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.