migraine-trigger areas, and improve vascular health. Although researchers conclude it’s too soon to recommend yoga as a primary treatment for migraines, they believe yoga supports overall health and may be beneficial as a complementary therapy.
8. Try biofeedback
Biofeedback is a relaxation method that teaches you to control autonomic reactions to stress. Biofeedback may be helpful for reducing migraine triggers like stress and early migraine symptoms such as muscle tension.
9. Take vitamins and supplements
Some vitamins and supplements (collectively known as nutraceuticals) may be useful therapies. One of the nutraceuticals that has shown some evidence of relief in preliminary testing is magnesium. Magnesium deficiency is known to be linked to headaches and migraines and studies show magnesium oxide supplementation helps prevent migraines with aura, and may also prevent menstrual-related migraines. Adding magnesium to your diet may be helpful. You get magnesium from foods like nuts and nut products, including almonds, sesame seeds, sunflower seeds, Brazil nuts, cashews, peanut butter, eggs, oatmeal, and milk.
10. Book a massage
A weekly massage may reduce migraine frequency and improve sleep quality, according to a 2006 study. The research suggests massage improves perceived stress and coping skills and also helps decrease heart rate, anxiety, and cortisol levels.
The Takeaway
If you get migraines, you know the symptoms can be challenging to cope with. You might miss work or not be able to participate in activities you love. Try the above remedies to possibly find some relief… they can’t make it much worse!
It might also be helpful to talk to others who understand exactly what you’re going through. There are lots of websites, support groups, and apps to connect you with real people who also experience migraines. You can ask treatment-related questions and seek advice from other people who totally “get it.” So do some googling for migraine support.
Calculate your Headache Burden
Another good idea… Some doctors like to estimate how much migraine disrupts your normal activities before establishing a treatment regimen. A questionnaire may be given to the patient to estimate how often they miss various functions (school, work, family activities) because of their attacks. You can also commonly find other surveys and tools online meant to be filled out, printed, and brought to a primary care physician to broach the subject of headache and/ or to discuss migraine types with specialist physicians to help define headache/ migraine type and zero in on the best treatment regime.
Treating Migraine: Medications
There are many types of medications for people with migraine headaches. Some help to reduce symptoms of acute migraine as they occur, while others prevent episodes from occurring. Captain Obvious says that taking any drug can have side effects, and that some are safer than others.
Two primary ways that medications treat migraine headaches: Acute medications aim to treat symptoms of migraine headaches as they occur. Preventive medications aim to reduce the risk of migraine headaches occurring in the first place by reducing migraine frequency and severity.
Over-the-Counter (OTC) Medications
-Acute medication to treat migraine
-A range of migraine medications are available without a physician’s prescription.
-These include analgesic medications like aspirin, acetaminophen, naproxen, or ibuprofen, may help to reduce pain.
-Many of these analgesic medications are nonsteroidal anti-inflammatory drugs (NSAIDs). This means that similar to steroids, they reduce inflammation which may help with migraine symptoms.
-It is best to take these medications when the first signs of an episode occur. The medicines will take time to enter the bloodstream, and taking them too late means that the headache will likely last longer and possibly won’t be susceptible to the medication; in other words it may not help.
-The risks associated with using OTC analgesics are relatively low.
-May cause mild side effects in some people, such as rashes.
When over-the-counter (OTC) medications do not work, a doctor may recommend stronger prescription drugs. There are several different types of prescribed migraine medications.
Prescription Medications: Treat Migraine
As opposed to preventing migraine
Ergot Alkaloids: Treat Migraine
-Medication to treat acute migraine
-I want to point out that ergot drugs are really old school. The American Migraine Foundation wants to point out that doctors don’t commonly prescribe them any longer, but they may recommend them in severe cases if someone doesn’t respond to other analgesics.
-Two main types are dihydroergotamine (DHE) and ergotamine (Ergomar)
-Ergot alkaloids may cause blood vessels to narrow, which can have serious side effects for people with cardiovascular disease issues.
-Other potentially serious side effects: nausea, dizziness, muscle pain, unusual or bad taste in the mouth, vision problems, confusion, unconsciousness, in addition to many drug interactions.
-These side effects and the drug’s interactions are so problematic that physicians typically severely restrict use of ergotamines except in very rare cases.
-Fun fact: many scholars claim that the behavior of Salem’s “witches” was actually due to a fungal infection in the grain used at the time; ergotamines are essentially a mimic of this grain infection. So maybe don’t take it unless you look good in black and like the pointy hat look. Yikes people! Because of the side effect profiles and lack of efficacy, this class is definitely not as commonly used as newer and more effective triptans and more novel compounds.
