Tag Archives: mental health

Differentiating between Bipolar Disorder I and Bipolar Disorder II

Many people have heard about the diagnosis Bipolar Disorder. Formerly this diagnosis was named Manic Depression. Today we differentiate between Bipolar Disorder I and Bipolar Disorder II. Bipolar Disorder I is characterized by periods of depression alternating with periods of manic behavior. What is manic behavior? It is discreet periods of high energy which can be either positive or negative in nature. The positive kind would manifest itself by an unusual burst of energy, not needing much sleep, high amounts of goal directed behavior, happy even euphoric behavior, increased amounts of impulsivity, creativity and sometimes grandiosity. Sometimes people in this state talk rapidly and cut others off. Usually, people experiencing this kind of mania like to be there. They enjoy being happy, productive, highly energetic and creative. The problem is that sometimes this mania is highly unpractical and distructive to theirs and their loved ones life. This is particularly true with Bipolar Disorder I which has higher levels of mania. A manic person may suddenly leave a long happy marriage for a random person they met in a bar. They may leave a good job to go explore the world. At the moment the person in a manic state may not understand or consider the implications of his behavior. They may not realize it is a problem. Its usually later when they are out of the manic state and more settled down when they may come to realize the problem. Frequently, family members are the first to mention the problem. Some patients never recognize the problem in themselves and only get help after family insist on it. While positive manic states are sometimes not recognized as being a problem, alternatively, the negative manic states almost always are. If not by the patient himself, certainly by family members, work colleagues or friends.
Negative manic states are high energy states also. There may be problem sleeping. Instead of happy or euphoric mood, in its place is an angry or highly irritable mood. You see these people driving down the road and in response to someone cutting them off they react in a highly explosive way. They may track down the perceived perpetrator and pull a gun on them or start a fist fight. However, this is more common in men. Negative mania is erratic and often scary to the patient and/or those around him. With women, they may report being highly annoyed and easily provoked emotionally. Family members may report they feel like they are “walking on eggshells.”
Bipolar Disorder II is similar to Bipolar Disorder I in that it has periods of depression but it alternates with lower levels of mania. The mania is not as distructive. A person may appear to be a person who is involved in a lot of things and has a lot of projects going at the same time. They seem to exude more energy and creativity than the average person during these times. We sometimes call this type of mania “hypomania” People who have hypomania may not have problems in this state. For them, the problems come when they are in their depressed phase.
Another thing I would like to mention is that sometimes manic states look like anxiety. Be sure to get your anxiety checked out by a specialist if the standard treatments of anxiety, ie. therapy or antidepressants aren’t doing the job. Manic episodes are often missed by the general primary care provider.
How is Bipolar Disorder treated?
If a person has been treated previously with an antidepressant, a mood stabilizer may be added. Some people with Bipolar Disorder( I or II) cannot tolerate antidepressants at all. They may make them too manic. In that case they may need a mood stabilizer or antipsychotic. The other part of treatment is psychotherapy. In my view, they should both be in the treatment plan for best results. Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Marriage and Family therapy and psychodynamic types of therapy can be useful. Recent research shows that CBT can be done effectively in short periods of time from 8-16 weeks in duration for some. CBT focuses on the present and doesn’t spend large amounts of time with what happened in the past. It is goal focused and skill building in nature. Other treatment modalities that I have found to be helpful is spirituality exploration and developing healthy health habits such as good sleep hygiene and an exercise routine. I have found herbal remedies are not as effective in Bipolar spectrum disorders. Although some people prove to be the exception to the

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.

Hyperactivity
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

Inattention
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

Impulsivity
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.

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.

The effect of plastics on mental health: Update 2011

04/20/11

Many experts now believe that plastics are hurting our brains. Teenage boys today have lower testosterone levels than their grandfather’s did 30 years ago. Teenage boys are also suffering more ADHD symptoms: lack of motivation, drive, ambition, ability to plan and follow-through as well as increased rates of depression. Gender confusion has escalated in recent years. Girls are developing way earlier than they did even 15 years ago. Many researchers now believe that this may all be due to the increased use of plastics (or bisphenol A) in our society. Another cause may be herbicides and pesticides which I will not address in this article and will save for another time.

Recently, the FDA has come out with a statement that basically reverses a previous statement they made claiming that low levels of bisphenol A (BPA-the chemical in polycarbonates) does not have long term health consequences in humans. Please note: they now believe that it is harmful to humans! There have been a plethora of research supporting this view in recent months. Frankly, I am surprised it isn’t more prominent in the news given the enormity of research and the severity of BPA effects. Please note that BPA release estrogenic chemicals that are endocrine disrupters.

