New Website

I've been blogging and have a new website:

www.healthandpsychology.webs.com

You can also follow me on Twitter:

  DonohueMA

Thank you all for your assistance and support.  To contact me I'm at

Margaret A. Donohue, PhD
Psychologist, A Professional Corporation
135 South Jackson Street
Suite 204
Glendale, CA 91205

818-389-8384 phone
818-394-6663 fax

Website

After forming a new S-Corporation in Los Angeles, I started looking for someone in Information Technology to help me start up a website.  I looked at lots of sites on the internet offering to assist in the set up of a website.  I purchased a domain name and a hosting company.  Then I attempted to "populate" my site.  Whoa. 

Then I made several phone calls.  It helps when I realize I have no clue about what I'm doing.  The majority of web designers can make me customized templates designed for my business.  The only thing I want at this point is a simple site with a few pages and the ability to link things.  At some point I might want to sell some things...like books, or artwork.  I'm considering self-publishing a memoir.  (I can already hear the screams from some colleagues saying "Don't do it."  and the screams from people who have been waiting a couple of years to be able to share it with friends "Finally!!"

One of the web designers sent me an email linking me to a free website company called http://webs.com.  So I went with them.  At some future point I'll move them to my domain name.  Or I'll move my domain name to them however it's supposed to work. 

For all those people who have just completed a web design course, there is a tremendous need for people like me to work with a web designer to use templates to create a site.  I had a low budget--around $300.  Some student could have helped create a website as a student project and offset expenses.  There must be a lot of people like me out in the world.  I actually thought about taking a web design course so I could do it myself and keep it all updated.  But the simple site is up.  Please bookmark it and visit.

http://healthandpsychology.webs.com

Gang Dog

Cinnamon died on Tuesday morning,  August 24, 2010.  She contracted Methicillin-resistant Staphylococcus aureus (MRSA) http://www.cdc.gov/mrsa/index.html in 2007 and gave it to our other Dalmatian Baxter.  Both dogs required multiple courses of antibiotics to treat their infections.  They contracted MRSA after an infection my husband contracted post-surgery from shredding soiled linens left out when he was rushed to the hospital.

The Bella Moss Foundation is an organization in England that provides information regarding MRSA infections in dogs and how it can be transmitted interspecies from humans to dogs.  I contacted them when the dogs became sick.  Long term infections can develop into problems with the immune system.  Both Baxter and Cinnamon developed autoimmune disorders.  Baxter developed an autoimmune thyroid disorder, dying of complications of infections in 2009.  Cinnamon developed what appeared to be autoimmune diabetes, and was no longer able to walk, lift her head, eat or drink, and likely had an intracranial hemorrhage resulting in a single seizure at the vet's office and labored breathing prior to her being humanely euthanized.  She became obviously sick at 6 am and was near death when she went to the vet's at 9 am when they opened.

She will be missed.

 

Natural Medicines

What is a natural medication?  These are usually herbal remedies used instead of pharmaceutical medications.  Pharmaceutical medications have to pass a process of evaluation by the FDA to ensure that the medication is safe and effective for the purpose the manufacturer says it is designed to be used.  Herbal or natural medications are allowed to be sold unless they are found to be unsafe.  That usually happens after they have been on the market for awhile.  There have been several "natural" products which have been pulled off the market due to injury, illness, or death.  The same is also true pharmaceutical problems but far less common than for natural medication.  Pharmaceutical medications get pulled off the market because they don't work as effectively as predicted or because when combined with other medications there may be an unusual side effect.

The biggest problem I see with people using herbs is that they do not know how they are supposed to be used.  People take herbs or even foods used as medications without a lot of medical supervision.  I met a woman who was dating someone who owned a health food store and was taking 14 different herbal remedies.  So I looked at the list and realized the herbs were in conflict with one another.  The Physicians Desk Reference company makes an Herbal Supplement.  I opened my copy and started showing her how to research the herbal preparations she was using.  Taking an herb to cause constipation along with an herbal laxative isn't a good idea.  The fact that the bottle of both medications says it is good for stomach prblems doesn't help people decide what to take.

Some pharmacists have a background in herbal medicine some don't.  But a pharmacist would be a place to start with questions.  The library may have books on herbs also known as "herbals."  Many of thee contain folk use of plant medicines.  There are research papers on herbs including parts of the plants, dose and preparation methods.  Any prescribing physician should be aware of any herbs, over the counter medicines, or foods used as medicine, prior to prescribing pharmaceutical preparations.

Use of medications

I often talk with people about their medications, use of herbs, supplements, foods used as medications, use of other people's prescribed medications and use of over the counter medications.  Physicians use prescribed medications for two main reasons.  First because medications have a therapeutic effect, and secondly because medications have side effects.  Sometimes physicians prescribe medications specifically for side effects.

The general public has a different idea about medications.  Some people believe that medications are somehow against the "natural order" of things and disturb how the body is supposed to function.  They are fine with herbs, supplements, and foods used as medications.  But they have a problem with pharmaceutical preparations standardized, refined, and produced under governmental supervision, to strict standards.  Some people believe that prescribed medication is needed in order to recover from any illness.  Some people treat medication as magical.  Lots of people use medications in a haphazard fashion neither knowing what the medication is for nor how it works.  They take medications not prescribed for them and combine them with other medications.  They take medications when they remember to do so or when they have what they think are a symptom the medication will fix.

I grew up in a rather unique environment.  My adoptive father was a pharmacist trained in plant medication and compounding or making prescription medications from plants.  I worked in his pharmacy for many years.  I have a medicinal herb garden in my yard.  So I'm certainly not opposed to medicines from herbs or plants.

I think when people know about prescribed medications they have a better understanding about what the medication is for, how it is used and how they are supposed to take it.  I don't think plant medicine or herbal remedies are intrinsically better than pharmaceutical medicines, and in some cases because of the lack of oversight in preparation and inconsistency in potency they can be much worse.  I had a physician mention echinacea as a treatment once.  So I asked what part of the plant was he recommending.  Roots or flower?  Did he suggest E. Purpurea or some other variant of the plant like E. Angustifolia or E. Pallida?  All of these are Echinacea.  All of them I have grown.  Pretty plants.  Very poor research on their impact on the immune system.  There are multiple ways to prepare them.  He didn't know.  He also couldn't advise on dosage.  I suggested he stick to pharmaceuticals or commercially prepared herbal products.  I gave him an E. Purpurea and an E. Angustifolia flower.

A man recently asked me about a medication he had "borrowed" from his wife which helped with some symptom he was having.  "Borrowing" medication from someone else is a very poor practice.  The medication is prescribed to a specific person for a specific symptom or for a property of the medication.  In this case the reason the medication was effective was because of an unusual side effect of the medication.  Trying to get the medication prescribed by his doctor meant that the medication wasn't being used for it's general purpose but instead for a side effect it has.  Unless the physician combed medical research journals to find the side effect and the fact that the medication has been linked to treatment for this condition the physician wouldn't be likely to think it should be used.  There are 4 or 5 classes of medications that can be used to treat the condition.  One is available over the counter very inexpensively.  The pharmaceuticals can be very expensive, and their use is based on side effect properties.

Health psychologists can provide information to both physicians and patients about why something is working.  We have a background in research.  We can provide extensive information to patients about medications and how they work, how to take them, and systems to improve medication compliance.  We can provide information on interactions with foods, over the counter preparations, the impact of taking someone's medication and use of complementary and alternative treatments.

Diagnostic Ambiguity

For most people a trip to a physician means that a doctor will tell them what is wrong and will tell them how to get better.  For some people it may take a couple of visits or a couple different types of medications.  But for some the diagnosis may take months, years or maybe never.

These people, the ones waiting to be diagnosed, go through an agonizing process which changes how they relate to the medical community, to themselves, to their support system and to information about health care.  In as few as six visits to a physician with no clear diagnosis a couple of things start to happen.  First, the physician is likely to blame the patient for the lack of a diagnosis.  "Maybe you aren't telling me everything."  "Maybe it's psychological."  "Maybe it's stress."  "Maybe you should be seen by a specialist."  Second, the social support system of the patient no longer wants to hear about the illness or the lack of diagnosis.  Third, people will provide information on alternative care techniques which may not help with symptoms and may complicate diagnosis and or treatment.  Over time, patients will avoid medical care and become stuck and focused on information about symptoms.  They will have a phobic, reaction to physicians, diagnoses and treatment attempts.  They will have outright refusal of care and avoidance reactions or become clingy and desperate.  Some will develop specific ideas about what makes them better and worse.  Some of those ideas will have no actual basis in reality.  All of these reactions from the phobic or avoiding, to the clingy, to the superstitious, are all normal variants in dealing with diagnostic ambiguity.  Physicians will become rejecting, hostile, irritated, or overly concerned, intrusive and paternalistic. 

