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Questions
of the Week
October through
December, 1998
October 5, 1998
Q Can you
explain what is meant by hypochondriac?
A
Hypochondriasis is a disorder with which most people are familiar. The
hypochondriacal patient is preoccupied with the fear of having a
serious disease. This preoccupation is based upon the patient’s
misinterpretation of bodily functions and despite reassurance, the
patient clings to these irrational beliefs and the consequent repeated
accessing of health care. Hypochondriasis is a somatoform
disorder that involves the preoccupation with the idea that one has a
serious disease based upon misinterpretation of bodily symptoms.
Despite reassurance from professionals that there is no disease or
disorder present, the hypochondriacal person maintains this
unwarranted fear. The person is not delusional; they realize that,
indeed, there may be nothing wrong, but their preoccupying fear that
there bodily functions suggest some undiagnosed condition. Work and
relationships are disrupted by this preoccupation. The preoccupation
may arise from minor abnormalities, misinterpretation of normal
functioning or have vague complaints which defy adequate examination.
In some cases, it is the fear of a specific problem such as heart
disease, and the individual will seek repeated confirmation from
studies and examination that they are, in fact, not ill. Some believe
that between 5 and 10 percent of those seen in general practice have
symptoms of hypochondriasis. Those with good insight often are able to
understand why their fears have arisen and to resolve them. For
others, the hypochondriacal complaints may be chronic and continue
without change.
October 12, 1998
Q I am an
internist, and I was taught that my patients with these vague
complaints of pain, or paralysis, or loss of sense of smell/taste etc
were are suffering from hysterical conversion. Is that what we have
been talking about here?"
A We now believe that there is a range
of somatoform disorders and that those with psychological factors
influencing the experience of pain and those with perceptions that
they have a disease despite reassurance that they do not, are
suffering from specific somatoform disorders. They are not all
suffering from conversion disorder (see Somatoform Disorders on this
website).
There is a somatoform disorder, however, referred to as
undifferentiated somatoform disorder in which the patient may have
concurrent conversion, hypochondrical and somatoform pain symptoms. In
order to diagnose this disorder, we assume or demonstrate that the
disorder is disruptive to occupational and/or social achievement. In
each disorder, even the undifferentiated variety, we are assuming that
there is either the lack of any physical findings or that the physical
findings are insufficient to create the distress and symptoms that the
patient reports. However, since there are physical conditions whose
source can initially be obscure, consideration is always given for the
potential for a missed organic (physical) diagnosis.
October 19, 1998
Q I feel
badly much of the time. I have an internist, and she has run numerous
tests, all of which she tells me are normal. I have a wide variety of
symptoms and thought perhaps I have that chronic fatigue syndrome, but
I have to accept that my marriage is shaky and that my job is not very
rewarding so maybe this could also be emotional. Any thoughts?"
A One possibility that should be
considered is Generalized Anxiety Disorder, and you may wish to seek
consultation to determine if this is potentially the problem or at
least a component in your problem. The symptoms of Generalized Anxiety
Disorder vary, but may include any or all of the following
presentations: The patient may report the sensation of trembling
muscles, feeling "shaky" inside, muscle tension,
restlessness and rapid fatigue. Complaints may include being short of
breath or the feeling that one is smothering, palpitations, cold
clammy hands, dizziness, nausea, diarrhea, hot flashes, frequent
urination or a "lump in the throat".
An exaggerated startle response may be present, as well as difficulty
in concentrating, trouble in falling or staying asleep, and
irritability. Importantly, the symptoms of anxiety can look like many,
many organic disease processes. Anxiety is often called the great
imposter, and there are a "gallery of aliases" for anxiety
disorders dependent upon which bodily system is most affected by this
free-floating fear.
October 26, 1998
Q My
daughter is obsessed with the shape and size of her nose. The school
psychologist feels this is not a minor problem adjusting to who she is
but a problem with which we should be concerned. In recent weeks, you
have been discussing somatoform disorders, and I do not believe that
this applies to her or what to do. Any input would be
appreciated."
A Body Dysmorphic Disorder is a
somatoform disorder characterized by an imagined defect in appearance
or excessive concern or preoccupation with a slight physical defect.
The person with body dysmorphic disorder is distressed to the point
where social, occupational or academic functioning is disrupted.
Patients with the disorder are continually checking their appearance
and occupy significant periods of their days examining themselves.
