Marks Psychiatry

Panic attacks can be extremely disabling, so much so that often individuals who have had a panic attack have already made a trip to their local emergency department. What is a panic attack? There are many physical symptoms associated with it, but in general it is a discrete period of intense fear accompanied by physical symptoms such as chest pain, racing heart, sweating, nausea, dizziness, and fear of dying to name a few.

With panic disorder, a person has unexpected panic attacks and persistent worry about having future attacks. The age of onset is late teens to early 30’s. It’s unusual to develop panic disorder after age 45, but is possible. The course is usually chronic over a person’s lifetime and waxes and wanes over time. A person can have a cluster of attacks that last for an extended period, and then go years with no symptoms.

Agoraphobia is a preoccupation with having another panic attack such that the person avoids being in situations where they fear they may have an attack and not be able to escape. They fear being trapped while having attack. Sometimes the anxiety associated with the fear of having an attack can become greater than the attack itself. Not everyone with panic disorder develops agoraphobia.

Panic disorder is common in cardiology settings, and typically those suffering with panic disorder have had some type of medical workup. The medical workup is important because there are medical conditions that can cause panic attacks. These conditions would include hyperthyroidism, seizure disorder, vestibular disease (such as inner ear problems), and cardiac disorders such as an irregular heart beat. The lifetime prevalence is generally thought to be 1-3% in the general population, but as high as 10-60% in medical settings.

Popularity: 56%

Dealing with a chronic illness is difficult on many levels. But how do you handle someone having a terminal illness that lingers on?

Let’s look at Judy

Judy’s mom has a medical illness that was diagnosed when Judy was a teenager. Her mom was in and out of the hospital for years then seemed to get better after she underwent a new procedure. Fast forward and Judy is 20; the affects of the procedure are wearing off. Mom is in and out of the hospital again, every visit seems it will be the last. Because of her illness, her mom missed key events like her college graduation, her bridal shower and almost missed her wedding. Mom always gets better, but it is still very stressful and sad to see her mom sick.

Another dimension to this is Mom demands a lot of attention when she is sick. So much so that Judy felt very little support from her mom during her pregnancy. Judy didn’t feel she could complain, because after all, Mom is sick. Judy gives birth and Mom is there, but takes a downturn shortly afterward.

Baby is 10 days old, Judy is exhausted and she gets the call that Dad is taking Mom to the hospital. Judy’s mother-in-law is helping with the baby, so Judy decides to take advantage of the help, get a good nights rest and go to the hospital in the morning. Judy knew the routine, she would spend a few days pampering her mom who would get better and be discharged. But this time Mom didn’t make it through the night.

Judy is racked with guilt and furious with herself for not being able to have the last loving goodbye conversation with her mom. But would Judy really have known this time was the last time and engaged in a goodbye talk? I don’t think Judy ever wanted to have a goodbye talk. How do you have that kind of talk?

No matter how much you anticipate someone’s death, you’re still not ready to concede that a person who is well enough to have a conversation with you is close enough to death to have a mutual goodbye discussion. You want to believe they can always get better until they don’t.

Judy had to let go of her focus on not saying goodbye. This was actually a diversion from the real issue which was the fact that Judy was angry and resentful toward her sick mother for not being there for her at milestone moments. Her Mom garnered so much attention over the years because of her illness, Judy felt lost in her shadow. Judy never discussed this with her mom and instead would put on a smile and give her mom all the attention she required, especially in the last months. Judy still has to deal with her resentment, but she realized her selfless attention to her mom was her goodbye that reaped much greater reward than a tearful goodbye speech.

Popularity: 36%

There seems to be a lot of buzz about Provigil lately. I’ve mentioned in a previous post that Provigil is used to treat wakefulness disorders such as narcolepsy, sleep apnea and shift-work disorder. Psychiatrists and others have used Provigil off label (non-FDA approved reasons) for other indications such as an adjunct to antidepressants, to counteract sedation from other medications and to help with cognitive slowness and other memory problems.

More recently researchers have found Provigil to be helpful in treating bipolar disorder patients who were depressed. Two studies in the August 2007 issue of the American Journal of Psychiatry (164: 1242 – 1249 and 164: 1143 – 1145) show some benefit to bipolar depressed patients when they were treated with 100-200 mg of Provigil.

These are preliminary results, but this is very promising and could be huge for the treatment of bipolar disorder. It is not uncommon for patients with bipolar disorder to have their mania managed with mood stabilizers but still bottom out on the depressed end. What’s even more positive are the findings that Provigil did not significantly increase a person’s risk of developing mania.

Popularity: 42%

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%