Anyone who has not been diagnosed in 6 to 10 office visits should be appropriately referred to a health psychologist.  What can be expected is specific assistance in managing the symptoms, developing strategies in managing the complex relationship with physicians, significant friends and family and concerned other people, and help in coping with the ambiguity.  A health psychologist can assist with tracking symptom data, setting up symptom recording systems, and looking at all the health care options available including traditional, non-traditional, alternative and complementary, as well as other treatments which may be exploitative for a patient with diagnostic ambiguity.  A health psychologist can provide information to the treating physician on how to provide information to the patient in a manner that best matches how they use medical information.  They can assist the relationship and lessen malpractice risks.

Failure to seek Medical Care

There was a study a few years ago in San Francisco that found 49% of people with mental illness failed to seek medical care for a condition they had.  The study cited concerns about coercive treatment, costs to obtain care, and worries about the process of seeking evaluation and care.  The study concluded that regular contact with a physician helped reduce medical costs and improved health care outcomes.

I think the percentage amongst the non-mentally ill failing to seek needed medical care is about equal.  Most people simply aren't sure if their medical condition requires a medical evaluation or not so they wait.  While they wait to improve or worsen to some vaguely determined threshold, they talk to people.  The checker at the market commenting on my yogurt that her frequent heartburn means she can no longer eat food like that.  My sister-in-law telling me about her failed attempts to lose weight and her painful joints.  My husband's cousin asking about substance abuse treatment for someone he knows who lives in Orange County.  The clerk at the office complaining she couldn't stop vomiting.  None of these people are talking to a doctor.  None of them are talking to a health psychologist.  Some of these people will talk online.  Some will call friends.  Some will check websites. 

Health psychology can help with all this.  Some people have been severely traumatized when seeking medical care.  Some medical doctors are abrasive and time pressured.  Some are simply perfunctory.  Some don't explain what they are doing or why.  Health psychology can provide a physician with information on how to treat a patient in a manner that matches their psychological make-up.  If you have an anxious patient worried about procedures then going through what to expect, how to remain feeling positive in light of ambiguity, and helping get questions answered can ensure the patient leaves knowing their questions were addressed.  For people who want a lot of information and require a lot of independence, then clarifying available options, providing research, and support assists that patient.  Some people just get overwhelmed and need to be helped step-by-step through each part of evaluation, diagnosis and treatment with information kept to a minimum.

If you have been thinking about seeking a physician for an initial consultation or second opinion about a condition or simply haven't sought treatment but have symptoms you are concerned about, feel free to contact me at DonohueMA1@me.com.

There's an application for that

I've been very busy this past month.  One of the new things I've purchased was an iPad.  so far I've downloaded just shy of 100 applications for it.  Lots of them have to do with health psychology.  Let me mention a couple of them.

Tinnitus Trainer
This application builds on the new science of neuroplasticity.  Changes in patterns of activity in the cortex of the brain result in a chronic hiss or tone which can be quite annoying.  By playing sound frequencies near the frequency heard the brain creates new wiring and changes the need to constantly produce the hiss or tone. It's available for the iPad and iPhone.  It needs to be appropriately calibrated for the tone the person hears and then the sounds need to be heard for several hours a day for a period of time but it cures tinnitus.

 Lose It
This is a tracking program for weight loss.  It allows the user to add food and exercise to monitor fitness and intake goals.  It provides calorie counts nutrient preferences and you can set up motivator systems to keep on track.

Blood Pressure
This is a tracking system for both blood pressure and pulse.

Dr. Speaker
This allows a person to ask basic medical questions in a variety of languages--Spanish, English, French, And Chinese.

WebMD
This is available on line as well and includes a symptom checker.  The person starts by listing their symptoms and the application starts adding diagnostic possibilities.  This might also be good for watching episodes of "House."

Those are just a few of the new applications for the iPad.  The device isn't a computer but can certainly help both medical professionals and their patients in new and creative ways.

Medical Illness and Stress

Medical illnesses often have a stress component.  Illnesses will flare up at times of emotional stress.  Psychological stress impacts the physical body.  Psychological stress uses up different nutrients, it alters our habits, it changes appetite and sleep patterns, it changes the immune system. 

There are ways to evaluate the impact of stress on the body.  By evaluating the stress someone is exposed to, it's possible to develop a plan to manage the stress better and to reduce the medical symptoms.  Tracking when symptoms occur can clearly document for someone the link between the stressful experience and the physical manifestations of stress.

A number of medical conditions have a stress link.  These are as common as neck and back pain, difficulty sleeping, or headaches, to less common problems of gout, hypertension, irritable bowel syndrome, asthma, and increased susceptibility to colds or flu.  Working with a health and medical psychologist can help to document the links between stress and physical symptoms, devise a treatment plan to manage the symptoms better, devise a plan to manage the stress better, and to decrease the actual illness in the process.

Rewiring the brain

The brain rewires itself in relation to environmental experience and things it must attend to.  The brain adds neuro-linkages to those areas.  The areas expand and develop in relationship to how often they are used.  This is extremely important and valuable information in relation to things like learning new tasks, recovering ability following injury or accident, or dealing with psychological conditions like depression and anxiety. 

People develop habits.  Those habits become wired through neural networks in the brain.  As the habits are practiced, the wiring is strengthened.  Other nearby areas of wiring don't get as much practice and eventually fall into disuse and are taken over by areas that are used.  If we want to change habits it's important to practice and pay attention to the new habits that are developing.

If I want to learn a new software program and I practice it, eventually it will become easier to use.  My brain will develop wiring attached to finger motions, eye movements, sounds in the environment, and will allow me to both smooth out the movements and make them effortless.  If I want to become less depressed or anxious I can apply the same strategy to change the focus of my thinking, relabel my thoughts, and rewire the previously laid down wiring and learn new ways to mange what is happening.  If I want to improve a skill, like memory, music, math, or general knowledge, then I have to practice it daily for a period of about an hour or so.  After somewhere between 5 weeks and 6 months I should be able to see substantial improvement in that area.  That means that I'm likely to need to track what I'm doing to be able to notice the changes.  Getting baseline data and noticing incremental improvement will help me to stay with the process and keep on task.  If I'm trying to change to something new from something I used to be able to do, I'm going to have to practice and also avoid doing all the old behaviors. The more I practice, the easier and smoother the transition.

Part of my current work involves setting up sequences, tracking systems, and reinforcement systems for people who want to learn new behaviors, rewire after something has happened, or change to something different.

Feel free to contact me for more information.
DonohueMA@aol.com

Distance Therapy

I've been working with a former client of mine online for the past two weeks.  Instead of seeing this person at my office (which is exceptionally far for them), I'm seeing this person online, via email, or cell phone.  Like Distance Learning, the computer has come to therapy.  So this person and I have to figure out how this treatment will work.  Here is what we've decided.  First, this is going to be formal therapy.  There are arranged times, homework assignments, readings, and substantial information being provided, including daily assessments.  We've agreed on a specific type of treatment.  There are a lot of security issues.  The internet isn't secure.  We use minimally identifying information back and forth online.  The phone isn't secure.  The information can be overheard. 

So in two weeks what's been accomplished?  The client has a new job, an improved relationship, and (I can document with the questionnaires that have been completed) a 50% reduction in depression and anxiety.  Not bad for two weeks.  Not bad for online and no face-to-face interactions.

So what are the clinical and ethical issues in this new world of computers?  Security is certainly an issue.  I don't know about how confidential anything is.  I assume everything on the internet is pretty much public information, but I don't think everyone else thinks that way.  I have to remind the client about this.  I certainly get more detailed records this way since everything is written out.  The client gets access to data that is tracked and trended, color coded and on an excel spreadsheet.  Daily.  I'm interacting on a daily basis instead of once a week or once every two weeks.  But the interactions are extremely brief.  High touch and high tech certainly.  The client has a workbook they are using in conjunction with treatment.  The type of treatment uses homework assignments and is readily available in workbook format by a number of authors.  I can explain concepts in general in email.  The rating scales can be readily downloaded from the internet and the results sent back over email.  Could I do more formal assessments remotely with say a web cam or remote server?  Maybe.  And the results are fast.  Same day, or next day.  But this is traditional treatment it's just the format that's different.  What about seeing someone online I don't know?  Is it ethical to provide online only treatment?  What if I'm seeing someone in another State?  I'm licensed in California and Nevada.  If my client were to move to say Idaho or Arizona would I need to be licensed in the State they are in to provide services online from California or Nevada or do my current licenses cover that treatment?  I don't know off hand.  I would have to check with the State licensing agency involved if that were to happen.  What about less traditional treatment?  What about assessments that are only normally done face-to-face?  Does a computer based assessment system change the results?  Does insurance cover this type of treatment?  How does it get priced out?  Lots of new questions to be determined. 

So far so good with this person.  As I add people in this format I'll keep updating.

