Listening to People with Cancer

 

Over the last couple of years, I’ve had the privilege of working with patients diagnosed with cancer who were referred to our clinic by local cancer treatment centers. I’ve seen people at all stages of the disease, very early to terminal. They are usually referred to me because they’re very depressed or anxious. Sometimes they are willing participants in treatment, eager to tell their story. Sometimes they are angry and resentful, feeling that their oncologist (cancer specialist) must believe that they are crazy if he or she referred them to a psychiatrist. Hopefully, we can get past that.

At first, I wasn’t sure how I could be helpful to them. After all, most people would be depressed, anxious, angry, and fearful when diagnosed with cancer. Those emotions are normal, though patients sometimes feel that they are being referred because of these strong feelings.  Doctors don’t always handle their patient’s intense feelings well, so sometimes that is true. Often though, doctors just feel that their cancer patients could use some help in dealing with the emotional side of cancer.  Usually, patients just need to ventilate for the first few sessions. They need to tell their story, how they were going along in life just fine and then this- a huge boulder hurtling down the mountainside towards them. Usually they feel blindsided, violated, enraged at the unfairness of it.

I realized that they need for me to be the person who can listen to their fears and not back away. Usually family members are cheerleaders, encouraging them to forge ahead with each new treatment, convinced that they are going to beat this.  That’s what family should do. Cheerleaders are important. But often patients feel that they can’t fully let their guard down and talk about how scared they are, or how they maybe don’t want that next treatment, or how they don’t feel like going on that big family vacation that the kids planned, or put into words the thought that families can’t bear – that maybe they won’t make it. They need a place where they can be gut level honest.

Sometimes I put the brakes on those worst-case scenario thoughts or remind them that the prognosis for cancer treatment is better than ever.  Sometimes we work together to find the words to ask for more information from their oncologist. Patients still feel intimidated by their very busy doctors, and they don’t want to “bother” them with questions, or they forget the questions when they see the doctor.  Occasionally they need to find the words to say “I don’t want to do this anymore.”   I help them find their voice. I remind them that this treatment thing is a two-way street, and they are an equal partner. They may not have the knowledge that the oncologist has, but it is their body.

It’s important to have a place where you don’t have to put on your game face.

Many of my patients won’t die of cancer.  They will be survivors. But I have been impressed with the ways that people process a cancer diagnosis.  One lady said to me recently that she stopped worrying so much about the future. She put more emphasis on today.  She had a blood cancer that was likely to go in and out of remission. She said that she accepted that she probably would not live as long as many people, but she would be more present, more appreciative for each day.   This quiet acceptance seems to benefit patients, but it takes some time to get there. It doesn’t mean that they’ve stopped fighting; it means that they are no longer angry with God and the Universe. They can battle cancer but still savor today.

Our medical profession has advanced unbelievably as far as technology. But I am afraid that we have lost some of our emotional connection with patients. We need to remember that quality of life is just as important as quantity of life.

I would highly recommend a book by Dr. Atul Gwande called Being Mortal: Medicine and What Matters in the End.  Dr. Gwande addresses the issue of quality of life and how that concept may run counter to what the doctor recommends. He discusses some creative and humane ways to bring more quality of life to the end of life.

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YOUR SMART PHONE AND RECOVERY

Technology has come to the world of mental health and addiction. Cell phones figure prominently in our lives now. They can also figure, positively or negatively, in mental health and addiction recovery.

The cell phone can be a gateway to positive help or an avenue to people who perpetuate illness. Patients starting treatment for recovery need to eliminate phone numbers of dealers and “friends” who use. They know that quick access to these people during a tough time can be disastrous. People experiencing depression and suicidal feelings may not use their phone often enough to call for help and support. They tend to isolate. Communicating with dysfunctional family members can exacerbate addiction and depression, anxiety, and suicidal feelings.