Others become so distressed that they avoid examining themselves in
the mirror in an attempt to decrease their sense of distress. They may
attempt camouflage and/or becoming markedly socially avoidant.
Your child's school psychologist may have valid concerns for your
daughter. You do not mention whether she would be willing to seek
professional care for the problem, but the earlier that the problem is
addressed, the more likely she is to work through this negative
self-assessment.
November 2, 1998
Q I
am wondering if I am having panic attacks. I have these severe periods
of stress and really feel miserable. Can you explain the disorder for
me?"
A A panic attack is a discrete period,
not just part of a continuum, in which you feel a sudden onset of
anguishing anxiety characterized by emotions ranging from apprehension
to fear to actual terror. The person may have shortness of breath
(SOB), chest pain, chest constriction, fear of losing control, fear of
impending heart attack (MI) and palpitations. It occurs in the context
of several anxiety disorders. It builds into its peak within 10
minutes. Among the following 13 symptoms, the individual may have four
or more of the following: sweating, palpitations, trembling, SOB,
choking, dear of dying, numbness/tingling, chills/hot flashes, chest
constriction, GI distress, dizziness/unsteadiness, feeling of
unreality or detachment, etc.
November 9, 1998
Q My
husband has managed to avoid promotions and professional advancement
by his avoidance of presentations that are part of his job. He even
avoids group functions such as office parties and holiday gatherings.
He appears to know and can talk about his discomfort. What is this
likely to be and what can be done?"
A A social phobia can, in some cases,
precipitate the panic attack discussed last week. The individual
develops a pattern of avoidance to prevent the occurrence of extreme
feelings of discomfort, anxiety, and dread. While such individuals can
often force themselves to act in these social situations, they do so
with extreme dread if at all. This, not uncommonly, disrupts their
relationships and their occupational advancement. They are often
tremulous as a result of their fear of ridicule or criticism and
concurrently fear that the tremulousness will be noted. These symptoms
do not spontaneously remit (simply cease) and the pattern of
anticipatory anxiety and avoidance can, and often does, generalize and
include more and more of the environment to be avoided. The person is
aware of the problem but feels powerless to do anything about it.
November 16, 1998
Q You
discussed social phobia last week, but my situation is somewhat worse
and seems to be increasing over time. I feel like I am trapped in
those social situations. I am not merely uncomfortable, but I feel
like literally I am going to die when in these settings. I feel
helpless, frightened and that I cannot escape and that something
dreadful will happen. As a result, dreadful this do happen. I get
increasingly uncomfortable and all the symptoms you discussed in the
past having to do with generalized anxiety disorder. Is this the same
thing just worse?"
A Agoraphobia involves the fear of being away from the
home, being alone, being alone or in a line of people, travelling or
any situation in which the individual believes they be overwhelmed by
their fears and no help readily available. Obviously, they then avoid
such settings. There is the fear of having an anxiety attack, and if
the outings are attempted, they are executed with great fear and
loathing. The often cited concept is "fear of the
marketplace." People can have panic attacks with or without
agoraphobia. Agoraphobia often represents more the avoidant pattern
that emerges when the fear of impending panic is tied to specific
events or potential events. The person creates for themselves, based
often upon minimal past experiences, a series of anticipatory states
in which they contemplate, obsess over potential outcome and, often,
thereby, assure that outcome. Desensitization procedures and
psychotherapy with and without medication if often very helpful to
these patients who need to amass a series of successful experiences to
offset the fears that they are developing while isolating themselves.
November 23, 1998
Q About
three weeks ago I was in an automobile accident. I was bruised but not
badly injured. It was a rather frightening three car pile-up, and I
thought I was okay, but about a week ago, I started having thoughts of
the accident which I could not stop, dreams of it happening over and
over, and I find myself very uncomfortable driving. Does this mean
anything?"
A Acute Stress Disorder occurs within
four weeks of an event in which a person felt at risk for survival,
intense fear and/or helplessness. The Disorder can be characterized by
a sense of detachment, feeling as though things are unreal, forgetting
parts of the event, and reduced awareness of daily activities. The
patient can have recurrent thoughts, dreams and sense of reliving the
event. Many patients begin to avoid settings similar to that in which
the traumatic even occurred. They concentrate poorly, are restless and
may startle easily. If the symptoms persist longer than four weeks, it
may be posttraumatic stress disorder which we can discuss next week.