Undiagnosed conditions

Most people expect their doctor to determine what's wrong with them at the first or second visit.  Just answer some simple questions maybe get a lab test or two and poof there you have it.

Not exactly.  In many cases it can take months or even years to get a diagnosis.  In some cases you just learn to live with not knowing and wait for science to catch up.  The difficulty between expectation on the part of both physician and patient makes for very strained relationships.  Doctors become surly and outright hostile.  Patient's become stressed and exasperated.  Litigation happens or patients seek services elsewhere.  Doctor's tell patients not to return.  Or imply the medical problems really don't exist.

Some patients recover from being told not to return or being told the doctor doesn't know what's wrong.  Some stop getting any medical care.  Some seek treatment from multiple physicians and then branch out to complementary or alternative treatments, mental health specialists or look to spiritual guidance or psychics.  Some physicians get overly cautious ordering countless tests and procedures.  Some refer out to specialists as soon as it gets ambiguous.  Some move into administrative services and limit direct patient care.

Complaints about medical symptoms which don't resolve within 6 office visits would benefit from treatment by a medical psychologist.  Either the physician or the patient could seek the treatment to help with the medical collaborative process.  A medical psychologist is knowledgeable about medical conditions, diagnostic decision trees, medical research, and how patients talk about symptoms. 

Several years ago I was in a risk management meeting with a major health management organization.  I was seated at a table with a group of physicians which included an internist, cardiologist, orthopedist, psychiatrist, gynecologist, and general practitioner.  We were discussing a case which came to the attention of the company attorneys.  All the identifying information had been stripped out of the case.  We were to discuss work flow, diagnosis and next steps in a step wise manner as the case unfolded.  A female patient presented with neck and back pain after exertion.  She was seen by the physician on-call at the clinic for a same day appointment.  She was seen for 20 minutes.  A full history was not taken.  She was given a prescription for anti-inflammatory medication and told to return if needed.  So I raised the issue of cardiovascular disease with the physician colleagues at the table.  The cardiologist disagreed strongly.  "It's neck and back pain, not chest pain."  "But" I countered "women experience heart problems differently then men, often complaining of neck and back pain with exertion."  I mentioned these findings were noted in medical journals of Cardiology and JAMA, as well as studies from the American Heart Association.   As we went through the documented scenarios of the next four treatment visits for the same problems which were worsening over time, the physicians came to agree that having a single physician in charge of her care would be useful.  Having a full history would be useful.  Up until the last visit where the patient collapsed, the cardiologist and orthopedist were convinced this was not a cardiac event but some problem with her neck or back.  In the final scenario the autopsy proved the woman died of a heart attack and the family sued the physicians involved.  The point was it could all have been avoided with collaborative treatment. 

Over the next several years at the company the physicians who had been at that table for the risk management seminar referred to me anyone they were not able to diagnose after the second meeting for the same symptoms.  Sometimes they just stopped me in the hallway to discuss a case.  These discussions benefited the company, the clinical practices of the physicians, and the patients.  I was able to help people cope with not having a diagnosis.  I was able to help physicians run through branches of medical decision trees or alternative branches, get information and clarify symptom presentation.  Together we saved lives and helped people improve their health. The physicians involved in those discussions didn't limit referrals to psychology to just people with mental symptoms.  The company went on to provide more medical psychology services and to integrate medical psychology into the medical services they provide.  The company remains innovative in treatment and use of psychological services.

If you are a patient or a physician dealing with someone who complains of medical symptoms which are not diagnosed you may want to seek a consultation with a health or medical psychologist.

Vascular system

This is information on Health psychology.  This is reprinted in large part from the University of Virginia's website.  I've added to it.

The vascular system, also called the circulatory system, is made up of the vessels that carry blood and lymph through the body. The arteries and veins carry blood throughout the body, delivering oxygen and nutrients to the body tissues and taking away tissue waste matter. The lymph vessels carry lymphatic fluid (a clear, colorless fluid containing water and blood cells). The lymphatic system helps to protect and maintain the fluid environment of the body by filtering and draining lymph away from each region of the body.

Click Image to Enlarge

The vessels of the blood circulatory system are:

• arteries - blood vessels that carry oxygenated blood away from the heart to the body.
• veins - blood vessels that carry blood from the body back into the heart.
• capillaries - tiny blood vessels between arteries and veins that distribute oxygen-rich blood to the body.
• arterioles-smaller arteries
• venules-smaller veins

Blood moves through the circulatory system as a result of being pumped out by the heart. Blood leaving the heart through the arteries is saturated with oxygen. The arteries break down into smaller and smaller branches in order to bring oxygen and other nutrients to the cells of the body's tissues and organs. As blood moves through the capillaries, the oxygen and other nutrients move out into the cells, and waste matter from the cells moves into the capillaries. As the blood leaves the capillaries, it moves through the veins, which become larger and larger to carry the blood back to the heart.

In addition to circulating blood and lymph throughout the body, the vascular system functions as an important component of other body systems. Examples include:

• respiratory system
  As blood flows through the capillaries in the lungs, carbon dioxide is given up and oxygen is picked up. The carbon dioxide is expelled from the body through the lungs, and the oxygen is taken to the body tissues by the blood.
• digestive system
  As food is digested, blood flows through the intestinal capillaries and picks up nutrients, such as glucose (sugar), vitamins, and minerals. These nutrients are delivered to the body tissues by the blood.
• kidneys and urinary system
  Waste materials from the body tissues are filtered out from the blood as it flows through the kidneys. The waste material then leaves the body in the form of urine.
• temperature control
  Regulation of the body's temperature is assisted by the flow of blood among the different parts of the body. Heat is produced by the body's tissues as they go through the processes of breaking down nutrients for energy, making new tissue, and giving up waste matter.

What is vascular disease?

A vascular disease is a condition that affects the arteries and/or veins. Most often, vascular disease affects blood flow, either by blocking or weakening blood vessels, or by damaging the valves that are found in veins. Organs and other body structures may be damaged by vascular disease as a result of decreased or completely blocked blood flow.

What causes vascular disease?

Causes of vascular disease include:

• atherosclerosis
  Atherosclerosis (a build-up of plaque, which is a deposit of fatty substances, cholesterol, cellular waste products, calcium, and fibrin in the inner lining of an artery) is the most common cause of vascular disease.
  
  It is unknown exactly how atherosclerosis begins or what causes it. Atherosclerosis is a slow, progressive, vascular disease that may start as early as childhood. However, the disease has the potential to progress rapidly. It is generally characterized by the accumulation of fatty deposits along the innermost layer of the arteries. If the disease process progresses, plaque formation may take place. This thickening narrows the arteries and can decrease blood flow or completely block the flow of blood to organs and other body tissues and structures.
• embolus/thrombus
  A blood vessel may be blocked by an embolus (a tiny mass of debris that moves through the bloodstream) or a thrombus (a blood clot).
• inflammation
  In general, inflammation of blood vessels is referred to as vasculitis, which includes a range of disorders. Inflammation may lead to narrowing and/or blockage of blood vessels.
• trauma/injury
  Trauma or injury involving the blood vessels may lead to inflammation or infection, which can damage the blood vessels and lead to narrowing and/or blockage.

What are the effects of vascular disease?

Because the functions of the blood vessels include supplying all organs and tissues of the body with oxygen and nutrients, removal of waste products, fluid balance, and other functions, conditions that affect the vascular system may affect the part(s) of the body supplied by a particular vascular network, such as the coronary arteries of the heart.

Examples of the effects of vascular disease include:

• coronary vascular disease - heart attack, angina (chest pain)
• cerebrovascular disease - stroke, transient ischemic attack (a sudden or a temporary loss of blood flow to an area of the brain, usually lasting less than five minutes but not longer than 24 hours, with complete recovery)
• peripheral arterial disease - claudication (limping because of pain in the thigh, calf, and/or buttocks that occurs when walking), critical limb ischemia (lack of oxygen to the limb/leg at rest)
• vascular disease of the great vessels - aortic aneurysm (a bulging, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning), coarctation of the aorta (narrowing of the aorta, the largest artery in the body), Takayasu's arteritis (a rare inflammatory disease affecting the aorta and its branches)
• thoracic vascular disease - thoracic aortic aneurysm (a bulging, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning in the thoracic, or chest, portion of the aorta)
• abdominal vascular disease - abdominal aortic aneurysm (a bulging, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning in the abdominal portion of the aorta)
• peripheral vascular disease - deep vein thrombosis (Also called DVT; a blood clot in a deep vein located within the muscles of the leg), varicose veins
• lymphatic vascular diseases - lymphedema (swelling caused by interruption of the normal drainage pattern in the lymph nodes)
• vascular diseases of the lungs - Wegener's granulomatosis (an uncommon disease in which the blood vessels are inflamed; mainly affects the respiratory tract and the kidneys), angiitis (inflammation of blood vessels), hypertensive pulmonary vascular disease (high blood pressure in the lungs' blood circulation due to vascular conditions)
• renal (kidney) vascular diseases - renal artery stenosis (blockage of a renal artery), fibromuscular dysplasia (a condition that weakens the walls of medium-sized arteries and occurs predominantly in young women of childbearing age)
• genitourinary vascular diseases - vascular erectile dysfunction (impotence)

Because vascular conditions and diseases may involve more than one of the body's systems at a time, many types of physicians treat vascular problems. Specialists in vascular medicine and/or surgery work closely with physicians in other specialties, such as internal medicine, interventional radiology, cardiology, and others to ensure comprehensive care of patients with vascular conditions.  