Why not use the phone in a positive way that supports recovery? There are many cell phone apps available now that can be helpful to people experiencing depression, anxiety, mood swings, difficulty with sleep, and/or addiction. Some are better than others. There is little objective research at this point to determine how effective these apps are from a statistical standpoint. However, as with all treatment, you get out of it what you put in. These apps are not replacements for therapy with a professional, but they can aid recovery. You have to find what works for you.

I am going to highlight some apps that have been reviewed online. There are many others, but these are recommended by several mental health sites such as Psych Central and Healthline. Most are free.

One of the most interesting is called Reach Out. It was originally developed for use by military personnel but is available to anyone.  This app is geared toward preventing suicide. It can be used by people who have suicidal thoughts and by family members or friends who are concerned about someone who may be suicidal.   For people contemplating suicide, it has several videos that suggest alternatives, give tips on stopping suicidal thoughts and combating the negative, all or nothing thinking that suicidal people have. It suggests activities that can distract from suicidal thinking. The app lists resources for more information about preventing suicide.  It has a Help Center that lists a suicide hotline number and allows the user to list phone numbers of contacts who can be helpful. Of course, people with suicidal thoughts have to be willing to use it. It’s probably most helpful for people who have recurrent thoughts rather than an immediate impulse, and who are willing to consider alternatives.

For those concerned about someone who may be suicidal, the app lists signs of suicidal thinking, makes suggestions about how to approach the person and what to ask. It also lists resources for more information about suicide.

There are several apps that are useful for persons suffering from severe anxiety and panic attacks. One of them is Breathe2Relax. It illustrates the proper technique for breathing during a panic attack. It gives step by step suggestions on how to deal with a panic attack. Another app for anxiety is SAM, Self-help for Anxiety Management. It also provides suggestions which can be used during a panic attack. These apps work best if you take some time to understand them. There are features that are simple and can be used immediately, but with some work on personalizing the settings, they can be more effective on an individual basis.

Depression CBT (CBT stands for cognitive behavior therapy) is only available for Android at this time. It was recommended by Healthline (healthline.com) as one of the 10 best mental health apps of the year. It offers an assessment tool that allows you to follow the severity of depression and offers audio programs that help with anxiety and depression. It directs the user to resources that help pinpoint negative thought patterns that underlie depression. Pacifica, which is available for IPhone, is similar to Depression CBT.

MoodKit was rated highly on several sites. It has a mood tracking feature and suggestions to improve mood as well as a thought checker to monitor mood.  However, it isn’t free.  It costs $4.99 to download.

None of these apps are appropriate for use alone when you are suffering from severe depression and suicidal thoughts.  You need to be in a formal, face-to face treatment, but the reality is that your therapist can’t be with you 24 hours per day. These apps can be helpful between sessions.

One of the better apps for addiction is Addicaid. It’s free. It has a check-in where you can disclose whether or not you used that day. Either way, you can post and get support from others. It has 12 educational sessions on various recovery topics. You can track your progress, get information on location of meetings and communicate with friends. There is a resource section with hotline numbers.

As I said before, you have to spend some time exploring these apps and getting to know how they work in order to really be able to use them quickly and efficiently.  There are others available. If you google mental health apps or addiction apps, you will come up with more.

So if you have a smart phone, utilize it as an aide in your recovery.

It’s National Recovery Month

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September is National Recovery Month.   It’s sponsored annually by the government agency SAMHSA (Substance Abuse Mental Health Services Administration).  National Recovery Month celebrates recovery from mental illness and addiction.

How do we define Recovery? SAMHSA has identified four dimensions of Recovery: 1. Health, 2. Home, 3. Purpose, 4. Community.  The ability to manage one’s disease symptoms by making healthy choices with regard to diet, taking medications as prescribed, and abstaining from substances and activities that do not promote well- being fall within the health dimension.

The home dimension emphasizes the importance of a safe and healthy place to live for recovery to take place. SAMSHA defines purpose as “Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.”1  

Last of all, the community dimension speaks to the importance of having a support system consisting of family and friends that provide love and hope.