Triptans: Treat Migraine
-Acute medication to treat migraine
-Approved to treat moderate to severe migraines: headaches where the symptoms interfere with the ability to perform daily tasks.
-Triptans act on the symptoms of a migraine headache in its early stages. -They will not stop the migraine headache, but they can help with some symptoms, such as nausea, pain, and light sensitivity.
-Several triptan medications exist:
sumatriptan (Imitrex)
zolmitriptan (Zomig)
rizatriptan (Maxalt)
-A person should take these drugs as soon as migraine symptoms start.
-They may not work if taken during a migraine aura.
-They are available in several forms: pill, orally disintegrating tablet, nasal spray, or injection.
-Triptans can cause side effects: dizziness, fatigue, nausea and vomiting, pain in the throat, chest, or head, numbness, dry mouth, burning or prickly feeling on the skin, indigestion, hot flashes, chills.
Antiemetics/Antinausea: Treat Migraine
-Acute medication for migraine symptoms
-Also known as antiemetic drugs, these can help people with migraine, even if they don’t feel nauseous.
-Don’t reduce pain, so some people take them alongside pain relief medication.
-Examples of antiemetic drugs:
chlorpromazine (Thorazine)
metoclopramide (Reglan)
prochlorperazine (Compazine)
promethazine (Phenergan)
CGRPReceptor Antagonist: Treat Migraine
-The FDA has recently approved several drugs that block calcitonin gene-related peptide (CGRP) receptors for the immediate treatment of migraine.
-CGRP is a molecule typically involved in migraine episodes.
-Examples of recently approved CGRP receptor antagonists include ubrogepant (Ubrelvy) and rimegepant (NURTEC).
Ubrogepant (Ubrelvy): Treat Migraine
-First drug in the class of oral CGRP (calcitonin gene-related peptide) receptor antagonists approved for the acute treatment of migraine with or without aura in adults
-Similar to Rimegepant (Nurtec ODT)
-Most common side effects that patients in the clinical trials reported were nausea, tiredness, and dry mouth.
-Contraindicated for co-administration with strong CYP3A4 inhibitors such as ketoconazole, clarithromycin, and itraconazole.
-Your doctor may change your treatment plan if you also use: nefazodone; an antibiotic – clarithromycin, telithromycin; antifungal medicine – itraconazole, ketoconazole; or antiviral medicine to treat HIV/AIDS – indinavir, nelfinavir, ritonavir, and saquinavir.
Rimegepant (Nurtec ODT): Treat Migraine
-CGRP receptor antagonist used for acute treatment of migraine with or without aura in adults.
-Similar to ubrogepant (Ubrelvy)
-Orally Disintegrating Tablets (ODT) for sublingual or oral use.
-Side effects include: nausea and
hypersensitivity, including shortness of breath and severe rash
-Important: like Ubrelvy, Nurtec will interact with other medicines such as: strong CYP3A4 inhibitors and moderate CYP3A4 inhibitors such as ketoconazole, clarithromycin, and itraconazole. Will also interact with inhibitors of P-gp or BCRP.
**This is the new medication for treating migraine that works like a miracle for moi people!
Lasmiditan (Reyvow): Treat Migraine
-First in a brand-new class of drugs (Ditans) that stimulate the serotonin 1F receptor found in different brain regions and believed involved in causing migraine
-Slows body’s pain pathways
-Used for acute treatment of migraine with or without aura in adults.
-Not useful for migraine prevention.
-Taken by mouth
-Common side effects: sleepiness, dizziness, tiredness, numbness
-Reduces inflammation that arises in the nervous system.
Prescription Medications: Preventing Migraine
-For people who get migraine headaches regularly, some medications can help to reduce the number and severity of episodes, ie prevent migraine.
-Most drugs for preventing migraine headaches are relatively low risk.
-May cause side effects such as constipation, muscle spasms, and cramps.
-Several categories of preventative medications:
Antihypertensives
-Antihypertensive drugs lower blood pressure, usually in people with high blood pressure.
-There are many different types of antihypertensive drugs that might help to prevent migraine headaches, such as: beta-blockers, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors
Anticonvulsants
-Anticonvulsant drugs treat seizures in people with epilepsy by reducing activity in the brain- and this can also reduce the risk of a migraine headache.
-Examples of anticonvulsants for treating migraines include topiramate (Topamax) or valproic acid (Depakene).
Antidepressants
-Antidepressants often work to increase the availability of serotonin in the brain. -Because of this mechanism, some of these drugs could also help to prevent migraine headaches, such as amitriptyline (Elavil).