People with vascular conditions are often on multiple medications and feel overwhelmed with the number of specialists, the risks associated with the disease processes, and the amount of information being presented to them.  Health psychologists can help break down the conditions into usable pieces working with the patient to understand the disease process, the medications, the risks and benefits of treatment options, and develop systems to manage special diets, exercise regimes, and medication compliance.  They can work with physicians to set up target systems and reporting to improve documentation and assist with compliance and communication.  They can help with symptom tracking to reduce risks.  Online information can provide direct patient assistance with multiple medications and drug/drug interactions as well as drug/herb or drug/food interactions.  Research on clinical trials for new treatments or new tests can also be provided for either patients or physicians.

Immunine Disorders

This is part of a series of articles on health psychology.

The body has great defenses to prevent disease.  These include it's physical design with organ placement and the skin covering as well as chemical and metabolic activities designed to ward off changes in cell abnormalities and disease.  With all this in place things still go awry and the body will sometimes have the immune system designed to protect us go haywire and start attacking itself instead.

Immune system problems require a great deal of medical understanding on the part of patients for them to cooperate in treatment.  Health psychologists can provide this understanding.

Our understanding of the immune system today is relatively small.  General scientists, microbiologists, immunologists, geneticists, and others have really been highly focused on the immune system since the big financial push to research Acquired Immune Deficiency Syndrome back in the 1980's.  Added to that were big financial pushes to research specific diseases such as cancer and autoimmune disorders in the 1990's. 

The immune system is based on complex interactions between the skin, the gastrointestinal system, the blood, and bone marrow.  Each of these produces changes to circulating cells which help to protect the body and keep it functioning optimally.  When some cells recognize abnormal cells are present such as viruses or bacteria, these cells signal the brain to produce cells to attack these abnormal cells.  They will produce chemicals like antibodies to make fighting these types of abnormal cells easier should they show up in the future.  They will send compliments which will speed the up the bodies response to antibodies.  They will send cells to clear up cellular debris.  They will thin or thicken the fat in the blood to assist to assist with the speed of reaching to infected or abnormal areas and produce inflammatory chemicals to help with defending the body.  Physicians will prescribe chemicals like antibiotics, antivirals, and anti-inflammatory agents to assist in the body's natural process.  These medications will reduce the risk of complications and reduce the possibility of death from these disorders.

Sometimes the diseases, like the virus responsible for HIV and AIDS, will set up inside a cell and trick the cells into thinking it's functioning normally by creating a protective shell around it.  It then changes chemicals and send out material to trick other cells into functioning in the same manner.  Sometimes the body will have a difficult time in switching off after fighting an infection and will turn on other organs or appropriately functioning cells causing an autoimmune disorder.  Sometimes the body's defenses will just get overrun.  Sometimes the bacteria or viruses mutate into forms that we have no medications to treat.  Sometimes the abnormal cells will grow rapidly and incorrectly becoming cancerous.

By understanding what the medical condition is, what medications are being used for, how medications work, and how the immune system functions, it's possible for the health psychologist to help the patient be informed about treatment options and to take a more active role in treatment.

My husband had a cold.  It didn't go away after a couple of weeks.  He went to his doctor who prescribed an antibiotic for what was presumed correctly to be a bacterial infection.  Immediately after starting the antibiotic he felt sicker.  But he wasn't running a fever.  He wasn't sure what was happening.  So I explained what happens when there is a sudden influx of antibodies to kill off cells.  As the bacterial cells die people get symptoms.  They sweat and get chilled.  They may have diarrhea, bloating, frequent urination, and nausea.  They feel hot or cold.  These symptoms last for a few days as the bacteria are being suddenly killed off and flushed from the body.  There are no changes in actual temperature or blood pressure suggesting a worsening of infection.  The antibiotics are doing their job.  Complements are being released to help speed up the body's recognition of the offending cells and storing that in cell memory so the cells that kill off bacteria will be able to more easily recognize this bacteria should it recur.  If the antibiotic is not completely used there is the possibility that the body will only be able to kill off the weak cells while the strong cells will grow and multiply and become resistant to that medication.  If the antibiotic is trying to fight off a viral infection rather than a bacterial infection it will not be effective.  After 10 days on the antibiotic his symptoms were gone.  My input was only a couple of sentences to explain that feeling worse was a normal part of the antibiotic doing it's job and how to tell if his infection was worsening.  He was able to stay on the antibiotic and let it complete it's job and recover.

Undiagnosed Illness

This is another post in a series on medical psychology.

Nothing is more frustrating than knowing you are sick and not knowing what is wrong.  It frustrates both patients and doctors alike.  After about six visits doctors may start to either doubt their ability to provide assistance or will become uncomfortable with the ambiguity of the situation.  Some physicians will handle the lack of a diagnosis by referring to another physician, and some will start to limit contact with the patient.  The visit will become shorter and the physician may become more irritable.  In some cases they will refuse services outright.  At the same time patients will become more demanding of answers and treatments, irritated with the physician, upset with the ambiguity and getting increasingly demanding.  In some cases patients will explore alternative treatments, look up symptoms online, and try various folk remedies for symptom relief or ask neighbors, friends, and people in chat rooms to provide assistance.  Both for the peace of mind of the physician and for the peace of mind of the patient a health psychologist can provide assistance.

For the physician, the health psychologist has tools to manage the patient's ambiguity.  They can clarify the symptoms being reported and can put the symptoms being reported into medical terminology.  Health psychologists can provide assistance for diagnostic clarification.  They can help the physician recognize that, apart from what was drilled into them in medical school, they are not expected to know everything about every patient.  Some illnesses present in unusual ways.  Some patients are not able to report symptoms adequately.  Some illnesses have not been discovered.  Some things just take time to figure out. 

For the patient, the health psychologist has tools to help the patient organize the symptoms into medical decision trees, to understand symptoms, to manage anxiety, to manage depression and pain, and to be able to help with making decisions about health information, research, clinical trials, alternative treatments, and folk remedies and herbal care.  The health psychologist can help to differentiate symptoms that are medical in nature from those that are psychological in nature. 

I met a woman who was a frequent user of herbal medicines to help with her symptoms.  Her local clerk at the health food and herb store was her functioning pharmacist.  She had lots of symptoms she was treating with herbs and supplements.  She had the idea that because herbs and supplements are classified as "natural" they are somehow safer than pharmaceutic products.  So I got a book out for her--the Physicians Desk Reference for Herbal Medicines.  I started by showing her how to look up the medicines she was taking.  She was taking herbal medicines for diarrhea, constipation, inflammation, and colic.  These interact and conflict with one another.  Without knowing the effects or methods of actions of these "natural" products, she was making herself much sicker.  We also talk about the skills and education of the clerk at the health food store versus the skills and experience of a pharmacist trained in herbal medicine.  We talked about the protections to consumers about licensed professionals.  We talked about the difference between herbal products and companies and the difference between herbs and pharmaceutical medicines.  Different companies use different parts of herbs with different potencies.  The herb and supplement industry is regulated differently than the pharmaceutical industry.  Some pharmaceutical medications are derived from plant medicines but they are manufactured for stability, consistency and quality.  Some people choose to grow their own herbs for medicinal use so they can control the plants, soil, and growing conditions.  As we talked about all that she began understanding that the mixture of herbal products was causing some of her symptoms and she had an inadequate understanding of what she was doing when she decided to take herbs.  She decided to gradually discontinue all the supplements and see how her body was functioning.  Over a period of a couple of months her health improved significantly and she stopped being symptomatic.  Since her treating doctor had never known she was using herbs he had never suspected that her use of herbal medicines was causing her symptoms.  Her undiagnosed condition turned out to be all due to side effects of herbal medications.

A patient came to see me because of hallucinations of spiders.  He saw spiders all the time, especially against white backgrounds.  He had been tried by his doctor on an anti-psychotic medication but the visions of spiders continued.  Visual hallucinations are atypical for psychiatric problems and are far more likely with medical problems.  So we talked about his history in depth.  The spider visions followed his eye movements and were far more consistent with visual field floaters than hallucinatory events.  Ocular floaters often are a consequence of head trauma.  He had a history of a head injury with a minor loss of consciousness.  The review of symptoms of head injury confirmed a diagnosis of post-concussive syndrome.  The patient completed a couple of formal questionnaires and the results were forwarded to his treating physician.  We were able to help him connect with a neurologist for follow-up and to online support groups to help him and his family deal with his residual symptoms.

