World Autism Awareness Day: April 2nd, 2009

This also happens to be my son’s 2^nd Birthday. 

I have neglected my blog over the past six months; a fact kindly brought to my attention by one of my patients.  This neglect has occurred, not due of lack of material or interest- I still have a small pile of clippings on various mental health topics of interest- but because at the end of September 2008 my world changed significantly. 

 I had concerns about my son’s lack of appropriate speech development, but was assured that he was “normal” and that boys just are “late talkers” at his 15-month appointment.  By his 18^th month appointment, he had lost his one word “cat” and all babbling of “mamamama”.   We initially were concerned that he might have a hearing problem, as he didn’t respond to his name or to other communication; but after multiple failed hearing tests (and nightmare scenarios of having to teach a language that I don’t know to a child who won’t make eye contact with me) a sedated ABR revealed his hearing to be normal.  We joked for a few weeks that he didn’t know that we knew he could hear since he slept through the test.  All in all, we are blessed.  Our concerns were heard and we were referred to our state’s program for children 0-3 yielding a whirlwind of evaluations, leading to multiple therapy sessions with some very gifted and dedicated professionals: including a speech pathologist, occupational therapist, child psychologist, and resource coordinator.

 There are so many ways that Autism affects our lives:  from the frustrations of communications challenges; the lack of sufficient research and recommendations for safe & effective treatments; the burden of time and financial commitments for therapies (that insurance companies are not mandated to cover); to the feelings of guilt and helplessness at not knowing…because there are no answers to most of the questions, including “What causes this? What can be done?”  Currently, there are no effective means to prevent autism, no single effective treatment, and no known cure. In the absence of scientifically proven treatment, people turn to “folklore” of anecdotal treatments that may potentially cause more harm than good.  Without proper funding for research, this “folklore” may be all that is available.  

 

So, in honor of my son’s second birthday, I am doing what I can to raise awareness for this condition and the organizations that are working hard on research to find scientifically proven, safe & effective treatments for this devastating condition.  Please join with me in supporting Autism Speaks as we celebrate the second annual World Autism Awareness Day.  Together we can increase the knowledge of the Autism epidemic and convey information regarding the importance of early diagnosis and intervention. By bringing together autism organizations all around the world, we will give a voice to the millions of individuals worldwide who are undiagnosed, misunderstood and looking for help. Please join us in our effort to inspire compassion, inclusion and hope. 

Facts about Autism

Did you know…

• 1 in 150 children is diagnosed with autism

• 1 in 94 boys is on the autism spectrum; Boys are four times more likely than girls to have autism

• 67 children are diagnosed per day; that means a new case is diagnosed almost every 20 minutes

• More children will be diagnosed with autism this year than with AIDS, diabetes & cancer combined

• Autism is the fastest-growing serious developmental disability in the U.S.

• Autism costs the nation over $90 billion per year, a figure expected to double in the next decade

• Autism receives less than 5% of the research funding of many less prevalent childhood diseases

• There is no medical detection or cure for autism, but early intervention improves outcomes

For more information on this condition and how you can help, please visit any of the following website:

www.autismspeaks.com

www.worldautismawarenessday.org

 We will be participating in the Oklahoma City 2009 Walk for Autism Event on June 6th, 2009 at the OKC Bricktown Ballpark.  For more information or to make a tax-deductible donation, please visit us on the web at:

www.walknowforautism.org/oklahoma/evan

8 Lifestyle fixes to help with weight loss

 

Psychiatric patients are at high risk of becoming obese—with rates up to 63% in schizophrenia and 68% in bipolar disorder. Moreover, weight gain from psychotropics is associated with medication non-adherence.

 

The 8 behaviors described below can help individuals become more active and take steps toward a healthier lifestyle.

 

1.  Keep a food diary. Keep a written record of everything you eat or drink in a day. Learn about healthy foods and look up the calories of common foods using food packaging, pocket books listing calorie counts, and online sources.

 

2.  Start walking. Pedometers could motivate individuals to exercise regularly and reach goals of taking a certain number of steps each day. A physically healthy individual should walk approximately 10,000 steps per day. Scheduling daily walks also provides structure and increases the likelihood of compliance.

 

3.  Plan meals and eat mindfully. Schedule meals and eat mindfully. This means keeping your full attention on eating by noticing the smell, taste, and texture of food. Eat slowly, enjoy every bite, and avoid eating while watching television or when occupied by another activity.

 

4.  Have a healthy snack before a meal. Eating a serving of boiled vegetables or a piece of fruit such as an apple before a meal can satisfy hunger and reduce food intake.

 

5.  Increase fluid intake. Feeling hungry might be a signal that the body needs more fluid.  Drink water, avoid beverages that contain sugar, and limit fruit juice to 4 to 8 ounces per day.

