What causes psychosis?

There has been a lot in the news lately about people suffering from psychotic episodes. Recently, a man, whom many thought was under the influence of bath salts, took off his clothes and chewed off the face of a homeless man. Toxicology reports denied him being under the influence of bath salts but confirmed marijuana being in his system. Another news event broadcasted the sad episode of a Jet Blue pilot who started behaving in an erratic way,  talking in religion themes and Iraq and the end of the world. He had to be restrained by flight attendants and passengers on the airplane before the plane making an emergency landing.
What causes psychosis? Is this a biochemical or genetic condition? Are there environmental factors or health habits that contribute to it? What can be done to treat or prevent the condition from happening?

The definition of psychosis found in Wikepedia is: refers to an abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a “loss of contact with reality”. People suffering from psychosis are described as psychotic. Psychosis is given to the more severe forms of psychiatric disorder, during which hallucinations and delusions and impaired insight may occur.
The two major categories of mental illnesses we often associate with psychosis are the mood disorders such as Depression and Bipolar Disorder as its substypes as well as Schizophrenia. In Bipolar Disorder these psychotic episodes occur during the manic phases of the illness. There are other condtions that can cause psychosis. People under the influence of psychostimulants such as Ritalin or Cocaine or Methamphetamine may become psychotic, particularly if predisposed genetically to psychosis. Lately, in the news we have heard about people acting strangely under the influence of Bath Salts. And very recently, marijuana may have been a factor in the face eating incident.
In later years there is another cause that is being more and more recognized. Children who experience trauma may exhibit psychotic symptoms, particularly hearing voices. These children often don’t meet criteria for drug usage, mood disorders like Bipolar illness or Schizophrenia.
I personally have concerns about Marijuana. Many people would like to think that Marijuana is harmless. It is used for some chronic health issues like pain control and lack of appetite. Unfortunately, it is also being used inappropriately. I have had patients who come see me for an Anxiety problem who have complained to me that pot makes them anxious or even “crazy”. Pot will do this in people that are genetically predisposed toward psychosis. I once saw a promising young 18 year old man deterioriate and contract Schizophrenia, and Marijuana was believed to be the major culprit.

What is the treatment? It depends on the cause. If it is Bipolar Disorder, mood stabilizers and psychotherapy are the treatment of choice. Schizophrenia will probably require antipsychotic medication. If psychostimulants brought it on, they probably will need to be discontinued. For children with the history of trauma, medications may not be as effective as psychotherapy. Although many may find some benefit from both. Finally, the cause of the psychosis of the Jet Blue pilot was found to be the lack of sleep. I can’t emphasize enough the role of sleep in good mental health. I teach all my patients sleep hygiene who come to see me. A brain cannot heal or function optimally without a good nights sleep. What is the optimal amount? About 7-8 hours for most people.

Alcohol intake effects sleep

There is an interesting article in the May 17th issue of The Journal of Alcohol and Alcoholism related to alcohol intake and its effect on sleep. The research showed that even small amounts of alcohol can alter the quality and amount of sleep a person gets per night.

This article is particularly relevant to those who are struggling with a mental illness who often have sleep difficulty. It is not a good idea to try to remedy that sleep issue with alcohol usage. Alcohol may initially cause a person to fall asleep but when that person’s blood alcohol drops that person becomes more and more alert. Alcohol is known to interfere with the brain’s sleep architecture. Some of the worst sleepers I’ve seen in my practice are people who have been drinking alcohol heavily for years. This research on even small amounts of alcohol causing problems is sobering. No pun intended!

So you might want to think twice before reaching for that night cap!

Treating mood swings during perimenopause

When you first start having perimenopausal symptoms, you may not put two and two together; after all, you’re too young to be going through menopause. The changes in your body can confuse you and drive you to distraction. It is not uncommon to be confused and for mood swings to occur. If you are experiencing episodes that you don’t understand such as extreme mood swings, there are treatment options.

Mood swings can have many causes. Sleep patterns may be interrupted by night sweats or hot flashes. Studies show that when a person doesn’t get enough sleep each night, episodes of irritability, lack of focus, and extreme stress may occur. Along with these symptoms, your immune system weakens because the body is not getting the downtime it needs to repair and restore from the day’s activities.

Mood swings can be brought on by difficult or changing situation in your life. A normal interaction with a child who asks for something repeatedly can pluck that last nerve and send you screaming out of the room. A cross word can send you into tears. An extra project at work combined with sleep deprivation can lead to poor work performance and/or missed deadlines.