CGRP inhibitors
-Calcitonin Gene-Related Peptide
-CGRP inhibitors are preventive migraine treatments that disrupt a protein called CGRP, which is particularly active in people with migraines.
-They block the flow of CGRP to the brain, disrupting signals that cause migraines.
-Unlike traditional migraine meds, such as sumatriptan (Imitrex), CGRP inhibitors don’t constrict blood vessels, so they’re safe for people who’ve had a stroke, heart attack, or vascular disease.
-Three new CGRP inhibitors are injected once a month to prevent migraines:
erenumab (Aimovig)
fremanezumab (Ajovy) galcanezumab-gnlm (Emgality)
-So new: may cause unknown side effects, and consequences of long-term use are still unknown.
Eeptinezumab-jjmr (VYEPTI)
-FDA 2020 approval, migraine prevention in adults
-First drug for migraine prevention via IV infusion.
-Treatment involves doctor administering this drug intravenously for 30 minutes every 3 months.
Devices: Treat/ Prevent Migraine
-There are three new noninvasive medical devices currently available:
Cefaly
-Placed on the forehead to stimulate a nerve that impedes migraine pathways.
-Used as prevention or for treating when a migraine strikes.
-SpringTMS
-Magnetic stimulator placed on the back of the head to disrupt migraine signals in the brain.
-Used as prevention or for treating when a migraine strikes.
gammaCore
-Third device
-Used for treating when a migraine occurs, cannot prevent migraine
-Placed at front of the neck to stimulate the vagus nerve.
Procedures: Preventing Migraine
There are two profedures used in an attempt to prevent migraine by reducing frequency and severity.
SPG Nerve Block
The sphenopalatine ganglion (SPG) is a group of nerve cells linked to the trigeminal nerve.
-Applying local anesthetics to this group of nerve cells can reduce sensations of pain related to migraines.
-Doctors can apply medication to this area through the use of small tubes called catheters. They can place these tubes inside the person’s nose, then insert numbing medication through the tube using a syringe.
Botox Injections
-OnabotulinumtoxinA (Botox) injections for people with chronic migraine headaches.
-Doctor might prescribe Botox if a person has experienced at least 15 headaches per month for 3 months, eight of which must have included migraine symptoms.
-Doctors tend to recommend two or three other types of medication before trying Botox injections.
-Comes as injection only, can have many side effects.
-Progress carefully monitored, treatment may be stopped if there is no response after 8–12 weeks or if migraine episodes fall to less than 10 per month for 3 months.
-Can also have many possible side effects, including numbness or mild nausea. -Some other side effects are more serious, such as gallbladder dysfunction, visual problems, and bleeding.
Your Migraine Treatment: Is it Working?
-Sometimes initial treatments for migraine either do not reduce the symptoms or only marginally reduce them.
-If, after trying prescribed treatment(s) about two or three times and getting little or no relief, you should ask your doctor to change the treatment.
-Patients are strongly urged to treat migraine attacks early: some references indicated to take it within about 2 hours of the start of headache to get full benefit of treatments.
-Taking it earlier is better: as early as possible.
Migraine Treatment: Medication Limits
-Some chronic headaches are due to overuse of medicine
-Avoid using migraine-prescribed medicines more than twice per week. -Using and tapering medicine for migraine should proceed under your doctor’s supervision.
-Narcotics are a bad idea except used only as a last resort for migraine because they are addictive and very easily cause rebound headache pain. For example, only in an emergent situation, an ER visit.
Migraine: When to Seek Emergent Care
Most people know the pattern of their attacks (triggers, auras, and headache pain intensity). However, new headaches, in people with or without a migraine history, that last two or more days should be checked by a doctor. However, if a headache develops with symptoms such as fever, stiff neck, confusion, or paralysis, the person should be examined emergently and should be taken to an Emergency Medicine Department for scans and thorough evaluation.
Okay people, now you know pretty much everything about migraine… I hope it’s information you don’t need for yourself, and that you can tuck it away in your brain for the who knows when future. If you learned something, great! If you’re interested in a blog about a specific topic, please feel free to leave that in this comments section and I’ll see what I can do. And don’t forget about the sex and orgasm survey people! We need people to agree to be contacted once we finish it, so leave that in the comments too if you’re willing to takw it. Please pass this blog on to friends and fam. And definitely check out my YouTube channel for all of my videos and please like, comment, and share those too. As always, my book Tales From the Couch is available on Amazon and in the office.
Thanks people!