In the January 27, 2011 edition of the Brain Development journal it claimed that prenatal and lactational exposure to low-doses of BPA alters adult behavior.

In the April 23, 2011 journal of Current Opinion Pediatrics it found that there was a relationship between prenatal BPA exposure and increased hyperactivity and aggression in 2 year old female children.

The Mar 22, 2011 edition of Reproductive Biomed Online found that BPA effects reproductive health by interfering with the process of implantation of endometrial stromal fibroblasts.

There are many more human and animal studies that cannot be ignored that I don’t have room or time to address. One such animal study from China reports that rats exposed to BPA take longer than control rats in figuring out how to get through a maze. The FDA also recognizes that these animal studies cannot be ignored and they are calling out for more research and more comments by the public. In the meantime, they have preliminarily warned the public about BPA in baby products such as baby formula, which cans are often lined with BPA and baby bottles and pacifiers. It is believed that babies are particularly vulnerable to the effects of BPA. They advise to use BPA free types of plastic.

The problem is, there have been other research showing that virtually all plastics have BPA in them, even those claiming to be BPA free. What is one to do?

My advice? Get rid of as much plastics in your house as possible. I threw out all my plastic tupperware and now use glass containers. I use wax paper instead of plastic. I try and use food products that have not been packaged in plastic or tin cans. (Tin cans are often lined with BPA.) Also, do not drink out of water bottles or juice bottles! We have no idea how long these bottles have sat in a warm truck somewhere leaching its BPA into the product. Studies show that by eating more fresh, unpackaged, unprocessed foods, BPA levels can be lowered.

I am concerned about the children…I hope you are too.

Workshop coming up in April!

1.5 CEUs available

For reservation information, cost, location, and time, see below.

+++++++++ And Next Month +++++++++

April 15, 2011

The Tender Loving Care and Feeding of the Brain:
Current evidence based research incorporating health habits, therapy techniques, psychopharmacology and spirituality in caring for our clients with mental health issues

Presented by: Satu Woodland, PMHNP

In this very practical presentation, I will discuss my practice as a psychiatric mental health nurse practitioner and what I have learned in my 25 years of research/practice in the areas of mental health. I will discuss medical conditions/deficiencies that can create mental health symptoms that are often missed, when to refer for psychopharmacology, why we must be concerned about our clients health habits, key elements of psychotherapy that must be present in any psychotherapeutic relationship, and why it is important to engage the patient’s own spiritual belief systems in providing care. Clinicians will be able to incorporate this information into their own practices and know when to refer out for help with their clients where there is a deficit in knowledge or practice parameters.

Learning objectives:

1) Recognize possible medical conditions that could be contributing to a client’s mental health issues.

2) Understand when referral for psychopharmacology is warranted.

3) Become familiar with current research in health habits that a client needs to be aware of for good mental health.

4) Introduce some current research regarding which therapies work for which types of problems.

5) Identify reasons of why and how to engage a client’s spiritual belief system in his care.

Satu H. Woodland PMHNP is a psychiatric mental health nurse practitioner in private practice in Bend. She has been working in the medical and mental health fields working with adults, teens and children since 1984. She has practiced mostly in the San Francisco Bay Area, California in various in-patient and out-patient settings with the last 5 years in private practice in Bend. Undergraduate work at Brigham Young University and California State University Dominguez Hills. Graduate school at University of California San Francisco. Married for 29 years to local mortgage broker David Woodland, mother of 5 highly productive children and 1 grandchild (with one on the way!), she has extensive practical experience working with children and families. For more information, please visit her website at http://www.bendmentalhealth.com

1.5 CEUs available pending approval

RESERVATIONS: to D’Arcy Swanson: darcys@bendbroadband.com or 419-3947 by Wednesday, two days before the Luncheon. Reservations made after Wednesday will be charged an additional $5. Specify vegetarian meal if desired. 24-hour notice of cancellation is required or you will be charged for your lunch. Visit our website for the latest news, questions and events at www.CliniciansNetwork.com.

These luncheons are held the third Friday of the month, September through June, at Touchmark from 12:00 Noon to 2:15 PM
Cost (includes lunch): $15.00 members; $20.00 non-members; CEU’s add $10 (if available);

Touchmark is at 19800 SW Touchmark Way in Bend. It is on the west side of the Bill Healy Memorial Bridge, just south of the roundabout at Reed Market Road and Mt. Bachelor Drive, and very near the Athletic Club of Bend. Click here for a detailed, interactive map: Touchmark Bend

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Hoarding Disorder: A subtype of OCD or ADHD?