 

6.  Obtain support from family and friends. Loved ones can reinforce a patient’s weight loss efforts by not eating high-calorie food in front of the patient and buying only healthy snacks such as fruits and vegetables.

 

7.  Improve nutrition.   Specifically:

* eat at least 3 meals and 2 to 3 healthy snacks per day

*  choose lean meats and whole grains

*  eat 5 servings of fruits and vegetables daily

*  avoid eating after 7 Pm or 3 to 4 hours before bedtime.

8.  Monitor weight regularly. Digital scales give more precise measurements, which can prompt individuals to reduce food intake when they notice weight gain. Frequent feedback can help facilitate behavior changes necessary for weight loss.  Weigh-ins should occur between once-a-day and once-a-week.  

People often need help setting appropriate weight loss goals because achieving their ideal weight may not be possible. Losing 10% of body weight usually is a realistic goal that can improve their health.

(Summarized from Current Psychiatry, Vol 7, No. 9: article by Imran S. Khawaja, MBBS)

Mind-Body Medicine Used to treat PTSD in Kosovo Teens

Traumatized children living in Kosovo experienced significant reductions in post-traumatic stress disorder (PTSD) symptoms when treated with a mind-body program according to a new study published in Journal of Clinical Psychiatry (8/12/08. PTSD is an anxiety disorder that can occur in response to traumatic events. Common symptoms include flashbacks, nightmares or difficulty sleeping, feeling emotionally numb, being easily startled and difficulty concentrating.

The mind-body techniques used in the study were developed by the Center for Mind-Body Medicine (CMBM) and included meditation, biofeedback, breathing techniques, guided imagery and self expression. Eighty-two high school students diagnosed with PTSD were included in the three-month long study. Instructors trained in the CMBM program provided 12 sessions, in small educational settings.

Patients in the mind-body group experienced a significant improvement in PTSD symptoms compared to the control group. The number of children with PTSD symptoms decreased from 100 percent to 18 percent by the end of the study. The techniques reduced stress and symptoms of withdrawal, as well as decreased the frequency of flashbacks and nightmares. The effects were maintained three months after the study.

This mind-body technique is currently being used to treat people in Israel and Gaza who are traumatized by war, as well as those traumatized by Hurricane Katrina in southern Louisiana. It is also used to treat depression in the United States and has been added to a stress reduction program in several U.S. medical schools.

The study, published in the Journal of Clinical Psychiatry represents the first randomized controlled trial of any intervention in war-traumatized children.

RX data used as health “credit report”

An article in the August 4th, 2008 Washington Post describes how health and life insurance companies are now accessing databases of individuals’ personal prescription records to rate their relative risk.

They note that consumers authorize the data release and that the services can save insurance companies millions of dollars and benefit consumers anxious for a decision. 

Why are we so focused on saving the insurance companies millions of dollars?  I frequently encounter requests from certain pharmaceutical benefit plans requesting that I change a patient from a medication, that they are usually doing well on, to one that is truly not a generic equivalent, for the sole purpose of saving money.  However, when examined more closely, it only serves to save the insurance plan money.  

 

More and more, I find myself concerned about the future of for-profit, insurance-driven medicine.  It seems too problematic to have such divergent interests working together:  serving the health care needs of the individual (providing quality care) and the business goals of the insurance company (minimizing costs).  We have already experienced the deterioration of the doctor-patient relationship due to time constraints that exist (de-facto) due to the insurance paradigm.  Now we are seemingly at the edge of a more efficient means of maximizing profits for the insurers by mitigating risk:  unfortunately, the risk that is avoided is providing healthcare to those who might actually need it.  What types of conditions will be considered too high a risk: diabetes, depression?  What happens to those individuals when they are excluded or have to pay rates that are cost prohibitive?  It is an unfortunate, and perhaps unforeseen by-product of the move to computerize our health records.  I am entirely in favor of information, but not at the expense of privacy violations or corporate profiteering.

Self-Disclosure in Therapy

One area that is sometimes contentious in therapy is that of self-disclosure. In traditional psychoanalysis, analysts deliberately refrain from revealing anything about themselves.  However, my therapeutic approach is that of Cognitive Behavioral Therapy (CBT).  There is no such prohibition in CBT and I find that I tend to do a lot of self-disclosure with patients whom I think will benefit from it.  I do, however, think it is important to differentiate between self-disclosure for the therapeutic benefit of the patient verses the burdening of the patient by unloading the therapist’s own baggage.  As one of my mentors, Dr. Murali Krisha once shared, “Never share things with patients that would add to their sorrow or cause them to worry about us.”