MGA
Learn MoreMigraines,Part 1
Migraines, Part I
This is a very personal topic for me, as I have had cluster headaches and migraines my entire life. While I was double checking a statistic for this blog, I came across a term that I’d never heard before: migraineur. Such a romantic sounding word to define a person with migraines. But when in Rome… As a migraineur, at times my headaches dictated my entire life, what I did and when I did it; or more accurately, if I did it. My cluster headaches are horribly disabling, like fireworks going off in one side of my head; bunches of them exploding at random intervals- in clusters- hence the name. Best medical intel indicates this barrage lasts 4 to 72 hours, though mine have always been a helluva lot closer to the latter than the former. And I swear that migraines and clusters somehow alter the spacetime continuum, tearing a hole in the fabric of time such that every minute lasts an hour. In any event, suffice it to say that every minute of a cluster or migraine is the Longest! Minute! Of! Your! Life! If you’re having difficulty imagining what that pain might feel like, consider yourself lucky. Most people (physicians included) don’t realize how consequential and life altering migraine can be. Migraine is the 3rd most prevalent illness on the planet and the 6th most debilitating illness on the planet, yet also the most misunderstood, underestimated, mis-/un-diagnosed, and mis-/under-treated neurological disorder, especially in relation to its symptoms and ability to incapacitate afflicted people, people. While most migraineurs have “attacks” or episodes once or twice a month, more than 4 million adults experience chronic daily migraine, which is defined as having at least 15 migraine days each month. Though it’s usually unintentional, medication overuse in treating episodic migraine is one of the most common reasons why episodic migraine becomes chronic daily migraine.
Migraine Fast Stats
-Affects 12% of the US population = 39 million people in US, 1 billion globally.
-Affects 18% of all American women, 6% of all men, and 10% of all children.
-Onset can occur at any time, but most commonly falls between ages 18 and 44.
-Approximately 90% of migraine sufferers have a family history of migraine.
Migraine and Gender
-Migraine disproportionately affects women, as 85% of chronic migraine sufferers are female, affecting 28 million women in the US.
-Fluctuations in estrogen levels are often responsible for increased severity and frequency of migraines.
-Before puberty, boys are more affected by migraine than girls, but adolescence sees an increase in the risk and severity of migraine in girls such that by adulthood, three times more women suffer from migraine than men.
Pediatric Migraine
-Very often undiagnosed or misdiagnosed
-Evidence suggests association with infant colic, possibly an early form of migraine.
-Occurs in kids as young as 18 months.
-50% of first migraine attacks occur before age 12.
-Occurs in 10% of school-age children 7-14 and 28% of adolescents 15-19.
-Migraines are hereditary: studies have shown that a child with one parent who suffers from migraines has about a 50% risk of developing migraines, but if both parents have a migraine diagnosis, a child’s risk of developing migraines jumps to 75%. If just a distant, non-parent relative suffers from migraine headaches, the risk for any genetically related offspring to also develop migraine is 20%.
-Childhood aged boys suffer from migraine more often than girls, but as adolescence approaches, the incidence rate increases faster in girls than in boys, and by adulthood, females with migraine outnumber males by three to one.
Costs of Migraine
-Migraine is a public health issue with major social and economic consequences.
-More than 157 million workdays are lost each year in the US due to migraine.
-US industry loses $36 billion per year due to absenteeism, lost productivity, and medical expenses caused by migraine.
-US headache sufferers receive $1 billion worth of brain scans each year.
-Over 90% of sufferers are unable to work or function normally during migraine, claiming at least a 50% reduction in overall productivity.
-24% of people living with migraine disease report headaches so severe that they have sought emergency room care.
-Medical costs of treating chronic migraine itself equal approximately $6 billion annually, but sufferers spend nearly seven times that treating the conditions often associated with it including depression, anxiety, and sleep disturbances.
-Healthcare costs are 70% higher for a family with a migraine sufferer than a non-migraine affected family.
Headaches vs Migraines: Who’s Who?
Headache refers to any pain within the head, face, or neck. This pain may be centralized to one focus or area, or it may be diffuse and emanating throughout all areas. While many people consider all “bad” headaches to be migraines and/ or use the two terms interchangeably, this is inaccurate. As I’ll explain next, migraines are a type of primary headache, so that means that all migraines are headaches. But the reverse, that all headaches are (or can be) migraines, is not true.
Headaches: Three Main Categories
Category 1) Primary Headache
Category 2) Secondary Headache
Category 3) Painful cranial neuropathies and other (facial) pain
Primary Headache: Refers to a headache that occurs on its own. The three major types of primary headaches are migraine, tension, and cluster.
