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Clinical
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Atlanta Medical
Psychology
The clinical
practice of Dr. David B. Adams is located in The Medical Quarters in
the northside of Atlanta at the junction of Scottish Rite, Northside
and Saint Joseph's Hospitals. Dr. Adams consults to occupational
medicine, surgeons, nurse case managers, insurers and employers
regarding the psychological impact of work-related injury and the
role of psychological factors in short- and long-term
disability. |
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| PAST QUESTIONS OF THE WEEK |
March 27, 2004
Q
"My mother is obsessed with
minor physical complaints that she believes are indication
that she is dying. She has done this for years and years.
Would psychological care help?"
A Traditional
care in a psychologists office is likely ineffective because your mother is
unlikely to comply.
"Hypochondriasis
is a chronic, disabling, and generally refractory condition that has a
prevalence estimated at 5%.
Hypochondriasis
leads individuals to selectively attend to benign bodily symptoms, amplify
and misattribute them to putative diseases, resulting in further symptom
amplification and disease conviction. As a result, social and role
functioning are also affected.
Cognitive
behavioral therapy (CBT) is effective for hypochondriasis.
Using
educational information, an illustrative exercise, and a scripted
discussion, each CBT session dealt with one of five factors underlying
symptom magnification and hypochondriasis: attention and bodily
hypervigilance, beliefs about symptom etiology, circumstances and context,
illness and sick role behaviors, and mood. The primary care physicians
(PCPs) of patients randomized to CBT received a consultation letter.
The CBT group had significantly lower levels of hypochondriacal symptoms,
beliefs, and attitudes and health-related anxiety at 12 months. They also
had less impairment of social role functioning and intermediate activities
of daily living.
Hypochondriacal
individuals are by definition convinced of the medical nature of their
condition and therefore psychosocial treatment seems nonsensical to them.
The treatment must be made more attractive in the future by seamlessly
integrating it into the primary care process and conducting it in the
medical setting." JAMA. 2004;291:1464-1470
March 22, 2004
Q
"We have malpractice crisis
here in Mississippi, and many of us are simply dropping out
of practice. Certainly, aside from reasonable caution, there
must be some way of limiting our vulnerability to these
thieving attorneys...yes...no?"
A There
are studies that indicate that disclosing errors as they occur may help
offset some litigious behavior. "Full disclosure of medical errors does not
generally increase or decrease a patient's intent to seek legal advice.
However, the physician-patient relationship is strengthened when clinicians
are more forthright. "Physicians can influence the consequences of the
disclosure process in a positive way if they disclose fully by explaining
what occurred, acknowledging responsibility, apologizing, and promising to
work to ensure that the error does not recur."
More than 90% of respondents stated that patients should always be informed
of errors, regardless of outcome. Although most believed that financial
compensation is in order if the patient is injured or disabled, less than
16% held the opinion that financial compensation was in order in the absence
of injury.
The results also show that taking responsibility for honest mistakes and
offering an apology was associated with higher patient satisfaction and
greater trust in the physician.
In none of the scenarios did admission of an error exacerbate subjects'
willingness to bring legal action. Indeed, "full disclosure may tip the
balance to give the physician the benefit of the doubt," they add, with
individuals more likely to "accept reasonable compensation more quickly if
they perceive the wrongdoer as having a heart and taking responsibility."
Ann Intern Med 2004;140:409-418,482-483.
March 15, 2004
Q
"Some
PTSD patients do not seem to get much better regardless of
treatment. Are there any new approaches being considered?"
A
"High-frequency repetitive transcranial magnetic stimulation (rTMS) may have
a therapeutic effect in patients with posttraumatic stress disorder (PTSD).
A research study included 24 patients (17 men and 7 women) who fulfilled
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
diagnostic criteria for PTSD. Patients were randomly assigned to receive
rTMS at low frequency (n = 8) or high frequency (n = 10) or sham rTMS (n =
6). None of the patients suffered from a chronic medical disease. However,
all but four of the subjects were receiving polypharmacy. Patients did not
stop or change drug treatment in the three weeks before or during the study.