It can seem like everything has gone to hell in a hand basket in no time at all. This slow descent into the abyss we call stress can lead to depression in many perimenopausal women. Not being able to get a handle on the symptoms leaves you in a vulnerable state without your normal coping mechanisms you’ve relied on during all those “normal” years.

Treatment Options

You are not alone in your despair. There are many options for treating this very common part of perimenopause:

• Support – This can be a group sponsored by your doctor, church, hospital, online group, or simply a group of friends who are also going through the same situation. Talking with others about your symptom can ease the burden. Women experiencing the same things may also be able to suggest ways that may help you cope better.
• Meditation – Taking time out in a quiet place to listen to your inner self can help you prepare for the day with a full suit of armor. Yoga is a type of meditation that also involves body stretches which prove to increase your fitness level and that mind-body connection.
• Exercise – There’s a reason exercise keeps coming up. Exercise is great for a variety of ailments. Physical activity increases oxygen levels in the brain and also releases the body’s natural antidepressants; endorphins. You think more clearly, experience greater mobility, and relieve tension and stress with exercise. That is why exercise is mentioned so often.
• Antidepressants – There are many reasons why antidepressants are prescribed; some reasons are obvious, while others, not so much. There are antidepressants which actually have helpful side effects which benefit perimenopausal symptoms; such as sleeplessness. Your doctor or nurse practitioner may prescribe antidepressants for many different reasons, for instance, to help you cope with mental and physical changes that are causing quality of life problems. You don’t have to stay on antidepressants forever. Your provider will help you wean off the antidepressants when you and your doctor feel you are ready.

Mood swings can be managed during perimenopause even though you might not think so right this minute. You do not have to suffer alone. Ask your doctor or nurse practitioner for information regarding the current research on ways to fight mood swings during this stage in your life.

Basic things to know about ADHD

What is ADHD?

ADHD is a term that’s thrown around so frequently these days, we all assume we know what it means. Used to apply to everyone from a kid who misbehaves in school to an adult who has trouble focusing on a single TV or computer screen at a time, ADHD is actually a clinical diagnosis. Learning more about what ADHD is – and isn’t – can help you determine if you or someone you love warrants further testing

ADHD stands for “attention deficit-hyperactivity disorder.” In common parlance, it’s used interchangeably with ADD, which stands for “attention deficit disorder.” However, this term refers to cases where there’s attention deficit, but no hyperactivity involved.
From a layperson’s point of view, ADHD means the person – often a child — has problems concentrating and paying attention.

Of course, that can be applied to pretty much any child over the course of a typical day. What sets people with ADHD apart is that the area of the brain responsible for clarity, mental focus and activity is actually wired differently. What that means is that even when you try to “settle down,” your mind just doesn’t want to comply. You can tell yourself to relax, focus, and pay attention, but you just can’t make your mind and body comply.

So from an outsider’s perspective, how do you tell if your child is just suffering from normal “wigglies,” or really has ADHD? Let’s take a look more closely.

Signs and Symptoms of ADHD

There are three main components of ADHD: hyperactivity, inattention and impulsivity. Each has similar symptoms but they can be distinguished enough to determine if your child has one, two or all of the components.

Signs of hyperactivity include:
• difficulty sitting still, frequent fidgeting and squirming uncontrollably
• the inability to stay seated, even when they’re instructed to stay still
• inappropriate behavior like climbing or playing at inappropriate times, or on inappropriate objects like chairs or desks
• problems playing quietly when requested
• incessant talking even when instructed to be quiet

Signs of inattention include:
• trouble staying on task for even short periods of time
• lack of attention when you are speaking to them
• issues with staying organized at school, work and home
• forgetfulness regarding assignments, requests, chores, homework, etc.
• easy distractability when performing a task

Signs of impulsivity include:
• difficulty waiting in line
• blurting out of answers in class or in meetings even when not called on
• constant interruption of conversations

If you or your child has exhibited any of these signs, the next step is testing. A professional assessment can give you more insight into the condition, with regards to possible treatment and management.

My letter to the editor on the NP payment parity bill HV 4101

To The Editor,

I was surprised at the level of error and inaccuracy in your recent editorial, “Equal Pay Bill Should Be Dead” related to HB 4101, the payment parity for Nurse Practitioners in Oregon.