Secondary Headache: Refers to a headache that is caused by something else, such as ‘medication overuse headache’ which is caused by using migraine medication over a long period of time. This is also known as rebound headache, a very disabling headache that is basically the result of taking meds for frequent migraines over an extended time period, even when taken as directed. I have a chronic daily migraine patient that at one time had 22-plus migraine days per month, and she got locked into a gnarly rebound headache. They’re super painful and the only way to treat them is to discontinue the causal migraine med… and that’s a problem if that’s the only thing that’s ever helped. Thankfully, these days we have more options for both preventing migraine and treating it when it rears its ugly head. But I’ll tackle all of that next week. For now, continuing on with migraines.
Painful Cranial Neuropathies and Other Facial Pain: Refers to headaches/ pain arising from, or related to, nerve abnormalities in the upper part of the head and neck. For example: a whiplash injury or disk injury with nerve damage (ie neuropathy) leading to inflammation and pain.
As opposed to “bad” headache, migraine is a neurological disorder whose accurate diagnosis requires the presence of specific symptoms and certain qualities.
Requisite Migraine Symptoms
Migraine attacks are accompanied by one or more of the following disabling symptoms: visual disturbances, nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch, and smell, and/ or numbness/ tingling in extremities or face.
Migraine Qualities
-(Mostly) occuring on one side of head
-Pulsating pain quality
-Moderate to severe pain intensity
-Made worse with physical activity
-Nausea and/ or vomiting
-Sensitivity to light (photophobia)
-Sensitivity to sound (phonophobia)
Migraine: Ancillary Symptoms
The presence of one or more disabling symptoms (listed above) are required for diagnosis of migraine, but many other ancillary symptoms can be (but aren’t required to be) associated with migraine. These can include abdominal pain, fever, dizziness, and fatigue.
Migraine: Triggers
Many things under the sun can trigger a migraine. Triggers are very individualized, they’re not the same for everyone; what’s more, what causes or triggers a migraine in one person could relieve it in another.
Migraines are commonly triggered by environmental factors, and these can be external factors like eating certain foods or taking certain medications, or internal factors like stress or blood sugar changes.
Triggers may be hormonal, behavioral, physical, emotional…they vary, but there are common themes. Below are some of the usual suspects, along with ways to avoid them.
Certain light patterns, loud sounds or strong smells
Alcohol: Red wine is a common and well recognized migraine trigger, but other alcoholic drinks can also cause migraine.
Weather changes: Even small changes in barometric pressure can cause migraine, especially those associated with storms and hurricanes. If weather is a trigger for you, ask your doctor about the possibility of taking medication at the first sign of atmospheric change.
Bright light: It’s believed that light “turns on” certain cells that can trigger pain. Wearing sunglasses indoors can increase your eyes’ sensitivity to light, so save your shades for outside. You can also try wearing FL-41 boysenberry-tinted lenses, which have been shown to minimize the triggering effect of light.
Caffeine: Caffeine is unusual in that both its presence, and its withdrawal, can trigger a migraine; and it is a common component of prescription and over the counter migraine remedies. If you have migraine, your best bet is to not vary your regular coffee/ tea routine and caffeine intake, even on weekends.
Processed meats and cheeses: Some people may be sensitive to tyramine, a substance found naturally in some foods: especially aged and fermented foods like some cheeses, kimchi, smoked fish, soy sauce, caviar, cured meats, and some types of beer.
Computers: Poor ergonomics and the screen’s bright light can combine to trigger a migraine. Practice good posture and take frequent stretch breaks.
Dehydration: Not consuming enough liquids causes blood volume to drop and decreases blood flow to the brain, which can trigger migraine. Low electrolyte levels and/ or the loss of electrolytes are also common culprits. Aim to drink at least eight 8-ounce glasses of water a day.
Hormonal changes: Migraines affect women disproportionately, which could be partly due to fluctuations in estrogen levels. Talk to your doctor about whether you should take NSAIDs a few days before menstruation.
Hotter temperatures: The risk of migraine jumps almost 8% for every 9-degree Fahrenheit increase in temperature. Stay hydrated and consider avoiding outdoor activities during the hottest seasons and/ or times of the day if you’re sensitive.
Anatomical Migraine Triggers
Rather than an environmental trigger, these are four distinct external sensory nerve regions in the neck and face that can act as anatomical migraine triggers. Patients who are subject to one or more of these triggers will feel as if migraines are emanating from these specific areas. The common trigger areas are 1) the area above the eye/ forehead, 2) the neck, 3) the nose (felt behind the eye), and 4) the temple(s).
Two long term treatment options act against these trigger points:
-Botox injections will relax all of these trigger sites except for the nose.