For some people with unusual diagnoses the conditions are both rare and serious.  I met a woman who suddenly stopped being able to function.  She couldn't sit down in a chair because she couldn't decide which chair to sit in.  She couldn't eat because she couldn't decide what food to eat first.  Her medical doctor thought she had become suddenly mentally ill.  She wasn't responding to psychiatric medication.  She was referred to me for an evaluation.  Her symptoms were consistent with an unusual neurological disorder sometimes associated with a toxic condition otherwise associated with a loss of functioning in the front and side parts of the brain.  She was sent for neurological testing which confirmed the diagnosis of loss of brain volume in the frontal and temporal lobes (frontal-temporal dementia).  As a health psychologist I could help her family make decisions about her care, help with information about hospice care, conservatorships and end of life decision making. 

Health and medical psychologists can provide a wide variety of services to both physicians and patients dealing with undiagnosed illness or unusual symptoms or illnesses not responding as expected to conventional treatments.  They can provide information and resource directly to physicians, patients and family members about research, symptom identification, and options.  They can help manage or eliminate the ambiguity and stress inherent in not having a diagnosis.

Technology and Learning Disabilities

My brother had a head injury as a young child.  It was a standing joke in the family.  "Were you dropped on your head as a kid or what?...Well yes I was.  Actually it was a large seashell that fell off the wall and dented my skull."  So he has problems reading.  He can read.  It's just painfully show and he says all the letters get mixed up in his head.

I did a couple of things with him while I was up at his house.  I showed him the Text-to-speech feature of my Kindle.  I also showed him the text-to-speech feature of my Mac laptop.  Then I lost my voice.  Completely.  So he talked and I talked back to him in a computer voice from my laptop.  He could read things I'd written in portable document files (.pdf) and I could type single lines of text and answer his questions.  The computer did all the reading to him and speaking for me.  My voice came back.  I turned the speech function off.

There are lots of things technology can do to help people with learning problems and there's a wide variety of computer types of devices that can be used.  I can send PDF files via email to my Kindle book reader.  I can change the size of the type on the books I download.  I can have the Kindle speak in a male or female voice with slow or fast rate of speech.  On my Mac I can change the screen colors, change the size of type, have the computer talk, have designated keys.  I can hook up programs that will allow the computer to type while I talk over headphones.  I can have email sent to my smart phone from my laptop.  I can send it to a wireless printer and have it print.  I can have it calculate with applications.  I have an iTouch with applications.  There are applications that will calculate, let me read books, help me stay focused on tasks, and let me stay in touch with people for support.


Some people have difficulty reading.  Computer-based accommodations for Dyslexia may not require specialized hardware or software. For example, a person with Dyslexia can benefit from regularly using built-in word processor features such as spell checking, grammar checking, font size and color changes.  Lots of people have difficulty seeing certain colors.  Many word processing programs also include the ability to outline thoughts, providing alternative visual formats, and ways to emphasize information that may compensate for difficulty in organizing words and ideas.  Additionally, color-coded text options and outline capabilities present in many word processing programs are useful tools for those with difficulty sorting and sequencing information found in text.  A word processor can also be used as a compensatory tool for a person with dysgraphia (difficulty writing). Use of a keyboard may be a viable alternative for an individual who has difficulty expressing his thoughts via handwriting.An individual who can take in information through listening much better than by reading may benefit from using a reading system. These systems allow text on screen (document, web page, or email) to be read aloud through the computer's sound card. A scanner and Optical Character Recognition (OCR) software (e.g., Freedom Scientific's WYNN or Kurzweil 3000) adds the feature of reading printed text. Hard copy text is placed on the scanner where it is converted into a digital image. This image is then converted to a text file, making the characters recognizable by the computer. The computer can then read the words back using a speech synthesizer and simultaneously present the words on screen.

Assistance with reading in technology includes options such as highlighting a word, sentence, or paragraph using contrasting colors. Increasing the size of the text displayed on the screen as well as changing text color can increase reading comprehension for some people with specific learning disabilities.

Some individuals have difficulty organizing and integrating thoughts and ideas while writing. Concept mapping software allows for visual representation of ideas and concepts. These representations are presented in a physical manner and can be connected with arrows to show the relationship between ideas. These graphically represented ideas can be linked, rearranged, color coded, and matched with a variety of icons to suit the need of the user. Concept mapping software can be used as a structure for starting and organizing such diverse writing projects as poetry, term papers, resumes, schedules, or even computer programs. Some programs will allow you to easily go from text to linked shapes, to formal outline and back.

People with Dyslexia often spell phonetically, making use of word prediction or spell checking software less useful. Devices (e.g., Franklin Electronic Dictionary ™) or software (YakYak ™) that renders phonetic spelling into correctly spelled words may be useful tools.

Spelling words correctly while typing can be a challenge for some people with Dyslexia. Word prediction programs prompt the user with a list of most likely word choices based upon what has been typed so far. Rather than experiencing the frustration of remembering the spelling of a word, the writer can refer to the predictive list, choose the desired word and continue with the expression of thoughts and ideas.

Speech recognition products provide appropriate tools for individuals with a wide range of learning disabilities. Speech recognition software takes the spoken word via a microphone and converts it to machine-readable format. The user speaks into a microphone either with pauses between words (discrete speech) or in a normal talking manner (continuous speech). The discrete product, although slower, is often the better choice for those with LDs because errors can be identified as they occur. Making corrections after the fact using continuous speech requires proficient reading skills. Speech recognition technology requires that the user have moderately good reading comprehension to correct the program's text output.

Organizing schedules and information is difficult for some people with dyslexia or a non-verbal learning disorder. Personal Information Managers (PIMs) such as a Palm Pilot or Casio  or organizational software such as Microsoft Outlook  or Lotus Organizer or calendar systems can accommodate these disabilities.

A talking calculator is an appropriate tool for people with Dyscalculia (impaired calculation skills). The synthesized voice output of a talking calculator provides feedback to the user that helps them identify any input errors. Additionally, hearing the calculated answer can provide a check against the transposition of numbers commonly reversed in reading by people with Dyslexia or Dyscalculia.

Not all assistive technology for people with LDs is computer-based. The use of common office supplies such as Post-It Notes™ and highlighter pens provide elegantly simple means of sorting and prioritizing thoughts, ideas, and concepts. Often, tools of one's own making provide the most effective and comfortable accommodations for learning difficulties.  Setting up index cards, laminating them and attaching magnetic backs allow for use on household appliance to keep track of multiple step tasks.

When deciding to purchase software, hardware, or even low-tech materials to help someone with a disability it's important to get input from the person who will be using the materials.  All learning problems are individual to a large degree and what works for one person may not work for another.   It's important for the disabled person to get hands on experience with anything they want to try.

Diabetes

This is the third in an ongoing series on medical conditions treated by health psychologists.

Diabetes runs in my family.  My mother died of cardiac complications of the disease.  My brother is insulin dependent.  My aunt has type II diabetes but also uses insulin to control her blood sugar.  I have impaired glucose tolerance but do not have diabetes. 

There are a couple of types of diabetes.  Type 1 diabetes is insulin dependent diabetes.  It's likely a genetic condition in which either the pancreas stops manufacturing insulin or doesn't make enough insulin.  Type 1 diabetes happens most often in children and young adults but can appear at any age. Symptoms may include:

• Being very thirsty
• Urinating often
• Feeling very hungry or tired
• Losing weight without trying
• Having sores that heal slowly
• Having dry, itchy skin
• Losing the feeling in your feet or having tingling in your feet
• Having blurry eyesight 

Type 1 diabetes is treated with insulin.  It requires monitoring levels of blood sugar and managing their levels with diet, exercise, and insulin.

Type 2 diabetes is acquired over time as the body fails to manage blood sugar adequately. 
Type 2 diabetes, formerly called adult-onset diabetes or noninsulin-dependent diabetes, is the most common form of diabetes. People can develop type 2 diabetes at any age—even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which fat, muscle, and liver cells do not use insulin properly. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, it loses the ability to secrete enough insulin in response to meals. Being overweight and inactive increases the chances of developing type 2 diabetes. Treatment includes using diabetes medicines, making wise food choices, being physically active, taking aspirin daily—for some—and controlling blood pressure and cholesterol.  The physical symptoms for type 1 and type 2 diabetes are the same.  There are medical tests that can differentiate the two types.

Health psychologists work with physicians, dietitians, physical therapists, and others to help people manage the complexities of the changes in diet, medication use, and exercise.