Notice that the SAMHSA definition of recovery doesn’t say anything about being “normal.” We can’t define normal. People who recover from a serious mental illness or addiction are usually changed in significant ways.  Recovery doesn’t require the person to be exactly as they were. You can’t go through the experience of dealing with a mental illness or addiction without becoming an emotionally deeper, stronger person. It also doesn’t require that the person be totally free of the illness.   People with mental illness and/or addiction (you can have both) are always vulnerable. I particularly like the SAMHSA definition of the health dimension – the ability to manage symptoms by making good choices, not necessarily to be totally without symptoms.

Many people, with and without serious illness, struggle with finding meaning and purpose in life. I like the SAMHSA examples of purpose – having meaningful daily activities such as a job, caretaking, volunteering, being creative.  Living life as best you can meets the definition of purpose in my opinion.

People with mental illness and/or addiction can recover.  If you know someone working to recover, the most important thing you can give them is hope.

 

Check out the resources on recoverymonth.gov

 

http://www.facebook.com/RecoveryMonth

http://www.youtube.com/RecoveryMonth

http://www.twitter.com/RecoveryMont

 

1 SAMHSA’s Working Definition of Recovery, download PDF at store.samhsa.gov.

 

 

So You Don’t Like Obamacare?

So you don’t like Obamacare?  Too expensive, you say. We just can’t afford it. Too much like socialized medicine.  Your co-pays are higher. Why should your insurance be more expensive just to help pay for others to have medical care?  After all, in our country, we expect people to take care of themselves. If they can’t, it’s their fault. Right?

Let’s think about the implications of that philosophy. If an adult fails to provide for his or her family adequately and is unable to afford health insurance, who pays the price? The children pay the immediate price, and we, society, pay the long-term price.  What happens when children don’t get adequate medical care? It impairs their ability to perform in school. Where does that lead? To dropping out of school, having fewer opportunities as far as jobs, decreased ability to support their own families, etc. You can see the consequences of that.  The extreme outcome is alienation from society and perhaps criminal activity. That definitely affects society as a whole.

What happens if parents of children don’t’ get adequate medical care? They can’t focus on the job of being good parents. That affects society as a whole.

We pride ourselves on our technical advances in medicine. We tend to think that leads to good medical care. But consider this.  Christopher Ingraham wrote an excellent article for the workblog of the online Washington Post in September of 2014 titled “Our infant mortality rate is a national embarrassment.”  The CDC (Center for Disease Control) had issued a recent report indicating that the infant mortality rate for the US was 6.1. This means that for every 1000 live births, there are 6.1 deaths.  Compare that with the infant mortality rates of Finland and Japan at 2.3, of Korea (yes Korea) and Spain at 3.2 and Switzerland, Netherlands, Ireland, and Greece at 3.8. We are # 27 in the rankings, definitely not #1. So that suggests that all of our technology is not benefitting certain segments of society.

Ingraham quotes from a draft paper by Chen, Oster, and Williams, which was later published in 2016 in the American Economics Association Journal of Economic Policy. There may be some differences in how pre-terms births are classified in other countries, for example whether a pre-term birth before 20 weeks is considered a miscarriage rather than a stillbirth. That may account for some of what seems like a surprisingly high infant mortality rate, but it doesn’t account for the entire picture.

The most interesting point of the Chen paper is that the infant mortality rate actually increases when you consider the post neonatal period, the time between birth and 12 months.  The infant mortality rate gap actually widens between the US and other wealthy countries during this period. The authors conclude that this is due to socioeconomic disparities in our country, in other words the higher post neonatal mortality rates are coming from disadvantaged groups.   Certain states actually have an infant mortality rate higher than some 3rd world countries, for example Alabama with an infant mortality rate of 8.7 per 1000 live births and Mississippi with a rate of 9.6.

So does Obamacare fix this? Will the post neonatal infant mortality rate go down now that more people have access to medical care? Possibly, but it’s too early to tell.  The Affordable Care Act has not been in place long enough to measure the impact on infant mortality, but it is a start.  The infant mortality rate certainly won’t go down without some intervention, and there had not been any significant move to make medical care available to those without insurance before the ACA was passed. There was Medicaid, but many people below the poverty line did not qualify for Medicaid particularly in states with very stringent requirements.

