MANAGING STRESS IN OUR LIVES

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? 

Friday
Oct192018

WHAT CAN WE DO ABOUT SUICIDE?

Dr. Igor Galynker, who is the director of the Galynker Suicide Research Laboratory at the Icahn School of Medicine at Mount Sinai in NYC was quoted in Clinical Psychiatry News [Vol 46 No 8 August 2018] stating that "using suicidal ideation as a risk factor [for suicide] is flawed" as this will miss 75% of people who end up dying by suicide. He recommends using the patient's feeling entrapped and the clinicians own sense of the patient being at risk, instead. Dr. Galynker also noted that while hospitalizing suicidal patients can help them to feel more in control and mobilize support systems there is still a spike in suicides after hospitalization [250 x for women and 100 x for men]. Dr. Galynker also notes that according to the CDC, the suicide rate has been increasing since 2000 and has been increasing by 2% per year from 2006-2016. Additionally, Dr. Galynker also notes that suicide intent was disclosed by less than 25% of people who completed suicide. However, Dr. Galynker does see a benefit for safety planning such as limiting access to firearms, nets under bridges and smaller quantities of medications. He also mentions risk factors such as romantic rejection, terminal illness and humiliating failures in buisiness.

David Brent, M.D. in a paper entitled "Preventing Youth Suicide: Time to Ask How" in the Journal of the American Academy of Child Psychiatry.2010.09.017 identifies several risk factors for youth to become suicidal. These include: mood disorder, especially if linked with non-affective comorbidities [conduct disorder; substance abuse; etc.]; a previous suicide attempt, especially if the child is still depressed and suicidal; suicidal ideation combined with alcohol or substance abuse; other family members having been suicidal or completed suicide; family adversity such as abuse; and parental criticism for youth that are already self-critical [work by Wedig and Nock in the Journal of the American Academy of Child and Adolescent Psychiatry. 2007;46[9]:1171-1178 and in the same journal Nock. 2009;48:237-239].

Also, in the AACAP News [September/October 2018. Volume 49; Issue 5] Tracy Asamoah, M.D. writes about "Suicide in African Americans." She indicates that the rate for suicide in African American children had increased from ages 5-11 while it had decreased for white children [JAMA Pediatrics. 2012;169;673-677]. Also, the CDC Data and Statistics Fatal Injury Report for 2016 showed that while suicide rates for African American youth was less than that for white youth, the rate of increase in suicides was greater for African American youth. Primary factors for this include the under recognition of mental illness in these youth as problem behaviors are more likely to be punished versus treated, and the lack of resources for these youth in underserved communitieis.   

Wedig and Nock identified a risk factor and the possibility of an interventional approach to reduce the risk. Clearly reducing risk for suicide is important as well as efforts that focus on prevention of suicidal behaviors. Access to mental health treatment can reduce the risk of suicide. This will require that mental illness in African-American youth be recognized instead of seeing their behaviors as criminal and requiring punishment. In addition, access to preventative mental health services and screening tools can help reduce the suicidal behavior.  Unfortunately, these services are less available in underserved communities that have a higher percentage of African-American youth.

Finally, a study from 2016 [Walker R, et al. A Longitudinal Study of Racial Discrimination and Risk for Death Ideation in African American Youth. Suicide and Life-Threatening Behavior. 2016; 47: 86-102] found that experiencing racial discrimination was correlated with death ideation and depressive and anxiety symptoms. Therefore, it is important to be aware of the impact of racial discrimination and disenfranchisement on risk for suicidal thought and also on the access to mental health services. This highlights the critical role that supporting families and extended families and local communities as they will help to empower youth, who are at risk for suicidal behavior, to seek and make use of treatments.

What do you think?

 

Tuesday
Sep252018

IS IT BETTER TO SHARE THAN TO KEEP?

One of my patients said the above as he was reflecting on how much he has benefited from attending alcoholics anonymous meetings. He felt that he had recieved a lot from others attending the meetings and had also gained a lot by sharing his story with others. I then said that I believed that it was not possible to worry about the past if you are sharing your life with others. My patient said that this seemed right to him and yet I wasn't sure about it. So, why would sharing our lives with others make worrying about the past impossible?

Maybe it is because if you are sharing with others you are listening to them without your own reactions and this allows you to feel connected to them and you are more likely to share with them as they listen to you. It could also be that listening is like sharing as you are sharing the othe person's life experience as you listen. So, maybe if we feel connected to others it is harder for us to worry about the past. If that it so, does it mean that we worry about the past because we feel isolated from each other and the worrying is our effort to feel connected to others? Yet worrying does not seem to actually connect us to others.

What do you think?

Tuesday
Sep252018

I'M AGAINST FASCISM/ I'M IN FAVOR OF ENCOURAGING AND SUPPORTING EVERY HUMAN

I would hope that all of us [humans] would be against fascism. So what is fascism? It seems like it is a way to justify controlling others [supposedly] for their own good. That, of course, is impossible as I believe that taking control from people is never for their own good. Fascism purports to promote the nation but it really seems to support sa favored race over the rest of the population. This often means that a few people under the leadership of a dictator will exert control over the rest of the people in their country purportedly for the good of those people. To maintain this type of control over others, the leaders need to completely suppress any form of opposition. They become bullies to sustain their power.

So what is attractive about fascism? Well, there is a promise to take care of those who support the fascist leaders as these leaders act like they know what is best for the people in their country. People are freed from having to make decisions and are often forbidden from acting independently in any manner. The problem with this seems to be that people need to make decisions for themselves and be responsible for themselves. They have difficulty functioning as humans if they don't. This might be why Fascist governments don't last as the people revolt. 

What evidence is their that we need to make decisions for ourselves and be responsible for ourselves? Is it really better to encourage and suport others versus telling them what to do?

What do you think?