-Trigger point surgery will physically release these nerves.
More on these next week.
Migraines: Diagnosis
Nearly one in four American households includes someone with migraine. This exceptionately high incidence rate means that every American knows someone who suffers from migraine (whether they’re aware of it or not) or they themselves struggle with it. Despite this high incidence rate, migraine is misdiagnosed more frequently than it is accurately diagnosed, most often as tension headache or sinus headache. Seriously? Misdiagnosed as often as it’s accurately diagnosed?! Scary, no? Blows my mind… but check out this this cute little factlet: 60% of women and 70% of men with migraine are misdiagnosed… period, end of story. But getting an accurate diagnosis is critical for arranging the right treatment, as some medications indicated for specific migraine types can actually be dangerous to people with other migraine types.
The science behind migraines can get complex people… we are dealing with the brain after all. But understanding exactly what’s occuring during a migraine can help in receiving the proper diagnosis and treatment options, as when it comes to migraine, it’s always better to err on the side of caution. Why? Aside from the fact I mentioned above, about how certain type-specific medications can be dangerous if utilized incorrectly… Well, if a migraine is not properly diagnosed and treated, an individual will typically experience recurrent and increasingly severe symptoms, including extreme head pain, fatigue, nausea, vomiting, and increased sensitivity to light and sound. Not only do the symptoms of the migraine become more severe when left untreated, the migraine tends to become more difficult to treat as it becomes more prolonged. In addition, the neurological disorder as a whole tends toward the progressive, such that subsequent instances of migraine and associated symptoms generally become more severe with time. But even setting aside the health and medical implications, there’s simply no reason to suffer pain needlessly and allow your life to be totally disrupted in the (horrifyingly) special way that only migraines can. Primary care physicians are often responsible for a preliminary diagnosis of migraine headaches, but it is strongly suggested that patients suspected of having migraines see a neurologist for a full workup, including a neuro evaluation and imaging studies if/ when indicated. Knowing exactly which type of migraine you have is essential to finding the safest and most effective treatment for you.
What’s Up with the Migraine Brain?
What’s happening in the brain to create such an excruciating storm? A migraine typically starts with a trigger, which is often incoming sensory information that wouldn’t bother most people… maybe opening the door to a bright sunny day or walking into Starbucks with the intense smell of coffee beans roasting. But a migraine brain is essentially damaged, so it doesn’t respond to stimuli the way a “normal” non-migraine brain does. So during a migraine, these incoming stimuli feel like an all-out assault.
Simple mechanistic view of a migraine brain: upon presentation of a trigger, the migraine prone brain produces an oversize reaction to that trigger, and its electrical system immediately starts (mis)firing on all cylinders. All of this electrical activity causes a change in blood flow to the brain, which in turn affects the brain’s nerves, causing pain and other associated symptoms. About 25% of migraine sufferers have an associated visual disturbance called an aura, which usually lasts less than an hour. In 15-20% of migraine attacks, other disabling neurological symptoms occur before the actual head pain, while in some other cases of migraine, these neurological symptoms occur without any actual head pain. More on these specific phenomena to come.
Migraine: Progression of Stages
Migraine attacks can progress through four distinct stages: prodrome, aura, attack, and post-drome. It’s important to note that not everyone with migraine goes through any or all of these stages.1) Prodrome Stage
Beginning one to two days before a migraine, some subtle changes that may warn of an impending migraine include:
-Constipation
-Mood swings, depression to euphoria
-Food cravings
-Neck stiffness
-Increased thirst and urination
-Frequent yawning2) Aura Stage
Reversible symptoms or sensations of the nervous system that might occur before or during migraines or other neurological events. They’re usually visual symptoms, but they can also include other types of disturbances as well. Each symptom usually begins gradually, builds up over several minutes, and lasts for 20 to 60 minutes before fading away.
Examples of migraine aura include:
-Visual phenomena, ie bright spots, flashing lights, and zigzag lines
-Vision loss
-Pins & needles sensations in extremities
-Weakness or numbness in face or single side of the body
-Difficulty speaking
-Auditory symptoms: noises/ music
-Uncontrollable movement,shakes/jerking3) Attack Stage
A migraine usually lasts from 4 to 72 hours, depending on its severity and if/ how it’s treated. Migraine frequency varies from person to person; may occur rarely or strike many times each month.
During a migraine, you will likely have:
-Pain on one side of your head, but can occur on both sides.
-Pain that throbs or pulses
-Sensitivity to light, sound, smell, touch to varying degrees.
