Marks Psychiatry

Clinically, health care providers consider heavy drinking to be more than 2 drinks a day totaling 14 or more drinks per week. But what is a drink? In general one drink is one 5oz glass of wine 1oz of liquor or 12oz of beer. Heavy alcohol use can have serious health consequences.

Let’s look at Larry

Larry comes to see me because he has been depressed and wants to take medication. As usual, I get new patient bloodwork and see that Larry has elevated liver enzymes indicating liver inflammation. When I see this, I usually think alcohol or overuse of Tylenol products.

When I first saw Larry he told me he drank 1-2 glasses of wine with dinner. With further questioning, he admits that he consistently drinks 2 glasses of wine each night. When I ask for details, he tells me his “glass” is a 10oz beverage glass that his wife calls his chalice.

So Larry was really having the equivalent of 4 drinks a night. Larry did not want to switch to a smaller glass as he felt the use of his special glass was part of his evening ritual. He reluctantly cut back to one glass that he filled to the lip, then he slurped down to a level that allowed him to pick it up without spilling. Clearly Larry is trying to maximize his one glass, but at least it’s one.

Larry was also concerned about a chronic cough he’d had for months and was afraid it was cancer. I suggested he see his internist for a medical work up.

Months later…
Larry’s liver enzymes return to normal. His chronic cough turned out to be a combination of gastric reflux and allergies. He was told to reduce his alcohol intake to help with the reflux. He cut back by filling the chalice to ¾ full and skipping a night here and there. After several weeks his cough nearly diminished.

Larry does not refer to a specific person, but real situations I have seen many times. He illustrates how people can unknowingly consume heavy quantities of alcohol putting themselves at risk to develop medical problems.

Popularity: 36%

Several recent studies show that in some elderly patients who met criteria for depression, a large percentage of them visited their doctors with only pain complaints. There seems to be a direct relationship between the number of pain complaints and the likelihood of having depression. That is, the more pain symptoms the more likely the person is depressed.

Chronic pain can trigger or worsen depression in a person of any age, but these findings suggest that depression can be more easily missed in the elderly population because they may not look like the typical depressed person. Since aggressively treating depression can improve the pain symptoms (if they are determined to be depression related), it is important to consider depression (and get an evaluation for it) in an elderly person with multiple physical complaints.

Popularity: 31%

Mark McDonough PhD, who specializes in brain injuries spoke at an international conference on combat stress and discussed the impact of brain injuries on troops. He concluded that traumatic brain injury may be the “signature injury” of the Iraq war. The Kelvar helmets help prevent penetrating head wounds, but don’t adequately protect an individual from a closed head injury.

Unfortunately brain trauma that affects the white matter of the brain difficult to spot on a CT scan. So a soldier can be close to a blast, survive it without losing any limbs, may get a quick scan of his head, and assume everything is okay because he doesn’t have any visible injuries.

This is important because soldiers with traumatic brain injuries could have slower reaction times, be subject to confusion or be more suggestible to leading questions. Dr. McDonough reported they could also be more easily implanted with false memories. All of these negative consequences of a traumatic brain injury could pose a security risk if these soldiers were returned to combat.

Popularity: 27%

Shift work can have a dramatically negative impact on the quality of your sleep and ability to sleep. There is a diagnostic entity called Circadian Rhythm Sleep Disorder, formally called Sleep-Wake Schedule Disorder of which shift work type is a specific subtype. Circadian Rhythm Sleep Disorder occurs when a person has recurrent or persistent disrupted sleep patterns as a result of a mismatch between the person’s body clock (when we would naturally sleep) and our environmental demands (when we are supposed to sleep or be awake). So typically, people with this disorder will complain of being awake when they need to sleep or excessively tired or sleepy when they need to be awake.

Other subtypes of Circadian Rhythm Sleep Disorder include delayed sleep phase where the person habitually falls asleep late and awakens late. These individuals can feel stuck in a cycle of sleeping late and have trouble moving their sleep times earlier. The other subtype is caused by jet lag. This is most severe when individuals travel more than 8 time zones in 24 hours. Traveling eastward is usually more difficult than traveling westward because it is easier to delay sleep than to fall asleep earlier.

Back to the shift work subtype – in these cases, the person usually has normal circadian rhythm patterns, but the demand of switching back and forth between shifts disrupts the normal pattern of sleep. Even those who consistently work a night shift may have trouble because of the need to attend to personal or family responsibilities during the day. As a result, these people can not get adequate sleep during the day and fall asleep during their night shift.

What’s a person to do? The full answer to that is too long for this post, as it involves some behavioral adaptations. Provigil is a medication that is FDA approved for Shift Work Sleep Disorder to improve a person’s wakefulness on the job. But this is only half the answer as the second part is promoting sleep during the day. As tempting as it is to want to get things done during the day, it is equally important that a person treat the daytime as if it were night and shut everything down for a period so they may sleep.

