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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 |
July 29, 2002
Q
"My wife and I have been married for five years. She was
diagnosed with manic-depression (sic) a year ago and is on a lot of
medication. What is the biggest risk of this disease?"
A
Adults with bipolar disorder
are at high risk of completed suicide in their early 30s, usually
within 7 to 12 years of the onset of the mental illness. Research
shows that bipolar individuals have a 25% to 60% likelihood of
attempting suicide at some point in their lives.
The investigators found that those who committed suicide were more
likely to have had a first-degree family member who had also
committed suicide. They were also more likely to have made more than
one previous suicide attempt in the past 7 years.
The most vulnerable times for suicide were two years following a
hospital admission, 7 to 12 years after the onset of the disease,
and before age 35.
J Clin Psych 2002;63:469-476.
June 24, 2002
Q
"I have been diagnosed with fibromyalgia. My doctor believes
that there are psychological reasons for some of my complaints. This
offends me. Why would she say that?"
A From
a recent study: "Functional magnetic resonance imaging (fMRI) and
neuroendocrine studies of people with fibromyalgia reinforce the
notion that altered responses to pain and exercise are
physiologically based (not psychological).
Fibromyalgia patients reported pain at about half the level of
pressure that caused the same feelings of pain among the healthy
controls.
The findings suggest that something is awry with the way the central
nervous system processes painful stimuli in fibromyalgia patients,
resulting in a lowered pain threshold.
Patients with fibromyalgia have an increased hypothalamic
somatostatin tone. They would like to see if long-term treatment
with pyridostigmine would improve growth hormone production in
fibromyalgia.
While behavioral factors likely play a role in symptom expression in
many of these patients, resulting in poor role functioning, the
commentators note that this phenomenon is similar for all rheumatic
diseases."
Arthritis Rheum 2002;46:1136-1138,1333-1350.
June 17, 2002
Q
"My sister was diagnosed as paranoid schizophrenia when she was
a teenager. She is now 35. She has easily had 15-20 hospital stays.
All were less than three weeks, and she is only briefly better. This
is very hard on the family. We were wondering if perhaps they
discharge her too soon."
A
Severely mentally ill patients may be less likely to be readmitted
if they are hospitalized for 6 months or longer rather than shorter
periods of time, according to a recent study.
The researchers compared the recidivism rates among patients who
stayed in mental institutions for different periods of time.
Short-term hospital stays were defined as those that lasted between
2 days and 4 months, while long-term stays were defined as those
lasting 6 months to several years. In the current study, patients in
long-term care had an average of six prior hospitalizations, in
contrast to an average of less than one among the short-term group.
Patients who are admitted to long-term units of a mental institution
are normally more ill than those who enter short-term facilities.
However, the investigators found that only 12% of long-term
residents needed to re-enter the hospital during the year following
discharge, less than half the recidivism rate seen among patients
discharged from short-term programs.
The recidivism rate among the long-term care patients is one of the
lowest published 1-year recidivism rates in any other group of
patients discharged from mental institutions, the authors note.
In addition to less recidivism, the researchers found that patients
who had already tried short-term facilities stayed out of the
hospital longer after being discharged from long-term care than when
they had previously left short-term care.
Patients admitted to long-term care can enter classes that deal with
issues such as anger management and substance abuse, which are not
available to short-term enrollees. Different medication regimens can
also be evaluated better in a long-term unit.
June 10, 2002
Q
"My husband is in anger management counseling (sic) because he
has beaten me a dozen or so times. I am worried about him. What can
I do?"
A
"Determining whether female patients have been physically or
sexually abused by an intimate partner can provide important
insights into the causes of presenting symptoms, according to a
recent report.
Previous reports indicate that women who are victims of domestic
violence experience health problems even after the abuse has
stopped... longer-term signs of abuse, such as illnesses associated
with domestic violence, are not well defined.
Women who had been abused were at increased risk for health problems
such as headaches, back pain, sexually transmitted diseases, vaginal
bleeding and urinary tract infections, the findings indicate.
Overall, women who suffered from intimate partner violence were up
to 70% more likely than their non-abused peers to experience
gynecological, central nervous system and stress-related problems.
...abused women had a 60% higher rate of all health problems
compared with their peers who had not been abused and a 42% higher
rate of gynecological problems. Women who had been sexually abused
were more likely to report at least three gynecological problems,
compared with women who had been physically abused and non-abused
women.
Similarly, sexually abused women were more likely to report a
chronic stress-related problem such as loss of appetite and
abdominal pain, compared with physically abused women and those who
were not abused."
Arch Intern Med 2002;162:1157-1163.
June 3, 2002
Q
"My boyfriend has rage reactions. They are getting worse. I fear
him, and I told him that he has a personality disorder or some
impulse disorder. Are there any current findings on a biological
cause?"