They also continued to receive supportive psychotherapy.
During
high-frequency rTMS treatment, mean PTSD Checklist scores decreased. The
patients who received 10-Hz rTMS showed significant improvement over
subjects from the sham groups in the Hamilton anxiety scale scores. Post-hoc
tests revealed no significant difference between treatments or times for the
Hamilton depression scale, however.
Fourteen patients across all treatment groups reported headache, but
treatment was generally well tolerated. Eleven participants across all
treatment groups also reported sleep improvement.
Am J Psychiatry. 2004;161:515-524
March 8, 2004
Q
"My
father is elderly...and depressed...I do not think I can get
him to a psychologist, and since my mother died, I am afraid
that he sees no reason to live and may harm himself."
A You may
be much more successful getting him to see his family physician: "A primary
care intervention can reduce suicidal ideation in older patients with
depression...Older Americans comprise about 13% of the US population, yet
account for 18% of all suicide deaths...The majority of older adults who die
by suicide have seen a primary care physician in preceding months.
Depression is the strongest risk factor for late-life suicide and for
suicide's precursor, suicidal ideation.
...intervention included a clinical algorithm for treating geriatric
depression in a primary care setting, which recommended a first-line trial
of (a) selective serotonin reuptake inhibitor...also included
treatment management by depression care managers.
Compared with patients receiving usual care, patients receiving the
intervention had a faster decline in rate of suicidal ideation...Patients
reporting suicidal ideation had a faster resolution of this symptom when
treated with the intervention than when treated with usual care...Because
depression treatment was provided at no cost to participants, the study
findings may not be generalizable to other settings.
JAMA. 2004;291:1081-1091
March 1, 2004
Q
"Since
my father's stroke, he has been listless. I guess you would
say he is depressed, right?"
A Perhaps
not. "Apathy is a symptom that is independent of depression in
poststroke patients, according to a presentation...Apathy and depression are
often confused...they are separate if overlapping syndromes...Apathy
Evaluation Scale (AES) stroke subjects had significantly higher depression
and apathy levels than did control patients. Depression only was present in
10% of stroke subjects, apathy only in 23%, and both apathy and depression
in 7%. ...four factors that best predicted abnormal AES score were
interest/motivation, social contact, insight/purpose, and effort. The four
factors that best predicted abnormal scores on the Hamilton Depression
Rating Scale were depressed mood, sleep, somatic symptoms, and agitation,
which accounted for 57% of variance. None of the apathy or depression
factors correlated significantly. Apathy was associated with deficits in
attention and processing speed, whereas depression was associated with
deficits in memory and executive function. Neuroimaging correlates of
depression and apathy were also different.
ICBP 2004: Abstract 5010. February 9-13, 2004.
February 23, 2004
Q "How does
sympathy differ from empathy?"
A The terms
have become largely interchangeable although at one time, sympathy referred
to feeling the other individual's misery while empathy referred more to
merely understanding their suffering without yourself experiencing it.
Some of the same
brain regions involved in feeling physical pain become activated when
someone empathizes with another's pain. And when it's time to feel better,
thinking that a drug helps can make it so, according to a different
brain-scanning study that finally caught the power of placebo in action.
In the empathy study, British researchers recruited 16 couples. One at a
time, the women were put into MRI machines; the men sat nearby. The women
could see only their loved one's hand and a computer screen. The women and
men got brief electric shocks to the hand. The computer screen flashed who
would get the next shock and whether it would be mild or very sharp.
When the women got shocked, the MRI showed how their brain's entire pain
network activated, researchers reported. They registered feeling the jolt
and how much it stung, from sensory brain regions, as well as how much it
made them suffer — the "affective" or emotional regions.
But when the men got shocked, part of the women's pain network sprang into
action, too — not sensory regions but emotional ones. They knew when the men
were being shocked only by watching the computer screen.
Much like the vivid feeling when imminent pain is imagined and the heart
speeds up before the actual sensation arrives.