Most of us probably know someone who has issues with hoarding, whether it be our great aunt who saves newspapers and cannot throw any away because she plans on one day reading them all, or a neighbor who has 25 old cars on his property that haven’t been touched in years.   Hoarding can often be a debilitating condition that is hard to cure.  Hoarding is defined as the acquisition of and failure to discard large volumes of possessions, resulting in clutter that precludes normal use of living spaces.  Yes, you may  have seen television shows that devote their entire existence to our voyeuristic tendencies of peering into the households and lifestyles of mentally ill individuals with hoarding disorder.

Up until recent years, I have largely believed that hoarding is a subtype of obsessive compulsive disorder (or OCD).  That is what I was taught in graduate school, although I’ve noticed that over the years my patients haven’t necessarily met the criteria of someone who has OCD. Maybe sometimes, but not always. Alas, there is a recent study that casts further light on the difficulties of hoarding disorder.

In the December 2010 issue of the Behaviour Research and Therapy Journal appears a study that examines the core features of hoarding which include clutter, difficulty discarding and acquiring to decide whether hoarding is more like OCD or attention deficit hyperactivity disorder (ADHD).  Participants underwent careful diagnostic interviewing and completed questionnaires that measured features of hoarding, OCD symtoms, negative affect (or mood) and the inattentive and hyperactive/impulsive symptoms of ADHD.  What they found is that OCD symptoms did not significantly predict any of the core features of hoarding disorder. Instead what they found was the inattentive (but not hyperactive or impulsive) symptoms of ADHD significantly predicted the severity of clutter, difficulty discarding and acquiring.

I find this information very informative and is helping me reformulate my ideas and treatment plan for the problems related to hoarding disorder.

Little known differences between bipolar depression and unipolar depression

12/08/10
In my practice I often see patients self referred or sent in by their general practitioner who tell me that he or she has Major Depressive Disorder. Problem is, medications and therapy have had little success so my expert advice is needed.

When evaluating a patient it is crucial not to miss the diagnosis of bipolar depression. A recent article in a Chilean medical journal (Rev Med Chili 2010 Jun) identifies suggestions of how a proper diagnosis can be achieved. This information resonates with my practical experience seeing patients through the years.

First it is important to use standardized diagnostic criteria such as the DSM-IV or ICD 10 manuals. Second it is important to check whether certain clinical features are present. These features tend to be less known to the general practitioner and population. These criteria include whether there are previous episodes of mood elevation. Mood elevation can include times when mood is either positively elevated as in euphoria or high energy that is distinct from other times, or it can be negatively elevated. An example of the latter would be “road rage”. One is driving and the person in front of him lingers a little too long at the stop sign and the drivers gets unusually angry and wants to punch the guy out. We all have heard of that happening.

Another lesser known criteria is current or past episodes of psychotic depression which are episodes of depression that are so severe and debilitating that a person has great difficulty getting out of bed in the morning and functioning.

Recurrent depressive disorder before the age of 25 and a strong family history of mood disorder and suicide are other red flags for Bipolar Disorder.

Finally there are the signs related to past antidepressant usage that can be valuable information in proper diagnosis. If a patient has had a lack of response or “wearing off” to well conducted antidepressant treatment, or an unusually fast response to antidepressants with features of elation these are all red flags of Bipolar Disorder.

Finally, it is important that the proper professionals are utilized in making the diagnosis. While it can be a starting place, it can not be adequately done by self-diagnoses through the internet!

Vitamin D links to mental illness

There is a growing body of evidence that many mental health conditions  are related to dietary deficiencies. A currently recognized deficiency these days is Vitamin D.

It is commonly reported these days that 75% of people have a deficiency of Vitamin D. This is all over the world. Interestingly, the country that is reported to have the highest Vitamin D levels isThailand.  I’m not sure it is known why that is. Vitamin D deficiency it turns out is related to many illnesses from Depression to Cancer. What is the recommended amount of Vitamin D these days?  In my practice I recommend a level no lower than 32 ng/ml. Although there is research that suggest levels of 50-70 are necessary to prevent Cancer.

People susceptible to Vitamin D deficiency are infants, pregnant and lactating women, the elderly, individuals living in Northern latitudes, those who avoid sun, and dark pigmented individuals.  There are also conditions that predispose a person to Vitamin D deficiency including people who have chronic renal failure, people with malabsorptions syndromes that come as a result of bariatric surgery, biliary tract disease, Cystic fibrosis, Celiac disease, inflammatory bowel diseases and certain medications.

If you are taking a Vitamin D supplement please be aware that it is recommended that you take Vitamin D3 as opposed to D2.  Most research uses Vit D3.  Also be aware that Vit A antagonizes the action of Vit D. (Attention Cod Liver Oil and Retinol users!)

Lastly, if you are being evaluated for Depression please have your medical practitioner check your Vit D levels before undergoing any other treatment. You may be able to save yourself a lot of time and money!