MANAGING STRESS IN OUR LIVES

Thursday
Aug082019

UNALIENABLE RIGHT TO LIFE, LIBERTY AND THE PURSUIT OF HAPPINESS AND TO OWN ANY AND ALL THE GUNS THAT WE CHOOSE?.

I've read that the ancient Greek democracy failed because it did not protect the individual from the majority. If we believe that all life is sacred [precious, etc.] then we must protect the rights of the individual from the majority. So, something being good for most people does not justify it being imposed on the individual. Or does it? If we see that the right to life is being taken away from some people by individuals with assault style weapons then does any individual have the right to those weapons when exercising their right can take away the right to live for innocent people? So where do our individual rights end and the majority's rights begin? 

We as individuals are guaranteed by our constitution to be free to pursue our lives. So, any thing that interferes with our ability to pursue our lives interferes with our individual rights. But what about the rights of others, such as the rights of children and adults to not be killed by a male with an assault rifle. Their right to pursue their lives is over. So, is it right to pursue our lives if it can result in the right of others to pursue their lives be taken from them? It has been argued that it is wrong to take assault rifles from people who have not killed anyone and yet the fact of and availability of these weapons has taken the right of many to be alive to pursue their lives. I believe that it is our responsibility to protect the lives of those innocent people.  If this is true regarding guns then it must be true for protecting those innocent people from the hate being promoted on line or anywhere else. We are free to speak what we believe but not free to take away the rights of others to pursue their lives.

What do you think?

Sunday
Jul282019

DOSING OF ADHD MEDICATIONS

Questions are sometimes raised about exceeding the maximum recommended doses of medications used to treat ADHD. I have reviewed the research studies for these medications and it is clear that the studies were to determine efficacy and were not dosing studies.  Specific doses were chosen to assess the benefit and minimize risk of side-effects.  Once efficacy was determined the study ended and there was no motivation to do further studies addressing the range of doses that were therapeutic. Thus, doses involved in efficacy studies can be mistakenly seen as being studies to determine limits of what is therapeutic. The studies could not recommend a different dose because they did not assess different [higher] doses.  Also, each person is unique and this uniqueness can include how they respond to medications with some people responding to higher doses and others to lower doses. The U.S. Food and Drug Administration recognizes this when they state “the dosing regimen [for stimulant and related medications] is adjusted according to a patient’s individual response to pharmacotherapy."

I believe that it is important to work with my patients to assess their response to medications and in collaboration with them determine an optimal dose. At times this dose may be higher than is “recommended.”  I hope that it is clearer now why this is the case and why it is necessary to prescribe higher doses for these patients.

 

Monday
Apr292019

WHY I AM AGAINST "GOOD INTENTIONS"

I have recently had a number of my patients say that they know that a person [family member or friend] had good intentions but that what they said or did was not helpful. So, what is wrong with good intentions? Most people are familiar with the proverb [aphorism?] that the road to hell is paved with good intentions. This has been explained as it is not enough to intend to do good things but one must actually do them.  Another has to do with possible unintended consequences after one acts on their good intentions. It seems that one can have good intentions for themselves as well as for others. So, it is considered bad if we have good intentions but never act on those intentions. This may be true for good intentions for ourselves but my concern is that good intentions for others may represent thinking we know what is best for others and by acting on these intentions end up taking over and making it harder for others to make decisions for themselves.  

I believe that we can't know what is best for other people because we are not them. People must take responsibility for themselves and make their own decisions. There seems to be no other way to live our lives.  Related to this, I have blogged a number of times about the importance of being supportive and encouraging towards others but to not tell others what to do or take over for them in any way, no mattter how good our intentions are. I believe that we must choose how we will live our lives and that this is easier if we are connected to others who are supportive and encouraging but respect our independence.  

What do you think?

Sunday
Mar172019

WHY DO AMPHETAMINES HELP PEOPLE WITH ADHD?

There has been a lot of concern expressed about amphetamines being prescribed for ADHD in children and adults. There is concern about addictions and dependence on these medications. It had been thought that these medications work by influencing neurotransmitters [serotonin, norepinephrine and dopamine]. These neurotransmitters are influenced by amphetamines. However, my patients have never responded to these medications as if they were amphetamines when they are helping them to focus. In fact, if my patients do respond to these medications as amphetamines [typically with increased energy, restlessness and irritability, appetite supression and difficulty falling asleep], they interfere with focusing and concentration and if they persist indicates a need to try another medication in the other group of medications for ADHD. When my patients respond to these amphetamine medications with improved focusing and concentraton, they are calmer, more alert, more able to complete tasks, less likely to finish tasks at the last minute and are less socially anxious. My patients who have problems with concentration [are ADHD], do not respond to these medications like they are amphetamines.