 

Examples of therapeutic self-disclosure may range from addressing issues that patients may have with unrealistic, perfectionistic standards through relating the standards and expectations I have of my own life to helping those who are struggling with feeling of frustration or low self-esteem by sharing how I motivate myself by “giving credit” or other such techniques I have used in my own life with success.

 

I don’t use self-disclosure with every patient but it does happen frequently. Self-disclosure is a way to give people a different perspective—a different way of thinking about their problems.   I have also found that it goes a long way in strengthening the therapeutic relationship when patients recognize that I am a human being who is willing to share something of myself to help them.  

Does this mean I can get a “pedi” with my FSA?

A small study in Japan (n=13) looked at the autonomic, neuro-immunological and psychological responses to wrapped warm footbaths.   “Warm wrapped footbaths” were associated with an increase in parasympathetic activity and decrease in sympathetic activity as measured by serum cortisol levels and salivary igA levels.  Hmmmm…. so footbaths are relaxing…..  

I actually do recommend bodywork, whether massages or pedicures, to patients to help manage and mitigate the effects of stress.  How much better to get a pedicure than to pop an extra benzo.

Why do I do what I do?

At the simplest level, it is because I love what I do.  A colleague/ mentor encouraged me a few years ago, to imagine what my practice would be like if I were free to practice medicine the way I wanted to.  So I did…then I made it happen…and it has made all the difference.

 

I was originally drawn to medicine through my love of science… and the observation that nothing “grossed me out”.  In junior high, I contemplated psychiatry…as I enjoyed helping my friends work out their problems.  In med school I was drawn to OB and ER, but quickly realized that I do not function well in the middle of the night.  After a few weeks on my psychiatry rotation, the decision was clear.  I signed a residency contract before the start of my fourth year of medical school. 

 

Psychiatry embodies several aspects that I loved from ER and OB/Gyn rotations:  an ongoing relationship with patients, the opportunity to really listen and hear people, and the fact that it is never boring.  I have always loved stories… I may not be the greatest with names, but I generally remember all of the stories.

 

I often discuss with my patients the concept of basic human needs:  obviously food and shelter… but also intimacy, joy, and a sense of “purpose”.   My medical practice fills many of those needs in myself.  I sometimes question why being a wife and mother isn’t “good enough”, although I do believe that they are most noble and important roles… it seems to come back to the thought, “…because I know I’m supposed to be doing something more.”

 

A therapist who offices with me, has a verse from Galatians 6:2 on his business cards… “Bear each other’s burdens, and in this way you will fulfill the law of Christ”.  I do consider my practice as my ministry.  I am blessed and honored by these people who trust me with their wounded souls and chaotic lives.  I do not take my responsibility lightly; I continually look for ways that I can facilitate relief from their suffering.

 

My patients sometimes remark, “How can you do this?  How can you listen to these stories all day?” I guess it comes to down to my steadfast and stubborn belief that things can get better.  I was once afraid to share this optimism with patients. Now I realize that giving someone hope and the assurance that they don’t have to go down the path alone, can be very powerful medicine.

Bipolar Voices

One of the frustrations that I hear voiced from my patients with bipolar disorder is the feeling of isolation and of being an outcast.  “How can I talk with someone who will think I’m crazy if I tell them I’m bipolar.”  Add this loneliness to an existing depressed mood and you have a downward spiral of negativity and hopelessness.  One of the few positive outcomes of direct to consumer advertising by drug companies has been the subtle move towards mainstream acceptance of mental health disorders.  Unfortunately, there are miles to go before one can admit with the same nonchalance that one has bipolar (or any other mental disorder) as one would with high cholesterol.  While a few support groups exist, they do not meet the needs of all patients and tend to be utilized by those who are not functioning well.  “Where are the bipolar patients who aren’t on disability and on five different meds?”  Most likely, they are working, spending time with their family….but probably not attending a support group; at least, not while they are doing well.  It’s a shame too:  it would be nice for those who have had success in managing their condition to share some of their strategies and tips with others.  Until then, there is a wonderful multimedia collection of stories on the New York Times website from patients living with bipolar disorder:

http://tinyurl.com/bipolarvoices

Fad Diet De Jour

As I was reading the Sunday paper, I notice an article entitled “Clinic Takes Advantage of New Weight loss Discovery”.  Turns out, this was not an article, rather a paid advertisement, and in no way a “new discovery”.  I am personally and professionally interested in weight management so I decided to do some investigation. 