First and foremost, I take exception to your claim that services provided by NPs are different from those provided by physicians. Ask the patients of nurse practitioners their opinion. You may be surprised to hear the nearly universal positive regard patients have for their NPs. Some may even say they value their NP more than their MD. This view is supported, in many cases, by decades of research which as revealed that NPs provide care that is equal to or better than physicians on the same service, meaning that not only are the services delivered the same, but the services provided by NPs are often higher in quality. Of course, some services are different based on the different providers’ scope of practice and years of experience and HB 4010 would have no impact on the reimbursement rates for physicians when they provide more complex or intensive care based on their education and experience. Rather, HB 4010 says that when a physician OR an NP provides the identical service, those services should be reimbursed the same way. It is difficult to understand how anyone can argue against equal pay for equivalent services. Even the health insurance providers who oppose HB 4010 understand that there are hundreds of examples of services provided by NPs that are exactly the same as those provided by a physician; this is why these services are given the same insurance codes by those insurance companies.

Additionally, your editorial calls into question the chaos that would ensue if NPs were to suddenly be reimbursed at the same rate as physicians. In fact, most NPs are already paid the same as physicians by private insurance plans. HB 4010 would simply require that this common practice be made the standard. Also, where NPs do not have payment parity, the actual and potential impact on patients is serious. For example, in many rural areas (where NPs provide crucial access for patients), some NPs have restricted their hours, are forced to decline patients covered by some carriers, or are considering leaving the area due to financial pressures on their practices due to decreased reimbursement rates.

Finally, you question the challenges raised by “contracts becoming invalid.” It is absolutely crucial to note that contracts between providers and carriers are not as sacred as asserted by the Bulletin or by Representative Conger. In fact, in most many cases, when an insurance provider decides to reduce rates for NPs, those insurance companies simply mail a notification that payment rates are being reduced. No rationale given, no explanation needed, and no negotiation available.
HB 4010 was designed to be a fix for the current system and there are few professionals more supportive of health care transformation than Oregon’s Nurse Practitioners. In fact, NPs have been actively participating in developing Governor Kitzhaber’s approach. The simple fact is this: Oregon can’t afford to lose the services of NPs any more than it can of physicians and Oregon’s NPs can’t afford to be paid less than physicians for exactly the same services.

Is Depression the result of a chemical imbalance?

The common thinking of the cause of Depression in the last 15-20 years has been that it is due to a chemical imbalance. Recently, it is found to be more complicated than that.
It is true that many people’s symptoms are improved with the use of antidepressants. Whether it be by a selective serotonin reuptake inhibitor (SSRI), or selective norepinephirine reuptake inhibitor (SNRI, tricyclic antidepressant or another class, they all are helpful for many people. But it is also believed that close to 50% of people do not benefit from antidepressants. Personally, I question that number when I think about my own practice and how many people have improved. In my own experience, I see 70-80% improving with antidepressants. The prior low numbers may be due to a person getting their meds from a general practitioner than from a specialist who is more adequately prepared to choose the correct type of medication. It could also be that in my practice, I follow my patients much closer than the typical GP who gives psychiatric meds to their patients. Additionally, most of my patients also receive from me some type of counseling or therapy and other health counseling so that should surely be a factor in my better outcomes.
Other factors that appear to be related to depression are genetic predisposition, other illnesses like Diabetes, heart disease, Parkinsons and Cancer, lifestyle factors such as substance abuse, exercise and nutrition. In the last few years there has also been much research directed toward inflammation and its influence on depression which is also showing a lot of promise.

Considering the complexity of issues related to Depression, in my practice I have a multidimensional holistic approach to target Depression.  I use a combination of psychotherapy, lifestyle counseling, nutritional counseling, spirituality, and medication prescribing if appropriate and the patient is interested. I have helped many many people overcome the terrible delibitating disease of Depression.

The role of apathy in the success of weight loss programs

Obesity is sadly at epidemic proportions. Most of us  are very aware of the devastating health consequences of obesity: diabetes and other metabolic syndromes, heart disease, stroke, even Cancer.  So many are trying to fight the battle of the budge whether it be Weight Watchers, Jenny Craig, Nutrisystem, Atkins and others. There is numerous studies identifying the pros and cons of these programs.
This month I read a very interesting article  in the journal of “Diabetes, Obesity and Metabolism” (December)  This article reported a very intriguing study not normally looked at in weight loss studies. The study looked at how different weight loss programs effected weight loss success. There were three groups. (1) standard nutrition counseling; or (2) the Department of Veterans Affairs (VA) weight loss program called “MOVE” ;, or (3) methylphenidate treatment plus the MOVE program together. The intervention was for 6 months (26 weeks). The last group targeted decreasing apathy. They did this by administering a medication that decreased apathy (Methylphenidate. ) The results showed all groups to lose weight but it was observed that those in the group that targeted the symptom of apathy lost the most weight. This is no surprise to me.
In my practice I see many people who present with the symptom of apathy, a state of being where this a lack of interest or caring in the things around them. Often a patient will have no motivation or energy to eat healthy, to exercise, to address a health problem or do those things that will help them feel better or be in a healthier state. Many of these patients are depressed but others have anxiety, psychotic illness or sometimes ADHD. Interestingly, I will notice after treatment which may include Cognitive Behavivoral Therapy, nutritional supplements, goal setting, and for some, the use of medication that has an added effect in decreasing apathy, that many report  they lose weight.  They notice a higher engagement in healthy habits that wasn’t there before. They may notice less binge behavior.