The symptoms can be distressing, may persist, and the prudent thing to
do would be to seek consultation to determine if care is needed.
November 30, 1998
Q My
husband appears to be having nightmares but swears that he is not. He
awakens both of us with yelling out in the night. He is miserable, and
I do not know what to do. Although he is overweight, he continues to
eat heavily before bed and maybe this is causing the nightmares.
A Sleep
disorders can be primary in which there is a defect in the sleep
timing mechanism (sometimes called sleep architecture) called
dyssomnias and by parasomnias which includes nightmare disorder. Sleep
disorders may also arise from medical conditions, another
psychological problem such as anxiety and/or depression or even
induced by substance (Eg. alcohol). I wonder if you may not be
describing a breathing-related sleep disorder in light of the manner
by which he awakens and his insistence that there is no nightmare.
This can be caused by breathing obstruction or a process that
interferes with breathing during sleep. In light of his weight and
eating, that may be one of the first areas to investigate.
December 7, 1998
Q ..about
homosexuality...(some) say you are born that way but the others are
convinced that you turn this way...are people born gay or do they just
turn that way over night."
A Years ago a father came to me with
his 21 year old homosexual son. The father said "doc, can you fix
him?'" I reminded him that the son was not unhappy, just
uncomfortable that the father could not accept his sexual choice and
that it was this father-son (and mother-son) alienation that was
distressing the son. The father replied: "Oh, now I
understand...but can you fix him?"
Homosexuality is not a psychological disorder. Homosexuals must deal
with social rejection and stereotyping. While there are unquestionably
traumatic experiences that can impact sexual preferences of specific
individuals, homosexuality is not considered a learned preference
which must be unlearned.The preference for the same sex is often
apparent to the individual early in life, and society shapes the
willingness to accept and act upon it.
December 14, 1998
Q You
had been talking about sleep problems arising from breathing
obstruction, but are there not people who have regular nightmares and
cannot this be a disorder for some people?"
A
Nightmares can be a feature of the anxiety disorders, acute stress
disorder and posttraumatic stress disorder. But you are correct, there
is a disorder called Nightmare Disorder that is one of the sleep
disorders.
Nightmare disorder is a repeated (over nights) series of alarming
dreams that lead to awakenings and full alertness from the individual
during the night. This causes lack of effective sleep and social/
occupational dysfunction during the day. The most common components of
such dreams are those involving danger to the individual (pursuit,
harm, etc) or involving humiliation or shame. For many such patients,
sleep avoidance leads to further impairment. There are sleep
laboratories which can measure for such occurrences. This can begin in
early childhood, and if unaddressed, persist through adulthood.
December 21, 1998
Q I do not
sleep well, and I have tried to explain to my husband that this is a
great concern. Often I feel quite miserable, but he dismisses this as
`when you get tired enough, you will sleep.' Is this a problem with
which I should be concerned?"
A Primary
insomnia is one of the dyssomnias and is characterized by difficulty
initiating or maintaining sleep or having nonrestorative sleep in
which the individual feels unrested. This results not only in daytime
somnolence (fatigue) but can impair reasoning, judgment and mood.
Additionally, this can result in appreciable health concerns including
blood pressure changes. And the medications most often given for short
term relief of sleep can complicate matters further since they tend to
be habituating and not particularly effective when used over extended
periods. It is also important to be certain that the primary cause is
not a breathing related disorder, nightmare disorder or problems with
mood disorder.
December 28, 1998
Q I have no
trouble sleeping. In fact, I could, and do, go to bed early and then
sleep late in the morning. I do not work and have no children so it is
easy for me to do my housework by getting up at 9am. I am in bed again
by 9pm, but recently I have begun to take naps. My husband is
irritated by this and says it is unnatural, but I feel that there is
nothing for which to get up, and I seem to require increasing sleep
this last year. Do you have any thoughts on this?"
A Primary
hypersomnia is characterized by excessive somnolence (sleepiness) with
prolonged periods of sleep and day time episodes of napping. This can
result from a mood disorder such as major depressive disorder and
needs to be differentiated from narcolepsy. There is always a concern
that diet or medication intake be separated and determined not to be a
factor in the excessive need for sleep. Such increased sleep
invariably causes difficulty in occupational and social interaction
since the drive for sleep exceeds the drive for achievement or
interpersonal contact. Sleep centers ask for journals and perform
polysomnography to measure the nature (architecture) and time periods
of sleep.
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