After my brother had a heart attack, he got overwhelmed with his health and I got an email from my sister-in-law talking about her frustration with him.  I drove up to Sonoma, CA where he lives, and he and I went food shopping.  I helped him with making food choices to understand the impact of the foods he eats on his heart, blood sugar and cholesterol.  We brought the food back to his house and I helped him to prepare a meal.  We talked about how his blood sugar works.  We had a discussion about glycemic index and how carbohydrates get broken down in a rapid or slow manner.  We talked about his usual diet and what kinds of foods he likes to eat.  We spent a long time talking about taste.  He was depressed because he felt like he had to have a diet that was restrictive.  I showed him how his current diet was extremely restrictive (he was eating the same foods on a daily basis) and the diet I was talking about would be to introduce him to new foods that were both sweet tasting and healthy.  I helped him fix a meal of carbohydrates that will be slowly broken down and lean protein.  He likes vegetables.  He gardens.  He has access to some of the freshest produce right from his backyard.  He has access to the farmer's markets in Sonoma, an area of California known for farms.  We talked about how he could walk to the store from his house.  It's less than a mile.  He had become afraid to exercise following his heart attack.  We talked about his symptoms during the heart attack.  We talked about the fact that he'd had symptoms for hours prior to realizing he was having a heart attack.  It wasn't sudden and it wasn't triggered by exercise.  We walked to the store and walked back.  I helped him manage his anxiety so he could return to a simple exercise program of walking which would help his diabetes and reduce his risk of another heart attack or a stroke.  Within a month his requirements for insulin reduced and he was placed on a "rainbow scale" of insulin rather than a fixed insulin dose.  He could regulate his insulin level more finely based on his blood sugar at testing.  He bought a juicer on his own and started walking to work a distance of 3 miles.  He lost about 35 pounds over the course of a year.  Although I only worked with him for a couple of days at that visit, the gains he made lasted for years afterwards.

Health psychologists routinely work to help people understand how to manage the medical complexities and psychological difficulties of chronic health conditions.  If you think you might have diabetes check with your doctor for an evaluation.

Headaches

This is part two in a series on medical conditions treated by health psychologists.

There are several types of different headaches.  Tension-type, Migraine, and Cluster are the most common.

The International Headache Society describes tension-type headache as infrequent episodes of headache that last minutes to days. The pain is usually occurs on both sides of the head and has a pressing or tightening quality. Tension-type headache  usually does not worsen with physical activity. Nausea is usually not a symptom.   Sensitivity to light (photophobia) or sensitivity to sound (phonophobia) may be present.  Tension-type headaches are the most common type of headache and 30% to 78% of people may experience them in their lifetime.  Some people have frequent tension-type headaches causing them to become disabled.  Most people with this type of headache have the headache infrequently.  Infrequent tension-type headaches occur once a month or so and are mild to moderate in severity.


Migraine headaches are less common than tension-type headaches.  They effect 6% of men and 18% of women.  Most people who have migraines are women.  Most women start having migraines after they start menstruating.  Up to 10% of children can have migraines as well.  Migraine is described as a recurrent headache lasting 4-72 hours and often has unilateral pulsating or throbbing pain, moderate to severe intensity pain, nausea or photophobia. The pain of migraine can be made worse by routine physical activity.  Migraines are often preceded by neurological symptoms called an "aura" with changes in speech, movement, vision, sense of taste or smell.  The auras can change from one migraine attack to another.  The headaches last from 4 to 72 hours without treatment.


Cluster headaches occur in about 1% of the population and are distinct from migraine and tension-type headaches on several levels. Most of the cluster headache sufferers are men with onset between ages of 20-40.  Cluster headaches are characterized by severe, unilateral pain that is around the eye or along the side of the head.  The headaches last from 15 to 180 minutes and occur once every other day to up to 8 times daily.  Attacks are associated with eyes watering on the same side of the head that the pain is located. Patients may also experience nasal congestion, runny nose, forehead and facial sweating, dropping eyelids or eyelid swelling.  Pain from a cluster headache is usually severe and people may be restless or agitated due to the pain.  This type of headache may be hereditary.  Headaches may be provoked or triggered by alcohol, histimines, nitroglycerine, or other medications.  The headaches occur in clusters often daily or several times a day and then cease for weeks, months or years, between attacks.

Other causes of headaches are less common.

Medication overuse headache or rebound headache is often a daily chronic headache that occurs with medications used to treat headaches in about 1.4% of the population.  Ergot, triptan, opioid or butalbital analgesics and non-steroidal antiinflammatory agents (NSAIDS).


New daily persisting headache is a chronic daily headache that continues without remission for more than 3 months.  These headaches are usually evaluated by CT, MRI, or MRA scans.


Hemicrania Continua is a daily continuous headache that remits only with treatment by indomethicin.  There are eye symptoms with tearing and swelling and the nose may run or be congested.  It impacts one side of the face and head only.


Post-concussive headache follows head or head and neck injuries in conditions like whiplash and concussion.  These headaches start off severe and may involve sensitivity to light and sound, dizziness, loss of balance, nausea and vomiting.  Over time they remit.  The headaches can recur up to about 5 years post injury.  Headaches may last longer when there is a history of multiple concussions.


Dental problems like temporomandibular joint disease (TMJ) can cause headaches.  The headache pain in precipitated by jaw movements.  When the jaw disorder is treated the headaches remit within 3 months and does not recur.


Sexual headaches or orgasmic headaches occur with sexual activity or orgasm.  These headaches may be the result of vascular changes or hormonal changes or they may be benign headaches related to movement and stretching of muscles.  The headache pain can be severe and there is sensitivity to light and movement.  Because these types of headaches can be associated with problems with blood vessels or high blood pressure it's important to have them evaluated by a physician.


Thunder clap headaches are severe sudden excruciating painful headaches.  These start suddenly and represent a torn blood vessel.  These headaches represent medical emergencies and need to be evaluated in an emergency room.  People will describe these as feeling like they were kicked in the head.  They may have a stiff neck.  The headache peaks within 60 seconds it may improve over the next hour or may worsen with signs of loss of consciousness.  There may be nausea and vomiting.


Ice cream headaches also known as cold induced headaches are triggered by anything cold like ice cream in the back of the mouth or roof of the mouth.  The headache is intense and goes away as the cold sensation stops.


Hot dog headache is also known as nitrate headache.  It's cause by nitrates in foods like cured meats such as hot dogs.  Again as soon as the food is digested the headache stops.


Migraine equivalents are episodic pain conditions without headache pain.  This type of headache can feature neurological symptoms or non-neurological symptoms, such as abdominal pain, vertigo, even emotional outbursts, depression or panic. The word "equivalent" suggests that sufferers instead of a headache, are having some other equivalent troubling symptom. This condition is much more common in children and can resemble stroke-like symptoms which are a numbness or tingling on the arm - absent of any headache. Also younger children often complain of an upset stomach without any headache. This can often also be a migraine equivalent. Once the child has  thrown up, there is often an easing up and relief of the headache symptoms. This headache type is experienced in the stomach where there are a lot of receptor sites for the neurotransmitter serotonin.

 
Health and medical psychologists can help patients understand their type of headache.  Help them classify symptoms for diagnosis.  Help them manage medications.  Help them understand the distinctions between classes of medications.  Set up food lists to avoid triggers.  And help them with pain management techniques.

If you have a new type of headache or a severe headache you should seek medical advice.

Asthma

This is the start of a series on chronic medical conditions. 

Health psychologists started working with several chronic illnesses, stress, pain, weight loss, headaches, physical conditioning back in the 1970's.  In the past 40 years the knowledge of those illnesses and conditions have grown exponentially.

Asthma is a chronic illness that impacts breathing.  About 1.8 million people have been diagnosed with asthma.  Asthma causes breathing difficulty by constricting the airways in the lungs and by causing swelling or inflammation in the airways.  This causes difficulty with being able to exhale without wheezing, gasping, feeling short of breath or coughing.

Medical treatment involves relieving the constriction and decreasing the inflammation of the airways and getting the symptoms manageable.  There are short acting medication, anti-inflammatory medications, vasodilators, and some other types of medications used to both relieve symptoms rapidly and to prevent symptoms from returning.

Psychological treatment involves managing the complexities of the illness, the side effects of medication, identifying triggers, and managing depression, anxiety and stress which accompanies the illness.

Let me give an example of a woman I'll call Sara.  She's had breathing problems for the past 25 years.  She is on two types of medication.  She has a rescue inhaler she uses four times a day.  She has a preventive inhaler she uses as directed twice a day.  She smokes cigarettes 2 to 3 times a week.  She has a nebulizer at home for breathing treatments but it's been broken for years.  She gets her primary treatment in emergency rooms.  She has no idea about what causes her asthma.  She's afraid to go anywhere or do anything.  The asthma attacks both frighten and embarrass her.  She thinks people will believe she is sick and contagious, so she avoids people.