A
Borderline Personality Disorder and an Impulse Control Disorder may
describe the problem, but there are, indeed, new findings suggesting
a brain control problem:
"Scientists have tied dysfunction in a particular brain region to a
psychiatric disorder marked by uncontrolled aggression. The current
findings extend the link that has been reported between the
orbital/medial prefrontal cortex circuit (OMPCC) and impulsive
aggression.... studied 24 patients diagnosed with intermittent
explosive disorder (IED). Considered an impulse-control disorder,
IED is marked by outbursts of anger that far outweigh the
provocation and that lead to aggressive or destructive acts.
For one, IED patients showed marked differences from other study
participants in tests of "emotion recognition." For example, IED
patients were more likely to perceive "neutral" facial expressions
as "disgusted" and "disgusted" expressions as "angry."
... IED patients failed to stop making "disadvantageous" choices
over time in a standard gambling task. According to the researchers,
this is similar to patients' everyday situations in which they react
to problems with aggression, despite the possible consequences.
When asked to gauge emotions in photos of people's faces, IED
patients showed problems in recognizing "anger," "disgust" and
"surprise."
Finally, in a test of sensory perceptions related to OMPCC function,
IED patients had more difficulty identifying various odors in
"scratch-and-sniff" samples.
All of this suggests that dysfunction in the OMPCC is involved in
IED... individuals with other psychiatric disorders that involve
impulsive behavior--such as antisocial personality disorder and
obsessive/compulsive disorder--show deficits similar to those found
in this study..."
Proc Nat Acad Sci 2002; May 28th Early Edition:00-00.
May 27, 2002
Q
"My niece has twice "accidentally" injured her? Once she
severely cut her arm and once she fell from an open window. She has
two children, and her husband left her a few months ago. Are these
really accidents?"
A
"Up to 70% of all nonfatal, self-inflicted injuries treated in
hospital emergency rooms were the result of failed suicide attempts.
A study by the US Centers for Disease Control and Prevention
revealed 158,466 of the estimated 264,108 people who visited
emergency rooms for self-inflicted poisoning, cuts, gunshot wounds
and other injuries in 2000 had likely tried to commit suicide.
Another 27,294 emergency room cases stemmed from possible suicide
attempts, according to the report, which was based on extrapolated
data collected from 66 hospitals across the nation.
Suicide is the eighth leading cause of death in the United States
and the second leading cause of death for people 25 to 34 years of
age. About 29,000 of the 650,000 suicide attempts each year in the
US are successful.
In the CDC study, adolescents between the ages of 15 and 19 years,
and young adults 20 to 34 years of age accounted for 59% of the
nonfatal, self-inflicted injuries reported by the hospitals. Women
made up about 57% of the injuries.
Surveys have shown 50% to 75% of Americans know someone who has
committed suicide. Researchers also have noted an increase in
suicide attempts, especially among young people, following media
coverage of suicides by celebrities.
Recommendations include encouraging the creation of suicide
prevention programs in schools, the workplace, prisons and nursing
homes."
May 20, 2002
Q
"My daughter was involved in a car accident in which one of her
passengers was killed. Will she develop posttraumatic stress
disorder?"
A
"People who experience problems sleeping shortly after a traumatic
event may be at risk for post-traumatic stress disorder (PTSD)...The
current findings indicate that survivors of motor vehicle crashes
who developed insomnia and reported excessive fatigue beginning 1
week after their accident were more likely to be diagnosed with PTSD
1 year later.
The findings suggest that diagnosing and treating sleep problems
early on may help accident survivors...
(In one study)
Furthermore, individuals who later developed PTSD had more severe
sleep problems than patients who did not develop PTSD.
"These results suggest that on the basis of sleep complaints it is
possible to detect subjects who will later develop PTSD as early as
1 month after the trauma," the researchers conclude.
Am J Psychiatry 2002;159:855-857.
May 13, 2002
Q
"My cousin is autistic as is a great uncle. My sister is
pregnant and I heard that complications in pregnancy cause autism.
Is that accurate?"
A
From a recent article: "An increased rate of minor birth and
pregnancy complications appears to accompany familial factors
associated with autism. This indicates that that minor pregnancy
complications are not a risk factor for sporadic cases of autism.
Children
diagnosed with pervasive developmental delay had significantly more
obstetric risk factors than did their unaffected siblings. However,
more complications were found in unaffected children with a higher
degree of family loading for the broader autism phenotype.
The researchers say these findings indicate that pregnancy and birth
complications are not a direct cause of autism, as a higher rate of
complications would be expected in cases without a positive family
history of autism.
Although this kind of study doesn't exclude severe complications
playing a role, it does suggest that clinicians have to be cautious
in overinterpreting minor complications. These children are probably
at higher risk for complications because they develop differently in
utero."
J Am Acad Child Adolesc Psychiatry 2002;41:572-579.
May 6, 2002
Q
"My mother is in her 70s, and since my father died, she has been
pretty depressed. I am worried because I know this depression will
shorten her life."