Do we care about the infant mortality rate? It probably doesn’t directly affect our day-to-day lives. But what are our values and ideals as individuals and as a country? Do we leave the disadvantaged behind and suffer the consequences as a society?  I just don’t think that’s compatible with who we are.

I’m glad to see that medical care is more accessible.  However, having access to care is not enough. It has to be good care equal to the care that the rest of us have. If it means that my insurance is more expensive or the co-pays are higher, then so be it.

We are one of the wealthiest societies in the world. Does that benefit trickle down to people who are poor? Are we isolationists in our own society, not caring about the welfare of others, or do we try to elevate the living standard of society as a whole? Certainly having access to affordable medical care doesn’t guarantee that people will take advantage of it. People still have the opportunity to make good or bad choices in life, choices that affect their lives, their children’s lives and our lives as members of society.  But healthy people generally think more clearly and are more likely to make good choices. That can make life better for all of us.

 

Patienthood vs. Personhood

For too long in the medical profession, we have referred to patients as “the diabetic” or “the schizophrenic” or “the addict” or “the bipolar.” Most physicians would say that this is just shorthand; we know that our patients are people. However, I believe that we need to apologize to all patients for this terminology. It dehumanizes. People are not defined by their illness. You are a person with diabetes or a person with schizophrenia, or a person struggling with addiction or bipolar disorder. Sometimes I think you, the patient, actually come to believe that the diagnostic label defines you. You begin to think of yourself as a schizophrenic before you think of yourself as a wife, husband, mother, teacher, friend, sister.  We in the medical profession need to stop this pigeonholing of our patients and you, patients, need to stop buying into it.

I sometimes wonder if this is primarily occurring because of the push to see more patients. As busy physicians, we have to focus on the problem at hand. Those of us who are employed usually have a target amount that we are supposed to bill each month.  That means seeing a certain number of patients each day. Those in private practice have overhead and malpractice premiums.  Some physicians see the electronic medical record as a barrier between patient and doctor. Patients may feel that the doctor spends more time looking at the computer than at them.  We are very focused on technology. Even in psychiatry, this is happening to some extent. But is that really an excuse?

My grandfather was a country doctor in a small town in Kentucky. I didn’t know him. He died before I was born. I grew up in the same small town. Many people told me how much my grandfather meant to them. He made house calls. He delivered babies at home. He saw his patients on their turf, not necessarily on his. I’m not saying that modern technology is bad, because the survival rate for babies and all patients is so much better now. But you can be sure that he knew his patients as people. He visited their homes, he saw them at their worst and at their best.  He treated their grandparents, parents, and children. There is something good about that. I don’t know how we can replicate that today.

When I wrote the required essay on my application for medical school, I remember writing that I thought medicine was the perfect bridge between science and art. We’ve tilted toward the science side, and that certainly has its benefits. We are saving more lives. We have a better understanding of why and how our treatments work. But I hope we don’t lose the art side of medicine.

So stand up for your personhood. Remind us, when we forget, that you are a person with a life above and beyond your diagnosis.  Remind yourselves that there is more to life than your illness, that you are members of a community, country, world and universe bigger than your illness.   Don’t get me wrong, I love the science of medicine.  We have made huge strides in the treatment of cancer, heart disease, mental illness and so many other diseases.  I love the black and whiteness of science. I love the certainty of science, though I sometimes wonder if that really exists. But I feel that we may have lost some creativity and humanity in the face of the explosion of technology.   When I end my career as a psychiatrist, I hope that I can say that I practiced the ART of medicine.

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Mindfulness Based Stress Reduction: Keeping the Brain in Shape

Mindfulness Based Stress Reduction at Work.

Mindfulness Based Stress Reduction at Work.