She and I chatted about her rescue inhaler.  She knows she's supposed to inhale deeply twice each time she uses it.  But she's frightened and inhales only shallowly and uses the second inhalation very little.  So she ends up using a rescue inhaler far too frequently, getting signs of toxicity, and feeling poorly when she uses it.  She has never heard of a peak flow meter.  When I described the plastic tube that measures breathing on exhalation, she had seen that in her doctor's office and in the emergency room but didn't have one.  Her use of her rescue inhaler or visits to the emergency room were based on her feeling short of breath not on any information about how her breathing was.  So she started a list for her doctor.  Item one:  Can I get a Peak flow meter?

She has no idea about what triggers her asthma attacks.  They seem to come at random.  So she has homework:  Keep a list of where you are when you feel short of breath, time of day, and what you are doing at the time.  Single sheet of paper, three columns, one week work of data.

Her nebulizer is broken.  Item two for her doctor:  Can I get a new nebulizer?  That's likely to stop the need for frequent trips to emergency rooms for routine health care.  She's never been hospitalized overnight for asthma.  She's never been intubated.  She's getting routine home health care or outpatient care that's needed on an urgent basis from an emergency room that provides the most expensive type of care available.  She's exposed to bacterial and viral illnesses unnecessarily.  Her condition doesn't need to be treated in an emergency room. She requires urgent care, not emergency care.

Her physician doesn't take time with her.  She's chronically ill.  She's not understanding her health care.  She returns frequently not getting better.  Her doctor spends less and less time with her.  She's changed doctors often.  They are all the same to her.  Both she and her doctor are frustrated.  Health psychologists spend between 40 and 60 minutes at a visit on average.  A primary care physician spends 15 to 30 minutes on average.  On follow up, primary care doctors spend less time.

She smokes.  Her asthma makes her anxious.  She smokes because paradoxically, smoking decreases anxiety.  Unfortunately, smoking is a common trigger for asthma attacks.  Even if she's only smoking 3 to 5 cigarettes a day she needs to stop.  She needs a stop smoking plan, a stress reduction plan, and a better way to manage anxiety.

She's overweight.  She doesn't exercise because she's afraid of getting an asthma attack.  Asthma can be triggered by exercise.  It can be triggered by foods.  It can be triggered by the environment.  She doesn't know what's causing her asthma to be triggered.  That list will help her determine her triggers.  She can exercise in her home, or outside carefully, monitoring her chest constriction.  She may need to premedicate with her inhaler prior to exercise.  She may need to change her diet.  Someone like me can help with both of those.

Because I provide boutique services I can go to people's homes.  I help them set up the lists.  I can assist with setting up support services.  I can go with them to their medical doctor's appointments.  I can go with them if they need to go to an emergency room.  Treatment is expensive for that amount of personalization.  It's not covered by insurance.  It's time consuming.  But she stops needing frequent doctor visits.  She gets better control over her asthma.  She loses weight and stops smoking.  She stops paying for cigarettes.  She's not seeing her doctors as much, so co-pays for her physician are reduced.  Her medication use is lessened and those expenses are reduced.   Boutique health psychology is offered in some large cities.  I live in Los Angeles.  It's not uncommon in this area, but it's still not that common.  For most people, getting control over a chronic illness is well worth the expense and the time.

Medical Evaluations

People don't plan well for medical evaluations.  They don't ask questions.  They don't understand what's required.  They therefore come away from the evaluation less than satisfied with what was communicated and often less understanding of what they went through and why.

I perform several types of evaluations in conjunction with a couple of multispecialty groups.  I've also gone through a number of medical evaluations personally. 

It's important to understand what you are wanting to get out of the evaluation.  Are you expecting a diagnosis, a treatment plan, a test result, a letter documenting a specific finding, a condition, a cure, reassurance, money in a legal settlement, a rating for a benefit?  Why are you going through the evaluation procedure?  Did you request the evaluation or did someone else require it?  Those things matter.  Regardless of whether you were required to go, it's still important to know what you want from the evaluation. 

I'm called on to do anywhere between 1 and 9 evaluations in a day.  On the days where I do a single evaluation there is an extensive history process.  The person completes lots of paperwork.  They perform tests that I administer, that are done on computer and complete questionnaires that are taken home and brought back later.  They are told to bring food, wear comfortable clothing, bring something to drink.  Depending on the nature of the evaluation, I may be attempting to exhaust them so I can document performance with fatigue.  I may repeat tests in different conditions.  I may have fluorescent lights on, distracting sounds, frequent interruptions, to see how people cope with visual and auditory distractions in the environment.  In other cases I may have a virtually soundless office with incandescent lighting, done in a very comfortable setting. I may see the same person in both settings.

On days where I perform up to 9 evaluations in a day the questions I am answering are simple.  Usually what is this test result?  The test is specified.  What is this person's full scale IQ score?  Easy.  Give me anywhere between 30 and 90 minutes and I can answer that within a range.  Some agency will ask that.  People might ask that but they really want to know more.  What am I good at?  How do I compare with other people?  How come I'm good in this area but perform poorly in this area?  What can I do to be better at this?  Why can't I pass tests even if I'm smart and know the material?  Those are more complicated questions requiring more time in an evaluation.

If I want to know if someone suffered a traumatic brain injury I can ask them about incidents of concussion, loss of consciousness, or findings on a CT or MRI scan of the brain.  If I want to know what happened to their thinking as a result of a traumatic brain injury I have to evaluate them using a battery of tests, measurements and questionnaires as part of a neuropsychological evaluation that will take several hours.  The more complicated the question the more complicated the evaluation.

It's important to know what question is going to be answered by a medical evaluation or a psychological evaluation to understand and plan for the evaluation adequately.

Clouds and computers

I've been buying books like crazy lately.  These aren't like little paperbacks you consume in an hour.  These are professional text books.  Some are updates to books I already have older editions of like Lezak's Neuropsychological Assessment and Strauss' A Compendium of Neuropsychological Tests.  Others are more fun like The Mind and the Brain.

I've also been updating forms.  That's where computers and clouds come in.  I have a Mac.  I have the basic idea of cloud computing from my iTouch and my Kindle.  Somewhere out in the universe are servers that hold information.  I can link up to those servers and get things from them like applications, files, books and music.  I can send things to them and pick them up somewhere else.

So my main office is in Los Angeles.  My home in California is in Santa Clarita.  I'm currently at my home in Las Vegas.  The office manager is in Reno.  A former student of mine is in West Los Angeles.  So I want to share a file with all of them.  It's a basic questionnaire I created.  It's created on my laptop.  I upload it to a file sharing program.  I then send an email to everyone and tell them how they can link into the file.  They can then all pick up an original file.  If I go to the Los Angeles office without my laptop, I can log into the program and pull up the file.  If I wanted to I could put it on an iPad or my Kindle since it's a pdf file.  Ultimately, it will be on some portable computing device given to someone to complete and save rather than fill out with paper and pen and filed or scanned.

There are some medical groups that are already doing this with history and intake forms and routine office procedures.  A tablet PC links to a desktop which links to a server.  It's all wireless.  The information is all stored in "clouds."  If anything needs to be printed at all it's printed only when it's needed.  No more bulky storage.  Since it's all digital, it's easier to move text and use in reports.

Cloud computing has been used by the government for years.  http://cloudcomputing.sys-con.com/  Now business and industry as well as individuals are starting to use cloud computing.  With Apple computers and the iPhone, cloud computing went to the home computer several years ago and mushroomed out within the past couple of years.  You can sync your phone, computer, laptop, and netbook, depending on technology. 

Head Injury

I met a person yesterday that reported they hurt their back and neck.  They had no idea why they were being referred to a neuropsychologist.  So I started going through a symptom checklist for brain injury.

Do you have headaches?
Do you have memory problems?
Do you have problems with thinking and processing information?
Do you have difficulty with balance and coordination?
Do you have problems with controling your modds?
Do you feel anxious or depressed?
Have others said that you seem changed since your accident?
Do you get lost?
Do you forget words?
Has your vision or hearing changed?
Do you have difficulty feeling "stuck" and having problems starting something, stopping something or changing from one thing to something else when what you are doing isn't working?
Do you have difficulty doing something you used to be able to do?

After he answered yes to most of those questions, we discussed his brain injury.  He had actually lost consciousness briefly when he hurt his neck.  Further he had a prior neck and brain injury which made his most recent injury more complex than it would have been if it was his first injury.  Although he's been seen, evaluated and treated by three different medical specialists he had no idea he'd had a likely brain injury at the time of his accident.

Brain injuries generally improve over time.  They continue to improve for at least 10 to 15 years and maybe longer.  People will often just start recognizing their symptoms over the first 18 to 24 months so it may appear to them that they are getting worse.  If there are orthopedic problems then those difficulties often get the first attention leaving the brain difficulties to take a back seat.  Complaints of brain related problems get referred to primary care or orthopedic doctors who may not be familiar with symptoms of post-concussive disorder and do not perform an adequate screening for loss of consciousness.