 

This local, family practice physician is promoting hCG Therapy for weight loss.  The ad includes the statement, “If you can’t lose weight, it may be because your body’s signals that used to come from brain areas like the amygdala, hypothalamus, and pituitary gland have stopped sending hormones to your stored fat, telling it to move.  HCG Therapy replaces this process.”  I have had two different patients try this program, in their words, “out of desperation”.  They were charged $2500 (paid up-front) for 6 weeks worth of injections of hCG.  Neither patient lost weight, but more shocking, neither patient was told that this was NOT FDA approved.  Stephen Barrett, M.D. talks about this “therapy” on his website: www.dietscam.org/reports/hcg.shtml . I found more information about this “discovery” on the Dr. Weil’s website as well:

 

The acronym hCG stands for human chorionic gonadotropin, a hormone produced during pregnancy. It is made by cells in the placenta and is believed to mobilize abdominal fat to help nourish the fetus. The notion that daily injections of hCG combined with a severely limited caloric intake of only 500 calories per day would prove an effective weight loss method goes back to 1954 when a British physician, A.T.W. Simeons, proposed it. The idea is that if the hormone can convert fat to calories during pregnancy for use by the baby and, in the process, speed the mother’s metabolism, it can do the same thing when injected into people who want to lose weight.

 

The trouble is, it doesn’t work. Over the years, a number of clinical trials have tested the diet both in Europe and the United States, and none has found that hCG has any positive effect. Sure, you can lose weight on this diet – but that’s because you consume only 500 calories per day, not because you inject yourself with hCG. A study published in the American Journal of Clinical Nutrition in 1976 found no statistically significant difference in weight loss, percent of weight loss, hip and waist circumference, weight loss per injections, or hunger ratings among patients who were on a 500-calorie-per-day diet combined with hCG injections and those who were on the diet and received placebo injections. Taking hCG doesn’t appear to be particularly unsafe, but there is no scientific proof that it does any good. (www.drweil.com/drw/u/QAA400413/Pregnancy-Hormone-for-Weight-Loss.html )

 

Such programs “takes advantage”…of individuals’ desire for an “easy fix” and belief that “if it is from a doctor, it must be real treatment.”  I am saddened that there are members of the medical profession engaging in such seemingly profiteering practices.  While I understand the desperation and frustration of failed weight loss efforts, why not promote increasing exercise and a healthier diet (nutritious, balanced)?  Even if individuals did lose some weight from the ultra-low calorie diet, what is the likelihood that they would be able to maintain that weight loss?  Extremely low, especially if the thoughts and behaviors that led to the weight gain were not addressed.  Sometimes there are no shortcuts.  As they say, “If it sounds too good to be true…”  

What does it mean to be a Christian Psychiatrist?

I consider myself to be a Christian Psychiatrist.  To me, this is a distinction that implies something more than the mere fact that I am both a practicing Christian and psychiatrist.  As such, I incorporate spirituality into my treatment when appropriate:  this can manifest through discussion of appropriate verses from scripture to suggestions of daily personal quiet time and meditation.  I will pray before (and sometime while) seeing patients for God to give me the words to relieve suffering, to shed light on a situation, or to give me discernment in the proper path.  I believe fully that I am an instrument of healing and that God is the true healer.  I also believe that our bodies have an innate capacity for self-healing that we are to facilitate.  This does not mean that I consider myself a “spiritual healer” or that I don’t use psychopharmalogic tools; in fact, I would estimate that 95% of my patients are on at least one medication or another.  Nevertheless, I am convinced that God is at work: I have experienced times when I felt the Spirit was present and times when I have had responses that I couldn’t attribute to anything from my formal training. 

 

I do not consider my position to be one of proselytizing:  while I fully acknowledge the “great commission”, I think it an abuse of my position to do so in my practice, especially directly.  Beyond “bearing the burdens of another” (Gal. 6:2), I endeavor to reflect Christ in all that I do.  One risk inherent in promoting oneself as a Christian Psychiatrist is that of alienating patients of differing faiths and viewpoints.  I have noted patients’ comments “I know you’re a Christian but…”;  I welcome such opportunities to reassure patients that I am not here to judge and that my only ambition for them is whatever ambition they have for themselves.  Another responsibility inherent in Christian Psychiatry is the same for all who practice medicine:  continuing education.  I frequently say, “Whatever you feed grows”.  My own spiritual lifei is fed through a non-denominational bible study:  BSF (Bible Study Fellowship).  BSF is a seven-year, intensive study that I find both spiritually and intellectually fulfilling. (www.bsfinternational.org) 

 

Is it necessary for a psychiatrist to share the same religion in order to effectively treat?  As was referenced by the Shrink Rap blog-post “A Shrink Like Me”, (http://psychiatrist-blog.blogspot.com/2007/05/shrink-like-me.html) I agree that shared religious belief is a preference… not necessity, much like the preference for male or female therapist; but also something more…it speaks to a desire for more complete understanding.  In “my neck of the woods”, it is certainly more common than not.  Overall, I like to think that spirituality represents another tool to be utilized judiciously and I am pleased to have it as a part of my stratagem.