Marks Psychiatry

Dr. Joris C. Verster at University of Utrecht in the Netherlands conducted a study and discovered that Ritalin significantly improved the driving skills of patients with Attention Deficit Hyperactivity Disorder (ADHD). They used a pool of 18 people ages 21-30 and compared their driving skills on and off of their medication. Off medication, they were able to maintain a steady speed, but they weaved more. The weaving was even more pronounced during the latter part of their trip.

This finding was not surprising because ADHD causes problems with sustained attention, or sticking to a task for a sustained period. The driving test in this study took 1 hour so the patients off their medication had more trouble staying focused on the road and not being distracted by things on the side of the road.

I’m not sure how the weaving (also called standard deviation from lateral position in the study) was measured. That is, are we talking weaving like a driver under the influence, or minor deviations from the center of the lane? I doubt that skipping medication means automatic driving into oncoming traffic, but these findings do illustrate the importance of knowing one’s limitations if you have ADHD.

I’m frequently asked if someone will have to remain on medication for ADHD forever. I tell some people that usually over time the impact of attention problems lessen in adulthood. Many people have attendtion deficit problems, but learn to adapt by staying away from activities or responsibilities that stress their attention capacity. So in this example of driving, rather than concluding that a person with ADHD is a dangerous driver off medication, one could say that the same person should not be considered the anchor driver for a long road trip.

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A study lead by Dr. Karen H. Seal of University of California, San Francisco found that 25% of the 100,000 veterans returning from Iraq and Afghanistan as of November 2005 were diagnosed with a mental disorder. This study was published in the Archives of Internal Medicine (2007:167 pp 476-82). The most common diagnosis was Post-Traumatic Stress Disorder (PTSD) which accounted for more than half of the veterans.

Of the roughly 25,000 vets diagnosed with a mental disorder, 44% had one diagnosis, 29% had two and 27% had three or more. Younger veterans ages 18-24 were found to be at higher risk of being diagnosed with a mental disorder. It was suggested this group was at higher risk because they were likely to be of lower rank and have more combat exposure.

These are disturbing statistics. Unfortunately the publication of research is often way behind real time as you can see with this article that was published in March 2007 and includes veterans returning home as of November 2005. Who knows what that number has grown to today, 18 months later? It is especially concerning that there are thousands with three or more mental disorders.

It is not uncommon for someone to have more than one diagnosis, as some disorders can beget others. PTSD and depression would be a good example. PTSD is an anxiety disorder that alone does not produce depressive symptoms. But individuals can subsequently develop depression or have had pre-existing depression and thus end up with two separate diagnoses if they later develop an anxiety disorder such as PTSD.

The study concluded by emphasizing the need for early screening and intervention to prevent these veterans from developing chronic mental illnesses, especially the younger population of veterans.

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The FDA issued a warning about buying medication online. The agency tested several medications including Ambien, Xanax, Lexapro and Ativan and determined they were contaminated with the drug Haldol. Haldol is an antipsychotic medication that can cause a number of side effects, but most notably muscle stiffness or other movement disorders.

In fact, the FDA statement noted instances of people who received emergency care for symptoms such as muscle stiffness and trouble breathing after taking the medication they bought online.

If you have purchased medication online, you can compare your pills to photos provided by the FDA at their site FDA Drug Warning Photos. According to the FDA, the packages were postmarked from Greece, but they still have been unable to determine their origin.

In March, the FDA recalled a dietary supplement that could be purchased over the internet because it was found to contain Cialis - the medication to help with erectile dysfunction.

What the take away message? Be very cautios when purchasing medications online. Most legitimate operations will require a prescription and have a pharmacist available for questions. Visit the FDA Buying Guide for more information.

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In April 2007, The US Supreme Court overturned the death sentences of three Texas men convicted of murder. Their sentences were thrown out by a 5-4 decision because it was the court’s opinion that the juries were not able to consider relevant information about their mental histories that could have been used to lessen their sentences.

One of the cases was Brewer vs. Quarterman (05-11287) see Brewer V Quarterman for details about the case. In short, in 1990 Brent Brewer stabbed a man to death during the course of a robbery in Amarillo, TX. He was found guilty of the murder, but during the sentencing phase wanted the jury to consider his history of being physically abused as a child and of him having a substance abuse problem.

The jury was not allowed to use this information to determine the severity of his sentence, but the prosecutor used the information to suggest that Mr. Brewer was a risk of future dangerousness. The court ruled that the prior judges were in error by not letting the jury consider this information as mitigating evidence (evidence that could lighten his sentence). As a result, Mr. Brewer was sentenced to death.

This ruling could affect the approximately 40 Texas inmates awaiting execution.

As a forensic psychiatrist, I’ve performed evaluations on inmates in similar situations, usually for the purpose of determining whether or not they have a mental illness that could have affected their behavior or made them unable to understand that what they were doing was wrong. Sometimes if the defendant’s legal team did not think the mental problem rose to the level of making them no longer responsible for their actions, they may still have a psychiatrist evaluate the extent of their problems so that a jury can consider this during the sentencing phase.

Juries have a high calling. They essentially exact justice by deciding people’s fate. As a psychiatrist, I’m asked specific questions about whether or not a mental disorder exists and what affect it has on the defendant’s behavior. Although this takes skill, I still consider the difficult decisions to lie with the jurors. What do you think of someone who has abused drugs who says have mercy on me for killing someone? Or, do you think someone who has been abused as a child should have a lighter sentence if they kill someone? These are hard questions that involve moral reasoning as opposed to purely clinical or legal reasoning.