Mindfulness is one of those terms that seems self explanatory, but it really isn’t. We all have minds, so aren’t we all mindful?  Probably not.  The concept of mindfulness is just entering the portal of mainstream medicine. For many years, mindfulness meditation (also known as Mindfulness Based Stress Reduction, MBSR) was thought of as something akin to yoga, practiced mainly by “health nuts” who had the time to sit for hours in a trance, and mainly appealing to people who were interested in Eastern religions. It seemed “experience distant” to most people, meaning that it was interesting but not really relevant to their lives.

First of all, let’s define mindfulness. Jon Kabat-Zinn, who is credited with bringing mindfulness meditation into mainstream medicine, says that mindfulness is the awareness that arises through paying attention on purpose in the present moment nonjudgmentally.  Many people think that mindfulness meditation is about clearing the mind, having a blank mind. That is not the case.   Mindfulness Based Stress Reduction usually begins by sitting quietly and focusing on the breathing. As thoughts begin to intrude, and they will, they aren’t pushed away.  Attention is gently brought back to the present by focusing on breathing.  This back and forth between mind wandering and bringing back attention to the present occurs over and over again for most people, especially when beginning MBSR. The key is that thoughts and/or bodily sensations are not judged as good or bad; they are simply observed.  For example, while engaged in MBSR, you might experience some discomfort, maybe some back pain or a sensation of hunger. You experience that sensation, but you don’t try to resist it. You don’t try to judge it as good or bad. You might be curious about it. You simply experience it. You try to develop the ability to observe your sensations objectively. Most people focus on their breathing during the meditation, but some find it easier to listen to a sound in the back ground or some quiet music.  I will discuss more about the actual practice of mindfulness in the next blog.

What is the purpose of this exercise anyway?   There are actually two components to bodily sensations and emotions.  One component is the actual physical sensation or the emotion, while the other component is our judgment of it, how we perceive it. Do we perceive it as bad, good, pleasurable, noxious?  How we perceive it is really what determines how we respond.  Pain is deemed to be bad because we judge it to be. Kabat-Zinn would say that learning to stand back and observe emotions and sensations more objectively makes them more tolerable.  We have a tendency, understandably, to fight what we see as negative emotions. This simply activates the sympathetic nervous system which increases blood pressure, heart rate, tenses muscles, etc. That is our fight/flight response. But though adaptive in some situations, constantly being in fight/flight mode takes its toll on the body.

Kabat-Zinn and MBSR advocates are not suggesting that we need to learn to like pain or anxiety. But practicing MBSR can keep us from being so overwhelmed by intense sensations or emotions. It’s an acceptance of our present state without letting ourselves go down the slippery slope of negativisms such as “this will ruin my day,” or “I’ll never be free of this pain.”  We are so accustomed to thinking through our day as we drive to work and imagining worst case scenarios.  The concept of simply focusing attention on the present is rather foreign to most of us. How much of the present do we miss by constantly focusing on the past or future?

So far, recent articles have shown that mindfulness training can reduce stress during a period of high workload on military helicopters (Meland et. al. in the International Journal of Aviation Psychology, Oct. 2015), decrease fatigue, anxiety and mood symptoms in breast cancer survivors (Carlson et. al in Psychooncology, May 2016), and decrease pain intensity, pain catastrophizing, interference of pain in daily life and depression in cancer patients (Poulin et. al., Supportive Care of Cancer, May 2016).  There seems to be evidence that MBSR can help patients with addiction by modulating responses to environmental cues that instigate craving.  There is even evidence that MBSR can slow progression of Alzheimer’s Disease (Quintana-Hernandez et. al. Journal of Alzheimer’s Disease, 2015) and improve some problems with memory loss.  It seems to exercise the brain and keep it free of unnecessary debris.

In my next blog, I’ll explain more about the mechanics of Mindfulness Based Stress Reduction, including some tips on getting started.  I’ve included a YouTube video that explains more about mindfulness based stress reduction.    There are numerous YouTube videos on this topic including several by Jon Kabat-Zinn himself.