While I don’t advocate the use of medication for everyone,  for some people with diagnosable mental health conditions medication may be quite helpful in losing or preventing weight gain through the mechnism of decreasing apathy.  Psychotherapy, particularly CBT, is also very useful in helping with weight issues. Anything that will help a person be more mentally healthy I believe will contribute to healthy weight.

Now, I know it is the holiday season, but please do not pass the eggnog!

How does personality effect happiness and health?

There has been very interesting research over the years discussing what types of personality traits effect the perception of happiness. There is evidence that suggests that extroverted people are happier than introverted people. This makes sense as it has been found that extroverted people are more likely to surround themselves with people, which we know is recommended to depressed people to help improve mood. Isolated people tend to be more depressed than more social people in my experience working with the mentally ill. Other studies attribute happiness with the quality of optimism

There is another study that I found that I find very interesting. It is found in the Journal of Affective Disorders in January of this year. “Personality and the perception of health and happiness” Cloninger CR, Zohar AH.  In this study they found that the traits of Self-directedness was strongly associated with all aspects of well-being. Additionally, Cooperativeness was strongly associated with perceived social support which we know is strongly associated with well-being. Another personality trait of Self-transcendence was associated with positive emotions.
Can these personallity traits be developed? The research is not clear but I believe it can. Cognitive behavioral therapy is one way. Another way I forsee in developing these qualities would be through the development of spirituality. I regularly see patients in my practice who have been able to develop these qualities to help them be more happy people. That is why I regularly engage my patients in CBT and also have discussions of spirituality to those patients who are open to it. Many have been able develop these personality traits and others that have helped them improve their perceptions of happiness.

Is caffeine good or bad for mental health?

There have been numerous articles extolling both the benefits and harmfulness of caffeine. Less often has there been research on the effects on mental health. What’s my opinion? I advise caution in its usage.

There has been insufficient studies showing any benefit of caffeine on mental health. A few studies have suggested caffeine has a positive effective on depression and ADHD. This may due to caffeine increasing alertness, attention and cognitive functioning and by possibly elevating mood. There is also preliminary evidence of caffeine benefiting some people struggling with Obsessive Compulsive Disorder which I thought was interesting because OCD is a subset of an anxiety disorder and my experience has seen caffeine making anxiety worse. Neveretheless, the research is compelling.

But do the benefits outweigh the negative side effects? We know that caffeine can increase heart palpitations and contribute to stomach problems such as Gerd. These are annoying troublesome physical side effects. What do we know about its mental health downside? We do know that caffeine is addicting and may encourage other types of addictions like cigarette smoking. We also know that caffeine in large amounts can bring out psychosis and manic behavior as well as exascerbate general anxious states, panic disorder or social anxiety disorder.

My advice is to keep caffeine to a minimum. If you struggle with Depression, OCD or ADHD, see your primary care mental health provider to investigate safer, healthier treatment for your mental health conditions. There are other things less harmful and that can do the job more effectively than caffeine.

Long-term antidepressant use could reduce the risk of myocardial infarction

Coming out this month in the British Journal of Pharmacoloy is an interesting article about the links between selective serotonin reuptake inhibitor (SSRI) usage and the risks of myocardial infarction. It has been believed for awhile that a SSRI, which is a particular class of antidepressant, acts immediately to prevent future heart attacks presumably by its anticoagulant properties. In this study they concluded there was something else in SSRI’s that works long-term to prevent heart attacks.
I am wondering if it is related to inflammation? In recent months, SSRI’s have been found to decrease inflammation. Perhaps that is the same mechanism that prevents future heart attacks? Or is there something yet undiscovered?

This is yet another example of how the body and brain effect each other. When one improves the condition and health of the body, the brain also is effected for the positive! It also works the other way around. If one improves brain health, the health of the body will improve also! If you have had a heart attack or are at high risk, you might want to discuss with your nurse practitioner or doctor the possible treatment of a SSRI.  Your heart and brain will thank you!