So why might that be the case. There is recent research suggesting that in people with ADHD, amphetamines influence the white matter [WM] portion of the brain that is deeper in the brain then the gray matter [GM] where our emotions, moods, anxiety, fears, etc., are. The WM is where the so called long tracks are located that function to connect different parts of the GM together and thus serve to help to coordinate brain activity and maintain stability, even when the emotions are activated. This location for concentration could serve to protect our ability to concentrate from the ups and downs of our emotional lives and preserve our ability to concentrate even if we are upset. This has not been demonstrated to occur in brains as it is difficult to see the WM with MRI's except by measuring the diffusional motion of water molecules using Diffusion Tensor Imaging [DTI] that assesses the micro-structural features of white matter studies that have found delays in brain white matter development in people with ADHD. This work has been added to by Bouziane, et.al. ADHD and maturation of brain white matter: A DTI study in medication naive children and adults" in Neuroimage Clin. 2018; 17: 53-59. who studied medication naive children and adults using DTI. They found that the WM of children with ADHD were the same as children without ADHD while adults with ADHD had reduced fractional anisotropy [FA] compared to adults without ADHD in several regions and the anterior thalamic radiation. FA is a normalized measure that quantifies the directional anisotropy of diffusion and is thought to reflect fiber density, axonal diameter and myelination in white matter. It is now thought that WM changes in people with ADHD occur in adults and not children. However, animal studies [van der Marel et al.Long-term treatment of adolescent and adult rats: differential effects on brain morphology and function. Neuropsychopharmacology; 2014;39:263-273] have shown that methylphenidate [a medication used to treat people with ADHD] in animals has upregulated the striatal genes that are involved in axonal myelination and thesse changes might be the changes seen in WM in people who are treated for their ADHD and thus supporting that these medications work in the WM part of the brian. 

So it seems that people with ADHD respond to amphetamine type medications with improved focus and concentration and not with responses that are typically associated with amphetamines. This would explain the benefit of these medications for people with ADHD and why they tolerate them without the problems that can be connected to taking amphetamines. In fact, research has repeatedly demonstrated that treating ADHD in young adolescents will reduce their risk of having an addiction. None of the thousands of people that I have treated with amphetamine type medicatons for ADHD have abused these medications.

Tuesday
Oct302018

IS LONELINESS AT THE HEART OF ADDICTION?

Recently I listened to a TED talk by Rachel Wurzman entitled: "How isolation fuels opioid addiction." She discribes her experience of having tics [Tourettes Disorder] that she calls "unvoluntary." Dr. Wurzman experiences her involuntary tics as unvoluntary meaning that she feels like she is doing the tic movement and not an external force. However, Dr. Wurzman recognizes that her tics are not related to her conscious intentions or attention. Dr. Wurzman then makes the point that we all have things that we do in healthy ways and other things that are not healthy and this can help us to understand what others are experiencing, including those with tic disorders and addiction. So, why is it important that we can understand each other? Dr. Wurzman goes on to talk about the opioid epidemic and it's connection to being lonely. She states that this epidemic is killing 91 people every day and it is getting worse. Dr. Wurzman understands that addiction is a medical, neurobiological problem and yet she feels that we can help people with addictions by changing how we respond to them. To change how we respond to people with addictions she feels that it is helpful if we understand how and why our brains cause behaviors like urges to use substances. Dr. Wurzman's research suggests that loneliness may be reinforcing the brains of addicts to seek comfort from substances as their striatum's are seeking things that have most frequently been associated with reducing their feelings of loneliness. These responses [seeking things] are like they are on autopilot, so that when there is a stimulus there is then a very rapid and automatic response from their brains. 

Importantly, according to Dr. Wurzman, feeling socially connected to others is part of what the striatum does. The experience of feeling pleasure in social interactions is modulated by opioid receptors in the striatum. If some one is experiencing intense loneliness the opioid receptors are sensitized so that anything that reduces this sense of loneliness, such as taking opioids, is intensely and very rapidly sought. Therefore, loneliness may keep people addicted and social connections may help people not be addicted. However, those social connections need to be strong enough to convince the striatum that it is safe to let go of the immediate and reliable relief that taking opioids [and other drugs] represents. Dr. Wurzman also believes that to establish powerful social connections, it is better to connect with each other not focused on one aspect of ourselves/others [like addictive behavors] but recognize how we all have unvoluntary or automatic type behaviors. This helps us to realize that we are connected to people who happen to have different unvoluntary or automatic type behaviors. 

After listening to Dr. Wurzman, I wondered about a connection between the social isolation experiences of people with addictions and those who suffer from Post Traumatic Stress Disorder [PTSD]. If so, then does the isolation theory apply to people who have PTSD? And how would this influence treatment of PTSD?

What do you think?