MENTAL HEALTH AWARENESS MONTH 2016

 

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May is Mental Health Awareness Month.   I’ve written articles for this month before, usually with statistics about the frequency of mental illness, the stigma surrounding mental illness that prevents people from getting treatment, or perhaps about the difficulty that people with mental illness have getting access to good, affordable treatment.  All of those things are important, but they are just facts, opinions. They don’t put a face on the illness. What is it really like to live with severe depression or bipolar disorder. What is it like to live with a family member who is mentally ill?

Now you have an opportunity to find out.  Mental Health America has set up an area for people living with mental illness to post their experiences. Feel free to post your own experience. Go to www.mentalhealthamerica.net/feelslike.

Sometimes we forget that an adult’s mental illness can affect children as well. For example, children growing up with depressed parents have a significantly  increased chance of developing depression themselves. This is due to both biological and environmental influences. Parents who are depressed usually have a hard time really being emotionally present.   Children, as we all know, tend to feel that whatever happens is their fault.  They have fewer positive interactions with parents which can lead to a more negative view of the world. Their self esteem may be lower, and they may not develop the same resilience in the face of adversity that other children have.

I’ve worked with several patients who had parents who were severely mentally ill. Some had parents who were psychotic (probably schizophrenic), severely bipolar, or so depressed that they required institutionalization.  You would think that growing up with mental illness would lead them to seek out mental health treatment, but I don’t find that to be true. Sometimes they have negative perceptions, accurate or not, of mental health treatment based on what they’ve seen with their parent.  I find that they question their own “normality.” They continuously wonder if they are “OK” or if they might really be ill like their parent.

If you are living with mental illness or know someone who is, be aware of the effects on other family members. Your treatment benefits them in the long run. Even if they don’t need treatment themselves, they need a lot of support.   They need contact with other families, they need positive experiences outside the family, at school or in extracurricular activities.   We may not be able to control our genetic makeup, but we can influence the environment that our children experience, and that improves the environment that their children experience. It definitely has a long-term pay off.

Don’t forget to check out www.mentalhealthamerica.net/feelslike.

Can My Primary Care Doctor Treat My Depression?

The short answer is maybe.   There are many factors that influence the success of treatment for depression. First of all, how severe is the depression? Are you still able to function in day to day life? Are you going to work, taking care of your children?  If so, your primary care doctor may be able to put you on an antidepressant medication that will significantly help. Most primary care doctors have a good, basic understanding of common antidepressant medications, and if your depression is relatively mild, that may be good enough.  However, treatment of depression is not always that simple. Your primary care doctor (PCP) is busy. Most PCP’s see 30 to 50 patients per day. They don’t have time to really talk at length about what is going on with you emotionally.

If your depression is more severe, and especially if you have any suicidal feelings, the PCP alone may not be enough. If you have good access to your PCP, that is a start, but your PCP may want to refer you to a mental health professional. Some primary care doctors are now integrating mental health practitioners into their practices. That makes mental health care so much more accessible. Some people hesitate to see a mental health professional because they don’t know where to start.  Should you see a social worker, psychologist, or a psychiatrist?  Hopefully, your PCP can help you navigate through the system and figure out what referral is best.

There are some reasons why you might want to consider seeing a mental health professional initially. Not everyone responds to medication. Sometimes the initial antidepressant medication doesn’t work and needs to be switched. This takes time and patience on your part. What do you do in the meantime? Mental health counsellors can provide some support during that time. Most recent studies have shown that the best treatment for depression is a combination of some type of “talk therapy” and medication.

Sometimes the best therapy might be counselling rather than medication. Many patients see their PCP and simply say “I’m depressed.”  They receive an antidepressant medication. In reality, there may be a problem in their lives such as marital issues, abuse, addiction. Sometimes patients don’t disclose this to a primary care doctor, and the busy doctor may not always probe.  Medication alone does not always get to the underlying issues that need to be resolved.

 

Here is a guide to help you get started:

 

  • If you are suicidal and don’t know where to turn, the emergency room of your local hospital is always an option. They should be aware of psychiatric facilities in your area.
  • The National Suicide Hotline number is 800-273-8255.

 

  • If you live in a town with a medical school, they almost always have a department of psychiatry. You can start by calling them and asking about their outpatient clinic.