The individual I spoke with said he had flown about 10 feet at the time he was hit by a car.  So I asked him about his trip through the air and his landing.  He didn't recall them.  He recalled seeing the car approach him.  He recalled getting up from the ground and feeling disoriented.  It wasn't until I asked him about what happened that he came to the realization he had had a brief loss of consciousness.  Because he came to prior to emergency personnel being on scene he had not had an adequate evaluation for head injury. 

We discussed how he could communicate better with his health care providers and make use of support groups, technology, and rehabilitation systems as well as help with support for his family to better understand what had happened to him. 

The screening evaluation I provided him was just the first step in an overall evaluation that will point him in the direction of greater understanding of what happened to him and how he can best profit from rehabilitation efforts.

Health and Medical Psychology

Health and medical psychology is a field which works at the intersection between medicine and psychology.  It answers questions and provides resources to patients involved in health care and wellness, and to physicians regarding providing health care in an effective manner.  It provides information to patients on how to reduce stress, lose weight, increase exercise, stop smoking, decrease health risks and comply with medications, treatment plans, and follow-up.  It helps physicians with diagnostic formulations by documenting an adequate patient history, patient selection for at-risk surgical procedures, reduction of malpractice, and provides a contact point in complex and problematic cases.

When you take your child for a vaccination health psychologists have determined that distraction is one of the better ways to get your child through the shot.  Telling the child that the shot won't hurt is not effective and undermines confidence in information being provided by the health care provider.

Having patients keep a diary of symptoms to bring into the doctor helps the patient focus on the target symptom and helps the physician look for patterns of symptoms.  It is a frequent treatment plan for chronic pain conditions such as headaches, fluctuations in blood pressure and blood sugar, peak flow values in asthma, and symptoms which are intermittent in nature to collect data to help with medical management.

For people on complex medication "cocktails" having a system of alarms, pill containers for daily medications, and an understanding of the medication, it's use, when it's to be taken and how it's to be taken is essential.  Health psychologists provide the systems and work with the person to put the systems in place that will help with compliance.  They can explain how pharmaceutical medications, herbs, supplements and foods all work together and help the person understand any interactions between them.  They can explain side effects and allergic reactions, and help patients understand risk-benefit issues of medications.

For people with medical symptoms that are unexplained after a few visits to the physician, the health psychologist can provide ways to collect data for symptom reporting to the physician, medical research into a diagnostic decision tree, and psychological support until a diagnosis is reached. They can help the person find support systems including online support groups, local groups and caregiver support groups.  They can help them understand the lab tests, and the medical research involved in their illness or symptoms.

Health and medical psychologists and rehabilitation psychologists work with stroke, heart attack, and head injured individuals to determine best practices in recovery, improving functioning, and explaining what has occurred in non-technical ways.  They help with things like phantom limb pain.  They help clarify what is psychological from what is physical.

Cognitive Science

Cognitive Science is the field of psychology that combines a number of fields (psychology, anatomy, medicine, neurology, and technology) to determine how people think.  Psychological assessment has used computers for years.  More and more types of psychological tests are being created for computer use.  As professionals become concerned about the way individual people function following discovery of disease, brain injuries or the determination of problems with learning, it becomes important to determine how a specific person thinks and interacts in their environment.  That allows for the best applications of structured rehabilitation plans, assessment protocols, and strategic interventions within the environment to help the individual gain the most optimal functional abilities and to maintain those gains in every day life. 

I've had a couple of head injuries.  Both were considered mild.  One was in 1985 the other was in 1997.  I was a psychologist at the time of both injuries.  I became a neuropsychologist after the first injury.  Following the second injury, I realized that some of the research in the field of neuropsychology was lacking some information.  In the past 12 years the field of neuropsychology has expanded exponentially.  As neuropsychologists we now recognize that there are hundreds of thousands of people impacted by head injury on an annual basis.  The impact of multiple concussive injuries is starting to be understood and the data base is moving from male professional athletes to the general population as a whole.  Data on the elderly and head injury including people considered old-old (over age 80) is substantially increasing.  The impact of medical conditions and head injury is starting to be understood.  As medical conditions, medications, and brain function becomes better understood we gain greater insight into how medications interact with neural functioning, and the field of psycho-neuro-immunology (the impact of thinking) on immunology is expanding.  The body is an integrated machine.  The heart, brain, and kidneys all function as a system to circulate blood and nutrients to keep the body able to function and the brain able to think.  Changes in blood flow and kidney function change how the brain works.  That system is being increasingly understood.  Our returning veterans having sustained multiple concussive injuries from rocket-propelled grenade blasts and improvised explosive devices will provide even greater information on the impact of multiple mild head injuries.  The numbers of people impacted by head injury will prompt greater advances in rehabilitation, protections for further injury and rehabilitation efforts.

Computers have the ability to speak to people, read for them, and provide information on visual tracking and perception.  As we integrate computers more and more into our daily lives we can harness their ability to make sense of the information we process to assist with diagnosis, treatment efficacy, and functional ways to interact with people.  

http://www.echalk.co.uk/amusements/OpticalIllusions/illusions.aspx  We have a better understanding of how the brain perceives things.  As our use of technology improves we will be able to have more psychological services available remotely, more automated and self-serve delivery systems, and greater ability to provide services both just-in-time and on-demand.

It's an exciting time in the field.

My Take on Hallucinations

There are lots of various types of hallucinations. A hallucination is a sensory experience without the usual sensory cause. Hallucinations can be visual (seeing things not present), auditory (hearing things not present), tactile/kinesthetic (feeling things not present), olfactory (smelling things not present) and gustatory (tasting things not present).

The most common types of hallucinations have to do with sleep disturbance and are auditory or visual in nature and occur at the onset or ending of sleep. These experiences are disturbances in dream states. While the person believes they are awake when this occurs, their body is actually asleep and dreaming.
Some types of hallucinations are related to neurological disorders. These include tactile hallucinations and a specific type of auditory hallucination of music.

Hallucinations related to mental illness often relate to associated sleep disturbance. Depression and manic states include symptoms of significant sleep disturbance. Problems falling asleep, staying asleep, and waking several hours too early can contribute to hallucinatory phenomena. Medications designed to help improve the loss of energy associated with depression incorrectly taken at bedtime will worsen the sleep disturbance and worsen the hallucinations. Maintaining good sleep hygiene will go a long way to improving hallucinations that are the result of sleep disturbance.

Many people can experience hallucinations as a side effect of medication. Antibiotics, pain killers, and medications that are sedating can cause hallucinations. Substance abuse causes hallucinations in several ways. The actual substance can produce hallucinations. The substance can disturb sleep. And when the substance wears off the withdrawal can cause hallucinations. Alcohol can cause visual, auditory and tactile hallucinations. Seeing pink elephants are likely occurring at the onset of sleep or waking. Hearing your name called or hearing whispers. Getting confused and having the sensation of bugs on skin or snakes wrapping around your arms or legs is a late stage of nerve problems from alcohol abuse and alcohol withdrawal.

There’s a difference between hallucinations and illusions. Illusions are things you experience that seem outside of you but you are producing. They are not a sensory experience. These are dissociated experiences. Traumatic events produce problems encoding cohesive memory. People feel unreal at the time of the event or outside themselves. When similar things trigger the memory of the event the person has an illusion. They may replay the event again in it’s entirety. This is a flashback. They may have only parts of the visual picture as a flash. This is a visual illusion. They may have only the auditory soundtrack. This is an auditory illusion. They may hear a commentary on the event. They may hear conversations of others present at the event. These are fragments of the event that occurred that haven’t been adequately processed. By identifying the triggers for the illusions, the information from the trauma can be more adequately processed.

Some traumatic events cause head injury. Often people hit the back or front of their head. The olfactory bulb which controls smell and 85% of the sense of taste sits right over the bridge of the nose. If this area is damaged by an impact either being hit in the face or head from the front, or hit in the head in the back and having the brain bounce to the front can damage this area. Smell and taste hallucinations can occur as a result of impact. Nerves heal over a long period of time. The sense of smell and taste may return to normal years after the accident or injury.

Infections especially dental or sinus infections can cause inflammation which disturbs the sense of taste and smell causing hallucinations or illusions.

Hallucinations associated with mental illness have unusual qualities to them. There are other symptoms that go along with the hallucinations that correlate with the illness. Delusional material goes along with schizophrenia. Sad mood goes along with depressive psychosis. Grandiosity goes along with manic psychosis.

Extrasensory experiences are not hallucinations although they may include delusional material. Seeing ghosts or dead people are often part of a cultural experience. These events may be experienced by a number of people who report the same phenomena. A trained psychologist or psychiatrist should be able to evaluate the experience and differentiate one phenomena from another.

For most people, hallucinations are an annoying or scary event that quickly passes. Large percentages of people have a single experience of a hallucination. It’s common. Hallucinations that interfere with daily life and interpersonal relationships should be professionally evaluated.