In the case of Mr. Brewer, the trial judge relieved the jury of having to answer the questions I just posed by not allowing the information to be heard. The Supreme Court said this was an error and he now can either be retried by Texas or have his sentence converted to life.

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Stuttering affects 1% of children before puberty and decreases to 0.8% in adolescence (source Diagnostic and Statistical Manual of Mental Disorders).  It can be very debilitating for some leading to years of shame and embarrassment.  In 98% of cases the onset of stuttering is before age 10 and research estimates are less specific about recovery estimating 20-80% recover by age 16.  Currently the treatments for stuttering involve behavioral interventions such as speech therapy or a stuttering device.

Until now, there has not been a specific cause that could be attributed to stuttering.  Eun Chang PhD presented new information at the 2007 Annual meeting for the Society for Neuroscience showing that children who stutter have a specific lesion (abnormality) in an area of the brain that connects speech planning and comprehension.  This abnormality can be seen on MRI brain imaging.

I see this finding as very hopeful as it now gives us a focus of attention for developing new treatments for stuttering in lieu of speech therapy or a stuttering device.  As I previously mentioned, many cases of stuttering resolve, however for those that don’t, the consequences can be life-altering.  For example, some adults who continue to stutter can develop social phobia.  Perhaps more on this in a future post…

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Postpartum depression hurts mom and the entire family.  Some epidemiologic studies have revealed that postpartum depression can have the following negative consequences:

• increases the chance of alcohol and illicit drug use in teenaged mothers
• adversely affects temperament and cognitive development in the infant
• increase the negative interactions with their toddlers and preschoolers

There are other negative consequences that impact other close relationships, such as the relationship with a spouse/significant other or friends.

In addition to seeking treatment from a health provider, support groups can be an invaluable resource. 

Postpartum Support International has many resources including local support groups.

Another resource is Depression After Delivery which is more of an information resource.

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Our relationship with our parents, particularly the opposite sex parent, significantly influences how we choose our companions. It’s commonly said that women marry their fathers and men marry their mothers. There is a lot of truth to this.

When a person has a bad experience with their parent such as emotional absence or constant criticism, they can consciously say they do not want to be with someone who treats them the same way and set out to find the opposite person. However at an unconsciously level they can be attracted to those very same characteristics.

Why would this be? Why would someone purposely choose to be with someone whose behavior they loath?

Well, first of all it’s not purposeful; it’s beyond the person’s awareness. Let use an example. This person is fictitious, yet similar to many people I have seen.

Sam has been engaged to Sally for a year. They have put the wedding on hold because of continual problems, most recently the knowledge that Sam has been unfaithful. Sam has been seeing Rachel on the side for the past 9 months. Sam says he loves Sally and had no intention of getting involved with Rachel but “it just happened.” In fact, he said he was about to break it off with Rachel just before Sally found out.

Sam said he finds Rachel exciting, but describes her as a superficial “gold digger.” She also criticizes him and he frequently has to “put her in her place.” On the other hand, Sally is kind, self-reliant, attentive and frequently praises him.

Months pass and Sam is still involved with Rachel – despite his frustration with her and despite his not wanting to lose Sally.

As for family background, Sam describes his relationship with his father as somewhat distant as his father traveled frequently with his job. He describes his mother as controlling, critical and pretentious. He said “she uses people to get what she wants, even her own children.”

Can you see the similarities? Rachel is mom; however Sam would have never thought he’d want a woman like his mother. He recognized that Rachel behaved in similar ways, but couldn’t understand why he was so attracted to her despite the irritating things she did.

What was wrong with Sally? Nothing. Sam could never find a negative thing to say about Sally – except their relationship lacked the excitement that he had with Rachel.

This isn’t the answer for everyone, but for Sam, he was attracted to Rachel because despite her objectionable behavior, this is what he was used to. Rachel’s behavior was familiar to him. Sally’s was not. So although he hated her criticism and superficiality, it’s what he knows best as he experienced it from his first female love.

Sometimes we can repeat relationship dynamics, particularly ones that were injurious as an attempt to now conquer and overcome the injury as an adult. In Sam’s case, as a child he could not control how his mother treated him and was not able to stand up for himself. Instead, as children do, he endured the pain and continued to strive for mom’s love. In contrast, with Rachel he is able to fight back and “put her in her place.” There’s a certain gratification he gets from mastering this dynamic.

It turns out, Sam has had several Rachel’s in his past. Sally has been the first of her kind. It’s going to be difficult for Sam to get out of this cycle because his attraction to the familiar makes it hard for him to be attracted to women like Sally. Sam admits he finds Sally boring. With help, Sam learned to let go of his need to undo his earlier insults by repeating the relationships so he could focus his energy and attention on embracing the right person for him and enjoying the unfamiliar.

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Postpartum depression is defined as depression that develops within the first four weeks after childbirth and occurs in about 10% of women. Postpartum depression statistics have shown the following risk factors:

• a history of a mood disorder
• unwanted pregnancy
• unemployment of the mother
• lack of breast-feeding
• the mother as head of the household (source: Journal of Clinical Psychiatry)

Regarding other postpartum depression statistics, women who have had depression in the past have a 24% chance of developing postpartum depression. Depression during pregnancy increases the chances of developing postpartum depression to 35%.

Depression that develops for the first time during pregnancy is more likely to become bipolar disorder later on. Likewise, postpartum psychosis is usually a manisfestation of preexisting bipolar disorder.

Postpartum psychosis occurs infrequently in about 0.1-0.2% of women.

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