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Questions of
the Week
November
through December, 1997
November 3, 1997
Q My husband and son
both have the same sleep problems: they have trouble falling asleep.
They both have problems with concentration, are very irritable and
worry continually. I think this may be a physical problem since both
complain of muscle tension and seem to have no ability to control the
worry. What sort of doctor should they see and what is likely wrong
with them?
A There are many physical causes for such complaints
including hypothyroidism that are readily diagnosed by your primary
care physician (family physician, internist or pediatrician). You do
not mention problems with mood other than the irritability, but
concerns for depression have not been eliminated by the information
you provide. There is also a condition called generalized anxiety
disorder (or overanxious disorder of childhood) which also needs to be
considered. There are numerous medications for depression that are
outlined elsewhere on this website as are some of the medications used
to treat anxiety. In the case of both, however, there are also
treatment modalities that enable the individual control of such
complaints without reliance upon medication (some of the anxiolytic
medications can produce dependency). The important thing will be to
explain all of their symptoms to whomever they see. Far too often,
patients will mention only the most troublesome symptoms without
mentioning those which would truly help with differential diagnosis.
November 10, 1997
Q I went to see a
psychologist with my husband. This is my first marriage and my
husband's second. My husband has not been pleased with my sexual
response, and we argue about this continually. The psychologist said
that I suffer from "inhibited female orgasm", but I do not
know what that means or if it is accurate. Can you shed some light on
this?
A If you have a persistent or recurrent delay or
absence of orgasm assuming that other phases of sexual stimulation
have occurred, you may be suffering from female orgasmic disorder (the
current diagnostic nomenclature). However, there is a wide variability
between in intensity of stimulation required and the intensity of
orgasm. Any doctor making such a diagnosis needs to take into account
the age, sexual experience and the adequacy of sexual stimulation that
the patient receives during a sexual encounter. From your brief
description, it did not appear that you were distressed as an
individual but that your level of response was a source of discord in
the marriage.
November 17, 1997
Q I understand that
depression comes from a chemical imbalance, but I am curious as to why
so many people tend to feel hopeless when they are depressed. Is this
because they feel that so little can be done for them?
A Actually your
question covers many important areas at once. Let me briefly try to
address some of the issues that you are presenting:
- the lack of available serotonin (a
neurotransmitter) is central to most biochemical theories of
depression, but other neurotransmitters such as norepinephrine are
also involved.
- many of the newer antidepressants
help the brain maintain a more appropriate level of serotonin
- among the physical symptoms of
depression are sleep disorder and changes in eating with attendant
weight gains or weight losses
- many depressed people do not feel
"sad" but instead feel a sense of depletion of energy,
increased irritability, frustration intolerance, impatience and
the lack of ability to enjoy (called anhedonia) things which were
once pleasurable. Such individuals will also report problems with
concentration and decision making
- patient's often feel helpless to
change their symptoms and hopeless (negative expectancies about
the future)
Among psychological disorders, we have
had the greatest recent successes in the treatment of mood disorders.
The combination of psychotherapy and medication is the most effective
means of addressing the problem, but unquestionably, in our society,
many individuals would prefer to take the medication without
involvement in psychotherapy. Likely, this arises from the individual
to see themselves as a victim of a chemical imbalance and not a
participant in the process of their disorder and its treatment.
November 24, 1997
Q I am not certain I
understand the reason why someone with a phobia needs medication. You
learn a phobia, and medication will not make you unlearn it. Please
explain.
A Part of the phobic
response is not only the exposure to the situation which evokes fear,
if not terror, but to worrying about the exposure before it occurs.
A person, fearful of flying for
example, will worry about an impending flight, make elaborate plans to
avoid the flight and may think almost continually about possible
exposure to the situation before it occurs.
Among the many benefits of medication
is the management of "anticipatory anxiety." Medication,
when used on a short term basis, can lower the individuals anxiety
prior to the exposure. This reduction in anticipatory anxiety can
relax the patient sufficient to enable them to begin to address the
phobic situation itself. Put another way: unless we lower the
patient's anticipatory anxiety, they may not be willing to deal with
the problem at all.
December 1, 1997
Q My mother died
recently, about four months ago, and both friends and family seem
excessively concerned about my grieving this loss. At what point does
grief over loss require professional attention?
A If the person is
still grieving after two months, then the diagnosis of Major
Depressive Disorder needs to be considered, but there are cultural
differences in grieving and a time span alone does not determine that
a clinical disorder is present. Some concerns would be that the
individual has guilt regarding the death, feels that they may be
better off dead or should themselves have died rather than the
deceased individual, the survivor feels worthless or has symptoms such
as believing that they are hearing the voice of the dead person or
that the death was some form of punishment inflicted upon them. In
such cases, there should be consideration for a clinical disorder to
have arisen during the process of grief or in response to the loss.
However, many individuals involved in normal grief reaction will seek
professional assistance in dealing with the loss. It would be
inaccurate to believe that all of those who seek care after a loss are
doing so as a result of the development of a clinical disorder.
December 8, 1997
Q My wife and I want
to enter into joint psychotherapy, and I do believe our problems are
not extensive or complex, but we have financial limitations and need
to know costs and length of time we shall be in care. Also, we do not
know how to go about finding a psychologist except through the yellow
pages, and frankly, that does seem the best approach. Any direction or
recommendations would be appreciated.