-Nausea and vomiting4) Postdrome Stage
After a migraine attack, you might feel drained, confused, hung over, and moody for up to two days. Some people report mood swings from elation to despair. Sudden head movement may briefly bring on pain once again.
Migraine: Treatment
Traditional migraine treatment involves a combination of medications, lifestyle changes, and potentially, alternative therapies like acupuncture. Migraine medications are usually divided into three groups: preventative, abortive, and rescue.
Preventative medications: Captain Obvious says that preventative meds are generally taken daily in an effort to avoid getting (aka prevent) a migraine, as they are intended to reduce the frequency and severity of migraine attacks.
Abortive medications: Abortive meds are generally the first-line, acute medications meant to be taken when someone gets a migraine. Unlike pain medications that only mask the pain for a few hours, abortive medications work to stop the migrainous process itself and end the associated symptoms, and they are most effective when taken as early as possible in a migraine attack.
Rescue medications: Rescue meds are often pain medications, and are intended to be used if and when abortive meds fail, or when abortive meds might be contraindicated due to allergy, side effects, or pregnancy in some cases. Other types of rescue meds can be used to help people relax and get through a migraine by reducing nausea for example. Rescue meds don’t have the ability to abort a migraine, but the idea is they may mask the pain for a few hours while the migraine runs its course.
While most migraineurs experience “attacks” or episodes once or twice a month, more than 4 million adults experience chronic daily migraine, which is defined as having at least 15 migraine days each month. Though it’s usually unintentional, medication overuse in treating episodic migraine is the most common reason why episodic migraine becomes chronic daily migraine. About 25% of migraine sufferers have an associated visual disturbance called an aura, which usually lasts less than an hour. In 15-20% of migraine attacks, other disabling neurological symptoms occur before the actual head pain, while in some other cases of migraine, these neurological symptoms occur without any actual head pain. More on these specific phenomena to come.
Migraine Types
Migraines are like ice cream… they come in a variety of different ‘flavors’ that ‘taste’ different to each of us. The basic ingredients may be the same, but the symptoms and severity vary widely by person, age at time of attack, and length of time they’ve been experienced. It’s always possible to have multiple migraine types, so talk to your doctor about your symptoms if you’re uncertain.
According to the ICHD-3 the International Classification of Headache Disorders, there are seven types of migraine, with diagnostic criteria based on scientific evidence. It should be clear by now that not everyone will have ‘typical’ migraine, so please view this information as a guide only, and not as a replacement for physician evaluation. Note that some references created different divisions.
ICHD-3 Seven Migraine Types:
1. Migraine without Aura
-Formerly called common migraine
-First & most widespread type of migraine
-Main symptoms: throbbing pain that starts on one side of your head (as opposed to starting behind the left eye where most migraines tend to start), moving around tends to make the pain worse, and it’s normal to feel nauseous, dizzy, and sensitive to light and sound.
-Duration 4 to 72 hours
-Prodrome brings: difficulty speaking or reading, increased urination, irritability and depression, food cravings, frequent yawning, muscle fatigue or tight or stiff muscles in the neck and shoulders, nausea, constipation, or diarrhea, poor concentration, sensitivity to light, sound, touch, and smell, and trouble sleeping.
-After the 4 to 72-hour headache attack, hits, postdrome with “migraine hangover” can make you: feel moody, feel sensitive to touch, especially in areas where the headache was focused, feel tired, have stomach issues
Here’s some more info about how the common migraine progresses.
2. Migraine with Aura
-Formerly called classic migraine, focal migraine, complicated migraine, aphasic migraine, migraine accompagnee.
-Main symptoms: visual disturbances before migraine begins, followed by common migraine symptoms
-Duration of visual disturbances: ranges from a few minutes to a full hour, usually before the actual migraine attack starts.
-Duration of migraine: 4 to 72 hours.
-25% of people with migraines also experience aura.
-Aura can cause visual disturbances, neurological symptoms, and unpleasant feelings like a numb face or tongue, or pins and needles that spread across body.
-ICHD3 breaks these down even further into four types: typical aura, brainstem aura, retinal aura, and hemiplegic aura.- ICHD-3 Subtype 1: Typical Aura
-Typical aura brings visual symptoms, inc temporary blind spots, geometric patterns, zigzag lines, stars or shimmering spots, and flashes of light. – ICHD-3 Subtype 2: Brainstem Aura
-Brainstem aura involves symptoms that seem to originate in the brainstem, like difficulty speaking, double vision, ringing ears, or vertigo.- ICHD-3 Subtype 3: Retinal Aura
-Retinal migraine (a.k.a. ocular migraine and optical migraine) differs from a typical migraine with aura in that you typically only have visual disturbances in one eye. Because they cause visual issues, they’re sometimes called “ocular migraines” or “optical migraines.”- ICHD-3 Subtype 4: Hemiplegic Aura
-Hemiplegic migraine involves symptoms like motor weakness or a loss in the strength of your muscles, usually on one side of your body; you may also struggle with language and feel confused or tired.