 

  • You can google therapists in your area. Simply search therapists in (your city), for example type therapists in Louisville in your search bar. You will get a combination of mental health practitioners, social workers, psychologists, psychiatrists.

 

  • Psychiatrists can prescribe medication, make certain that there are no medical causes for your depression and provide counselling. Some psychiatrists mainly provide medication management and refer to social workers or psychologists for therapy.

 

  • Psychologists and social workers provide psychotherapy (counselling) Some may specialize in seeing families or children. Most psychologists and social workers have a psychiatrist that they refer to if medication is needed. You can always start with a therapist and then see a psychiatrist for medication later if necessary.

 

Treatment works best when your providers collaborate. Your therapist, psychiatrist, and primary care doctor should be communicating with each other.

 

Don’t simply ignore your depression. It’s a signal, a red flag.  Pay attention.

Are You Sleeping?

Don’t you wish!   Nothing contributes more to a bad day than lack of sleep. That guy who gave you the finger when you passed him on the way to work this morning probably is sleep deprived. Insomnia doesn’t just affect the person suffering from it. Ask the spouse who has to deal with a cranky, foggy, depressed partner day in and day out.

According to the American Academy of Sleep Medicine, about 30% of the population has some symptoms of insomnia, while 10% have symptoms severe enough to cause problems with daytime functioning.

Sleep apnea is one of the more widely known sleep disorders. It is characterized by loud snoring and periods of several seconds to a minute of apnea (no breathing) during sleep. There are the parasomnias which are disorders of sleep behavior. For example, sleep-walking, sleep-paralysis (waking from sleep and feeling unable to move), sleep-terrors, and sleep-eating disorder (yes, it actually exists) are some of the parasomnias.  The most common sleep disorder, though, is plain old primary insomnia. It’s the inability to sleep for no clear reason.  For some people, the difficulty is getting to sleep. Once they get to sleep, they’re OK. For others, the problem is staying asleep. Some people have both problems. Others seem to be sleeping, but the sleep quality is not good. They don’t reach the deep levels of sleep, and in spite of seemingly sleeping, they feel just as tired and cranky as if they hadn’t slept a wink.

There are medications for primary insomnia out there, for example Ambien, Restoril, Lunesta. However, none of them are really recommended long-term, and the new ones are expensive. It can be difficult to get insurance plans to pay for them.  If all else fails, taking a sleep medication is probably better than not sleeping. However, many of these medications lose their effectiveness after awhile, or they don’t work for some people, or they have side effects such as very vivid dreams.  Ambien in particular is known for causing bizarre behavior during sleep or the day after taking it.   There is some potential for dependence as well. When people have been taking these for a long time, it’s hard to tell whether they still have the sleep problem or they’ve become dependent on the medication and can’t sleep without it.

It is possible to treat insomnia without medication. The most common techniques are called stimulus control therapy and/or sleep restriction therapy.   Stimulus control therapy involves managing possible stimuli that could affect sleep.  For example:

  • No caffeine after 6:00 pm or even earlier for those who are really sensitive
  • No alcoholic beverages after 6:00 pm. Though alcohol tends to make people sleepy, as it is metabolized during the night, it actually shortens the sleep cycle.
  • Minimize stimulating activities just before bed such as exercise or reading emotionally charged material.
  • If you aren’t sleeping, don’t just lie in bed. Get up until you feel sleepy. Don’t watch TV because some of the light from TV and even cell phones is the same frequency as sunlight.
  • Don’t oversleep the next day to compensate. Get up at the same time each day.
  • Don’t watch the clock. You don’t need to know what time it is. Put your clock out of sight.

If that isn’t successful, sleep restriction therapy may be the next step. This is usually best done in conjunction with a sleep therapist.  You will keep a sleep diary for a couple of weeks. Then, based on your actual sleep time, your sleep will be restricted to that amount of time. So if you really are only sleeping 5 hours, your therapist will have you go to bed at 12:30 and get up at 5:30.   Sleeping during the day is not allowed. Usually after a period of strictly following this regimen, the sleep cycle begins to normalize and bedtime can be moved back slowly.  See this YouTube video by author Lois Maharg illustrating sleep restriction therapy. Check out her book, The Savvy Insomniac, and her website, thesavvyinsomniac.com.