A Managed care has forced many psychologists to
re-examine their treatment parameters and guidelines for frequency and
duration of care. Many problems can be addressed with very few visits
(E.g. 1-4) and perhaps most problems that are not extensive and of
longstanding duration, can be addressed in visits spanning a very few
months. Some doctors will see their patients every two weeks for the
first several visits and then space visits, enabling the time needed
for the patients to work upon their problems and for change to occur.
Costs vary according to common factors of what is usual and customary
for the community. The most commonly sited costs for an appointment
varies between $90 and $150 (with the appointment time ranging from
30-50 minutes). However, there are smaller communities where the cost
per visit is considerably less (E.g. $60) and communities in which the
cost may exceed $250 per visit. Access to credentials and areas of
expertise can be found in such directories as the National Register of
Health Service Providers in Psychology. Additionally, your State
Psychological Association may have a compiled list of doctors with
their specific areas of clinical interest listed. The American
Psychological Association and many State associations also maintain
Internet Web Sites.
December 15, 1997
Q School was difficult
for me. My job, which involves data analysis is also difficult for me.
Neither my brother nor my sister graduated from high school, and I
barely made it through college. To my knowledge no one has ever tested
my intelligence. I do not know what my I.Q. is or even what that
means. Can you give me an overview on intelligence and the role of
I.Q. in determining one's ability to succeed?
A The concept of intelligence quotient (I.Q.)
is a statistical convenience. I.Q. is not a biological reality but
merely a means of comparing groups of individuals in their ability to
perform cognitive and motor tasks. It permits us a means to look at
the distribution of general intellectual functioning across a
particular population. An IQ between 85 and 115 would encompass more
than two-thirds of the population. An IQ above 145 would be
statistically rare as would an IQ below 55. There is little doubt that
individuals of superior intellectual functioning can fail, and those
of subaverage intelligence can succeed. Motivation is a central factor
in academic and work successes. The debate as to whether intelligence
is wholly genetic or is environmentally modifiable likely will always
rage in the scientific community. Most psychologists believe that
there is a genetic basis for intelligence and an environmental basis
for motivation. I am not at all certain that knowing one's IQ is as
important as knowing your body weight. To date, no one has died from
too high of an IQ. It may be important to know someone's IQ to
determine why they find a particular task either challenging, boring
or threatening. As a worker or employer, your concern should focus
upon an individual's motivation to do a job well.
December 22, 1997
Q Since the media
reports an increase in the use of marijuana, I was curious as to how
the justice system sees it as defensible to make illegal a substance
that brings relief to cancer sufferers and has been demonstrated to
have no adverse effects on the body or the mind. Do you have a take on
this?
A The question would appear to be more
political than clinical, but there are several issues that impact
health care and need to be addressed.
The issue as to whether a substance, be it tobacco or marijuana,
should be incorporated into the criminal justice system is for a
different forum than CyberPsych®. There are many substances to which
we have access with which we can also cause self-harm. Many would
argue that it is not the role of government to protect us from
ourselves and that our choice as to whether to use any harmful
substance should be at our own discretion. In many countries, as you
are likely aware, access to what we consider prescription drugs is
readily available. Individuals make their own decisions.
For purposes of our own discussion, however, let us assume that we are
not questioning the law but whether cannabis is a safe and effective
drug. Let's take that question in reverse order:
There is little question that people with various diseases and
conditions benefit from the pharmacologic properties of cannabis and
that many people feel such patients should have access to any
substance that brings relief from their symptoms. If marijuana is more
effective in doing so than other agents, some argue that we are
withholding needed care by obstructing access. Others argue, with
equal conviction, that the agent is still illegal and that the issues
of law must be addressed first.
For purposes of CyberPsych®, the more telling question is whether an
individual can develop psychological symptoms of sufficient severity
to be considered mental disorder by ingesting cannabis. If your
question was also meant to address that issue, please be aware of the
following conditions associated with cannabis. Among them are:
- Cannabis Abuse, Dependence and
Intoxication
- Cannabis Intoxication Delirium
- Cannabis Induced Psychotic Disorders
with Delusions and Hallucinations
- Cannabis Induced Anxiety Disorder
and other conditions
When considering your personal/social
position on any health care topic, it is critical to include data from
both sides of that argument and attempt not to be polarized by your
individual preference. That is, base your decision upon data whenever
possible.
December 29, 1997
Q Several years ago I
had a problem with drinking, but that is all behind me now. There are
many people who tell me that I can never drink again, but I have been
sober for five years and never needed anything like A.A. Do see any
reason why I cannot drink socially at this time?
A There has been a continual debate as to whether an
alcoholic can learn to drink in moderation. The consensus would seem
to be that some alcoholics can and do drink in moderation although
such behavior is seek as extremely risky.
There is nothing inherently healthy, nutritious and necessary in
consuming alcohol. Your life can go on without it and arguably, in
your case, it may even go on better without it.
There is one other critical factor to consider:
You refer to yourself as sober when most think of sobriety as not
simply the absence of alcohol but having taken account of yourself and
the damage that you did while drinking. Perhaps you are clean of
alcohol without having developed the insights of sobriety. b
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