Men were not studied for their reaction to how women responded to a shock.
The couples were not told that this was a study of empathy so as not to rig
the results. But when the women were asked to describe how they felt when
their partner was zapped.
It was not "emotional contagion," like how one person's yawn can set a whole
room to yawning, because the women could see only their partner's hand, The
women were using the same brain areas that anticipate one's own pain.
In the second study, volunteers put inside MRIs had either electric shocks
or heat applied to the arm. The pain activated all the expected neural
pathways. Then, researchers smeared on a cream they said would block the
pain. In fact, it was a regular skin lotion.
When the volunteers were zapped again, they reported significantly less pain
— and pain circuits in the brain showed they really felt better. Those were
the same brain regions that respond to painkilling medication.
Then researchers spread on cream again, this time telling the volunteers it
was a placebo — and they hurt all over again.
Doctors long known have known the placebo effect is real. It is one reason
that they talk up the benefits of a drug as they write the prescription.
February 16, 2004
Q
"Can mood impact whether a person gets an illness like
diabetes?"
A There
are some interesting findings regarding depression and diabetes: "Depressive
symptoms appear to be predictive of the development of type 2 diabetes. The
researchers observed a positive association at baseline between depressive
symptoms and body mass index, fasting insulin, systolic blood pressure,
caloric intake, physical inactivity, and current smoking. The association
between depressive symptoms and the risk of diabetes remained after
adjustment for stress-associated lifestyle factors.
The authors suggest that there are at least four possible mechanisms by
which depressive symptoms and diabetes could be linked. One is that
"depressed individuals are less likely to be compliant with dietary and
weight loss recommendations and are more likely to be physically inactive
and nonadherent with medications." Others involve low socioeconomic status,
antidepressants that might cause weight gain, and neurohormonal changes.
Diabetes Care 2004;27:429-435.
February 9, 2004
Q
"I was circumcised at the request...or demand...of my
wife. I am now having problems with erection and think I likely need Viagra.
Why do they not tell patients that this could happen?"
A "Circumcision
does not adversely affect sexual function...It does prolong ejaculatory
latency, but the authors suggest that this may be an advantage.
...Before circumcision, and again after a postoperative interval of at least
12 weeks, sexual performance was evaluated using the Brief Male Sexual
Function Inventory (BMSFI) and ejaculatory latency time.
Although the differences... before and after circumcision were not
statistically significant in... the BMSFI, the mean ejaculatory latency time
was significantly longer after circumcision.
...the
psychological influence of circumcision may be more pronounced than the
organic effect."
Urology. 2004;63:155-158
February 2, 2004
Q "My son is
having a rough time with toilet training...going "number 2" if you know what
I mean...We have reminding him how important this is, and he makes no
progress. What is wrong with him?"
A Likely
very little. Research indicates that "hiding while defecating is
associated with toileting refusal, constipation, and stool refusal in
children who are being toilet trained...that parents should avoid negative
terms and praise defecation to shorten the duration of stool toileting
refusal.
"We hypothesized that children become cognizant of the negative connotation
that feces have in our culture through parental and nonverbal signals. This,
in turn, causes children to feel shame and embarrassment when defecating,
leaving them to hide when defecating in the diaper."
The 115 nonhiders (53.4%) were significantly less likely to have stool
toileting refusal, frequent constipation, or stool withholding. Caregivers
received one of two handouts that emphasized a child-oriented approach to
toilet training. The intervention handout instructed parents to not refer to
stool in negative terms and, in the months preceding toilet training, to
increase praise for defecating.
"Although the
direct relationship between toilet training and problems such as refusal,
constipation, and encopresis has not been established, at the very least,
parents should be educated about the signs of problematic toilet training (eg,
hiding, stool holding, painful bowel movements) and how such problems can be
managed if they do happen during training."
Arch Pediatr Adolesc Med. 2003;157:1153-1154, 1190-1192, 1193-1196
January 27, 2003
Q "I have
a friend who almost suffocated in a cave collapse. They say he now has PTSD.