 

 

Of course many factors influence sleep. Some good resources are:

 

American Sleep Association – http://www.sleepassociation.org

 

WebMd – www.webmd.com/sleep

 

The Sleep Foundation – http://www.sleepfoundation.org

 

insomnia

 

 

Are YOU Keeping a Secret?

This past week was National Eating Disorders Association Awareness Week. The National Eating Disorders Association (NEDA) supports those affected by eating disorders and educates the public about various types of eating disorders.  These disorders are more common than most people think. That’s because people who have eating disorders are so secretive. Often even close family members, including spouses, don’t realize that their loved one is suffering from an eating disorder.

When most people think of eating disorders, they think of anorexia nervosa. This is probably the most well-known of the eating disorders. However, it’s not the only one. Bulimia and binge eating disorder are the other types.   The most sensational cases get publicity. Most of us remember Karen Carpenter of the singing group, The Carpenters, who died of anorexia.  However, there are many people suffering silently, perhaps not even aware that they actually suffer from a diagnosable eating disorder.

These are the most common types of eating disorders.

  • Anorexia Nervosa is characterized by extreme fear of gaining weight. These women are severely underweight, and amazingly enough, they don’t recognize it. They completely lack insight into the fact that they are starving themselves. They may look like a concentration camp survivor to everyone else, but that isn’t what they see when they look into the mirror. According to NEDA, up to 1% of women in the US suffer from anorexia.   Although there are men who suffer from anorexia, 95% of those with anorexia are women.  Some people with anorexia will binge and then purge (purging behaviors cause the person to eliminate food already eaten, for example self-induced vomiting or using laxatives).  About 5-20% of people with anorexia will die of the disorder.
  • Bulimia Nervosa is characterized by binging and purging behaviors. In other words, large amounts of food are consumed, larger than what most people would consider normal. This is followed by purging, self-induced vomiting or use of laxatives. The hallmark of bulimia is a feeling of loss of control while eating. People with bulimia are very focused on appearance as a source of self-esteem, as are those with anorexia. Usually, however, the sense of loss of control and the amount of food consumed during a binge are what distinguishes bulimia from anorexia. People with bulimia usually do recognize that their eating behaviors are abnormal. They may not be extremely under or over weight. There are more males with bulimia than anorexia, though 80% of bulimic patients are still women.
  • Binge Eating Disorder (BED) was recently recognized formally as an eating disorder. It is characterized by episodes of consuming large quantities of food, larger than what most people would consider normal, to the point of discomfort. The food is consumed rapidly, generally within 2 hours, and the binges occur at least weekly. People with BED do not usually compensate by purging. They do experience a sense of loss of control when binging. They usually feel terrible afterwards, and they may experience depression, anxiety, and other mental health issues. BED is the most common eating disorder affecting 3.5% of women and 2% of men. BED is more evenly spread between the sexes with 60% being women and 40% men.

 

Eating disorders are treatable.  Medication in addition to psychotherapy may be helpful. Recently a report from the Agency for Healthcare Research and Quality found several medications, including some antidepressants, Topamax (a seizure medication), and the stimulant vyvanse (used for attention-deficit disorder) particularly helpful for BED.  In extreme cases, particularly in people with anorexia who are at dangerously low body weight, inpatient programs may be necessary. If you aren’t certain whether you have an eating disorder, go to mybodyscreening.org for an online screening tool. If you believe that you may have an eating disorder, check out the NEDA website at nationaleatingdisorders.org.  They have great information about diagnostic criteria, treatment resources, and support.

Eating disorders, besides being potentially lethal, can cause many medical issues including heart and metabolic abnormalities.  There is no shame in having an eating disorder.  Remember almost 3 women and 2 men out of 10 suffer from an eating disorder. Get treatment today.