A
Not necessarily. A recent study indicated that elderly women with
subthreshold depression tend to live longer than those without
depression
Depression was assessed with a modified version of the Center for
Epidemiologic Studies-Depression Scale (CES-D), which included 20
questions regarding particular emotions experienced during the
previous week. A score of 6 to 8 was defined as subthreshold
depression.
Among the women, subthreshold depression was significantly
negatively related to 3- to 4-year mortality. Among the men,
subthreshold depression was not associated with mortality.
A low
subclinical level of depression in women "may lead to adaptive
activities that are in some ways protective of health."
Am J Geriatr Psychiatry 2002;10:283-291.
April 29, 2002
Q
"I am a 29 year old pregnant woman. I am also depressed, but I
hear that I cannot take antidepressants. What are my options?"
A
Most importantly, you should be seeking professional advice in your
community and determining the cause, course and treatment for your
depression. Antidepressant use during pregnancy is controversial,
and there have been few treatment options for the 5% of pregnant
women who meet criteria for major depression. These women may
respond to bright light therapy in the morning, according to results
of an open trial published in the April issue of the American
Journal of Psychiatry.
For 3 to 5
weeks, 16 pregnant patients with major depression received bright
light therapy for 1 hour after awakening in the morning and showed
no evidence of adverse effects. On the Hamilton Depression Rating
Scale, Seasonal Affective Disorders Version, mean depression ratings
improved by 49% after 3 weeks of treatment and by 59% in the 7
patients who had 5 weeks of treatment.
Some data suggest that light therapy advances the timing of the
daily biological clock, which may then bring about the
antidepressant effect.
Am J Psychiatry.2002;159(4):666-669
April 15, 2002
Q
"I use St. John's Wart (sic) for the treatment of my
depression. I think it works better for me than Zoloft which was
prescribed before...any recent articles about this?"
A
In an 8-week, randomized trial reported in the April 10 issue of The
Journal of the American Medical Association, St. John's wort was no
better than placebo in the treatment of major depression, and
sertraline was better only on a secondary outcome measure. A second
study and an editorial in the same issue of the journal stress the
importance of placebo controls in trials of antidepressants.
Major depression is treatable, but this research suggests that major
depression of at least moderate severity should not be treated with
St. John's wort,.
Neither St. John's wort nor sertraline proved to be more effective
than placebo on primary measures of effectiveness St. John's wort
and other herbal remedies can adversely interact with prescription
medications, including antiretroviral therapy, certain
cardiovascular drugs, and immunosuppressants.
A National
Depressive and Manic-Depressive Association Consensus Statement on
the use of placebo in clinical trials of mood disorders, published
in the March issue of the Archives of General Psychiatry, concluded
that findings of equivalence between a new drug and standard
treatment are not evidence of efficacy unless the new drug is also
significantly more effective than placebo.
JAMA. 2002;287(14):1807-1814, 1840-1847, 1853-1854
April 8, 2002
Q
"I heard that a few drinks a night is actually good for me, but
everyone tells me that if I drink daily I am an alcoholic. Can you
point me towards an article?"
A
Cutting one's alcohol intake can have health benefits. Habitual
heavy drinkers who cut their alcohol intake in half for just 3 weeks
experienced a drop in both blood pressure and heart rate.
In the reduced alcohol group, the men cut their intake to about 19
milliliters (mL) of ethanol a day, which is roughly one beer (18 mL
of ethanol) or less than one glass of sake (27 mL of ethanol).
During the alcohol restriction period, the participants had a drop
in daytime systolic blood pressure of about four points, the authors
note. The men's diastolic blood pressure did not change during the
reduced drinking periods, the report indicates.
Heart rates were lower also when the men cut alcohol intake,
dropping by four beats per minute during the daytime and seven beats
per minute at night, as reported in the March issue of the American
Journal of Hypertension.
Studies have suggested that light-to-moderate alcohol consumption
protects against heart disease. For most people who consume no more
than 30 mL of ethanol per day (about one to two drinks per day), no
changes seem necessary." Those who consume more than 30 mL of
ethanol a day may want to cut back on consumption, the researcher
added.
Men should restrict their drinking to 30 mL or less [of ethanol]
throughout their lives to prevent alcohol-related diseases.
Am J Hypertens 2002;15:125-129.
April 1, 2002
Q
"My wife is pregnant, smokes and drinks. This is our first
child. I assure her that this is risky and can harm the baby. Can
you point me toward an article she can read?"
A
Pregnant women who drink alcohol and smoke may more than double
their child's risk of developing attention-deficit/hyperactivity
disorder (ADHD), according to a new report.
The investigators found that, compared with non-ADHD subjects,
children diagnosed with ADHD were 2.1 times more likely to have been
exposed to cigarettes and 2.5 times more likely to have been exposed
to alcohol in utero.
Previous studies have found similar associations. The researchers
point out that environmental exposure to alcohol and tobacco smoke
may combine with pre-existing genetic factors to increase a child's
ADHD risk, and suggest more research on the matter is needed.
J Am Acad Child Adolesc Psychiatry 2002;41:378-385.
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