-Like with typical aura migraines, these symptoms usually last only minutes, and usually for no more than an hour, though may be longer for some; but memory loss and problems with your attention span can linger for weeks or even months. -Sometimes, hemiplegic migraines can cause more serious issues, like seizures, coma, and long-term problems with brain function and body movement.
-These facts might be frightening to read, but these types of migraines are rare and the extreme side effects are uncommon.
3. Menstrual Migraine
-Also called “hormonal migraines.”
-Pretty much as they sound: migraines in women triggered by hormonal changes.
-Duration: 4 to 72 hours
-ICHD-3 notes that menstrual migraines can happen with aura or without, and usually strike just before or at the beginning of your period.
-If you experience migraines during this time in two out of three periods, they are likely to be menstrual migraines.
-According to the US Office on Women’s Health, menstrual migraines might be triggered by the quick drop in the hormones estrogen and progesterone that happens before your period starts. -Affect about 7% to 19% of women
-Most women who usually get menstrual migraines also have other migraine types at other times.
-Frustrating but good-to-know: menstrual migraines tend to last longer than your average non-menstrual migraines, and might be more painful.
4. Vestibular Migraine
-Main symptoms: vertigo, dizziness, and trouble with balance
-Duration: ranges from a few seconds to a few days
-Surprisingly common, affecting 30%-50% of migraine sufferers.
-Vestibular migraines can give you sudden bouts of vertigo, where you see the world spinning or feel like you’re moving when you’re not.
-These bouts of vertigo might not always occur like aura symptoms, ie right before a headache sets in…
-These vertigo bouts may happen for just a few random seconds or may even happen intermittently for a few days.
-Sometimes this occurs when you move your head too quickly or when you see something particularly stimulating.
5. Migraine without Headache
-Main symptom: no actual headache pain, thank you Captain Obvious.
-Duration: each aura symptom can last 1 hour or less
-If you get aura symptoms but never get the telltale splitting pain in your head, you might have a migraine without a headache, sometimes known as a “silent migraine,” “painless migraine,” or “acephalgic migraine.”
-ICHD-3 simply calls them a “typical migraine with aura without a headache”
Whatever!
-An acelphagic migraine, or a migraine with no pain, can have all the same symptoms of migraines with aura, except the headache just never shows up!
-Interestingly, migraines without headaches become more likely as you get older. Something to look forward to!
6. Abdominal Migraine
-Main symptom: stomach pain instead of a headache
-Duration: 1 to 72 hours
-Migraine can cause extreme pain in your abdomen rather than your head; this is an abdominal migraine.
-Causes pain near the belly button, can make you feel nauseous, give you no appetite, cause vomiting, and make you look pale.
-This is more common in children than adults, but 2/3 of the children with a history of abdominal migraine actually end up developing migraine headaches as adolescents.
-Just like common migraines, abdominal migraines can be triggered by things like stress, bright lights, and food additives like monosodium glutamate (MSG). -Typically treated using the same medications as standard migraines with headaches.
7. Status Migrainosus
Main symptoms: a migraine that that lasts more than 72 hours
Duration: 72+ hours
-Basically a migraine (with or without aura) that lasts longer than the standard max of 72 hours.
-ICHD-3 recognizes status migrainosus, and points out that overusing migraine medications could be a likely cause
-Other triggers can bring on Status Migrainosus, like: changes in food and sleep habits, changes in medication, changes in weather, head and neck traumas, hormones, illnesses like the flu or a sinus infection, sinus, tooth, or jaw surgeries, and stress.
-Status migrainosus can be extremely frustrating; called a “trick candle on a birthday cake,” because the headache might briefly respond to medication, just to flood back randomly after a break.
Next week I’ll get into more specifics on these seven migraine types, along with the various medications used to treat the specific types and why they’re used. Also lots of intel on non-pharma methods of managing migraine, including devices.
That’s all for today folks. Please make sure to share my blogs and YouTube vids with friends and fam, and like, subscribe, and comment people! As always you can find my book Tales from the Couch on Amazon.com.
And don’t forget that Dawn and I are going to need everyone’s help to take a simple, anonymous, sex and orgasm survey coming up here before too long. The more people that take it, the more meaningful the data, and the better the book will be! And you want it to be good, right people?
Thanks and be well!
MGA
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