Was this just from the sense of being trapped or could it be caused by the
fact that there was limited air?"
A PTSD
arieses when there is a threat of serious harm to self or others which is
terrorizing to the individual. Thus, both factors in a cave collapse could
individually, and certainly combined, be a cause of PTSD.
A
recent "follow-up study showed a high rate of posttraumatic stress disorder
(PTSD) in survivors of acute respiratory distress syndrome (ARDS)
ARDS can result from various disorders (e.g.,
trauma, pneumonia, sepsis). The threat to the normal matter-of-factness of
breathing, dependency on supportive apparatus, and the enormously impaired
ability to communicate ...are central aspects of these patients' frightening
experiences.
Am J Psychiatry. 2004;161:45-52
January 19, 2003
Q "Is
there a relationship between stroke and memory impairment even if the person
has no paralysis after the stroke?"
A Certainly.
"Increased risk of stroke as determined by the Framingham Stroke Risk
Profile (FSRP) is associated with increased risk of cognitive decline...(and
the) pattern of these cognitive deficits is similar to that seen in
cognitive impairment of vascular origin.
...people don't just suddenly develop vascular dementia or Alzheimer's
disease (AD) — it is very likely a long-term and subtle process...In people
who have never had a stroke or been diagnosed with dementia, there is a
higher risk for performing in the lower range of cognitive ability for those
who are at higher risk of stroke within 10 years. The FRSP uses weighted
combinations of age, systolic blood pressure, presence of diabetes,
cigarette smoking, history of cardiovascular disease, and treatment for
hypertension and atrial fibrillation to determine 10-year stroke risk.
Researchers "hypothesize that the link between risk for future stroke and
lowered cognitive performance may be due to structural and functional
changes in the brain that do not rise to the level of clinical
detection...abnormal brain atrophy is related both to higher risk of stroke
and poorer cognitive ability."
It is critically important to prevent risk factors which increase risk for
stroke and to intervene early in the process of cognitive decline where the
benefits of intervention are greatest and most likely to be successful."
Stroke. 2004;35:000-000
January 12, 2003
Q "High
blood pressure leads to strokes, right? Then high blood pressure
leads to Alzheimer's Disease too?"
A This is
an article I found interesting on this topic:
"A
low diastolic blood pressure, below 70 mm Hg, is associated with an
increased risk of dementia in people over 75 years of age, according to a
new report. This risk seems to pertain only to Alzheimer's type dementia and
is highest in subjects with persistently low pressures.
For each 10-mm Hg drop in diastolic pressure, the risk of dementia increased
by 20%, the results indicate. A similar effect was seen with reductions in
mean arterial pressure. Low pressures were only linked to an increased risk
of Alzheimer's type dementia, not vascular dementia.
Analysis of the results by defined blood pressure groups revealed a
decreased risk of Alzheimer's type dementia for patients with moderately
elevated systolic pressures (140 and 179 mm Hg). However, this association
was not statistically significant.
Compared with other subjects, individuals with consistently low blood
pressures throughout the first two years of the study were twice as likely
to develop dementia.
Low BP may be both the cause and the consequence of dementia; maintaining
blood pressure at optimal levels may some day be found to reduce the risk of
dementia in elderly individuals.
Neurology 2003;61:1667-1672.
January 5, 2003
Q "I read
somewhere that worry causes breast cancer, and that if we stopped being so
stressed, we could eliminate the disease. True?"
A In
general, this is untrue. However: "Stressful life events do not, in general,
appear to be associated with the risk of breast cancer, according to a new
study. However, a "modest association" was found between breast cancer and
the death of a spouse, relative, or friend.
Studies examining the relationship between stressful life events and breast
cancer risk have produced conflicting results.
The biologic explanation of the overall association and these additional
findings might be that stress disturbs various areas of the immune system
and that impaired immune system function predisposes to malignant growth."
Int J Cancer 2003;107:1023-1029.
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