Popularity: 33%

A survey out of the University of Chicago conducted by Dr. Stacy Lindau found that one third of individuals aged 64-75 are having sex at least once a week. This survey was administered to 3005 older people who were divided into 3 groups of roughly one thousand each. The three age groups were 57-64, 65-74 and 74-85.

In the younger group (57-65) 40% of the men and 34% of the men reported having sex once a week or more. But a very interesting finding was seen in the oldest group (75-85). In this group, 23% of the men and 24% of the women reported having sex at least once a week. This percentage was similar to what they saw in a different survey of 18-59 year olds. Imagine that. Some of the oldest seniors reported having sex as frequently as some 18 year olds! Go Seniors.

Of course sexual problems were common, usually related to physical problems. They discovered only 48% of the men and 34% of the women with sexual problems had ever discussed their sexual problem with their doctor.

I think the common perception is that the elderly are not at all sexually active so many physicians may not think to ask their elderly patients about their sex lives. If nothing else, this study shows that the elderly are not to be forgotten in this area. And as 50 becomes the new 30, sexual activity in older adults will continue to be real entity.

Popularity: 37%

A symptom of depression can be anxiety, but a person can also have a co-morbid (meaning simultaneously occurring) anxiety disorder that is a separate entity from their depression. Some anxiety disorders that can occur with depression are Panic Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Social Phobia and Post-Traumatic Stress Disorder. It is not uncommon for the anxiety to present prior to the depression. In fact, according to an article in the Journal of Psychiatric Research (2003;37:187-92), the prevalence of generalized anxiety occurring with major depression is close to 70%. This is a high percentage.

Other studies show that 28% - 38% of those with bipolar disorder have a separate anxiety disorder. One study in the American Journal of Psychiatry (2004;161:2222-9) showed that an anxiety disorder occurring with bipolar disorder was associated with an earlier age of onset. The authors noted that teenagers developing bipolar disorder at an earlier age likely began with anxiety problems as a prelude to developing the mood symptoms.

Why is this important? Unfortunately we have seen that anxiety disorders can worsen the course of depression or bipolar disorder, making it harder to achieve remission of symptoms. The untreated symptoms can lead to substance abuse as a way to self-medicate. If a person is in the throws of serious mood episode (depression or mania), it can be easy for all those involved to overlook the anxiety disorder or not aggressively manage the anxiety because of the attention to the mood symptoms. So these findings emphasize the importance of diagnosing and managing comorbid anxiety disorders in individuals with major depression or bipolar disorder.

Popularity: 50%

Theresa H. M. Moore of the University of Bristol in England and her colleagues have conducted research which concluded that having used marijuana at any point in your life increases the risk of having a psychotic episode by 40%. This was more than twice the risk of those who have never smoked marijuana. The heavier the use, greater the chance of developing psychosis. Heavy use was defined as smoking more than 100 times in a lifetime or currently smoking marijuana weekly.There study does not definitively establish a causal relationship between marijuana and psychosis, but it’s about the best that it gets because the only way to establish causality would be to do a randomized, controlled study having some people smoke marijuana to see what happens later in life. This type of study would be unethical.

I found this study interesting because I often hear people say “there’s nothing wrong with marijuana” or “marijuana should be legal.” These findings illustrate the fact that marijuana is a drug that can have very negative effects on your life, for the rest of your life.

Popularity: 32%

I saw a flyer advertising Life Coaching at a local medical center. The flyer said that Life Coaching promoted change and you could expect the your life to be changed by adding “zest” to your life, look at things from a different perspective, create action plans and be more creative.

I read that and thought, those are pretty big promises how could anyone pass that up?

I often feel as though I am doing life coaching with patients who do not have serious mental disorders but are simply seeing me for life issues. It has taken me a while to depart from my more rigid, psychoanalytic stance that I learned in my residency training to a stance that allows me to give more direct, practical feedback (as opposed to deep, psychoanalytic interpretations).

But I’m still doing therapy. I’m listening to patients discuss their issues and helping them recognize blind spots, form a different perspective, suggest other alternatives they may not have thought of, etc. As a therapist, I have to remain neutral, that is, I’m not giving advice based on what I would do if I were in the situation. That’s one of the differences between professional feedback and advice from a friend or colleague.

I can’t imagine having anything useful to say to people (that was not my own personal opinion) if I were not a trained therapist. So I’m still a little baffled at how the trained life coaches achieve the results listed earlier without some experience/knowledge of psychology.

Some people may not need psychological interpretations but may benefit from having a person who gives you their undivided attention and is supportive. But be cautious in whom you choose to work with especially if you plan to share your innermost thoughts with them as the life coaching industry is not regulated in the same way as therapists. In this type of work, maintaining professional boundaries becomes of utmost importance.

Popularity: 24%