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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 |
September 26, 2005
Q
"My adult son has ADHD among other growing problems.
Are all of his problems caused by ADHD?"
A
While it cannot be answered with certainty with so little
information: "Adults with attention-deficit/hyperactivity
disorder (ADHD) have significant lifetime psychiatric
comorbidities...ADHD is a highly heritable
neurodevelopmental syndrome with significant lifetime risk
for functional impairment...Coexisting psychopathology is
common, and the potential clinical importance of comorbidity
has been recognized in children. Our understanding of
psychiatric comorbidity in adult ADHD is based on a limited
number of reports...In a genetic study of families
containing multiple children with ADHD, ....Parents with
ADHD were significantly more likely to be unskilled workers
and less likely to have a college degree. Compared with ADHD
subjects, non-ADHD subjects had more lifetime
psychopathology, with at least one other psychiatric
disorder in 87% vs 64% and at least two other psychiatric
disorders in 56% vs 27%. ADHD was associated with higher
rates of disruptive behavior, substance use, and mood and
anxiety disorders and with earlier onset of major
depression, dysthymia, oppositional defiant disorder, and
conduct disorder.
Age-corrected risks did not significantly change group
differences. Male sex increased the risk for disruptive
behavior disorders, whereas female sex and oppositional
defiant disorder increased the risk for depression and
anxiety. After controlling for male sex, disruptive behavior
disorders, and socioeconomic status, ADHD was not a
significant risk factor for substance use disorders.
Adults with ADHD are more likely to be white with lower
education and occupational achievement. Comorbidities
include conduct disorder, major depression, substance abuse,
oppositional defiant disorder, and multiple anxiety
disorders. In adults with ADHD, women are more likely to
have mood and anxiety disorders, whereas men are more likely
to have substance use disorders. Risk of substance abuse is
mediated by disruptive disorders, conduct disorder, male
sex, and lower socioeconomic status."
Am J Psych. 2005;162:1621-1627
September 19, 2005
Q "I
have sleep apnea, and they want me to use one of those CPAP
machines. This is going to be a nuisance, and I have a
lot of other things in life to deal with. This has not been
a good year."
A
You may be interested in, and with to discuss with your
doctor: "New
research suggests that symptoms of depression are fairly
common among patients with obstructive sleep apnea and that
treatment with continuous positive airway pressure (CPAP)
may improve these symptoms.This does not mean that all
patients presenting with symptoms of depression should be
tested for obstructive sleep apnea.
While the findings suggest that CPAP can improve depressive
symptoms in obstructive sleep apnea patients, the
association between these two disorders requires further
study...Are the symptoms of obstructive sleep apnea just
being mistakenly attributed to depression or is there a
cause-and-effect type relationship?"
Chest 2005;128:1304-1309.
September 12, 2005
Q "My
niece committed suicide...her children have had a very hard
time coping with this...what are some of the concerns for
children of suicidal parents or mothers?"
A
A recent study indicates that "children of mothers who have
attempted suicide are themselves at increased risk of the
same behavior. Although there have been studies suggesting a
genetic component in familial transmission of suicidality,
most were biased, including only patients in treatment.
Moreover, none focused on the age of the first manifestation
of suicidality in offspring.
The odds of suicidal ideation was about five times higher
among offspring of mothers who had attempted suicide, while
the rate of suicide attempts was nine times higher.
Furthermore there was a tendency toward the occurrence of a
suicide attempt at an earlier age in the offspring of the
mothers who attempted suicide compared to the offspring of
mothers without suicidality.
The odds for suicidal ideation, but not suicide attempts,
were only slightly increased among children of mothers with
suicidal ideation.
Controlling for maternal anxiety, alcohol use and major
depression did not significantly alter the outcomes. While
it's possible that imitation may at least partially explain
their findings, other studies addressing these issues do not
support the hypothesis that increased suicidality is due to
imitative behavior.
Results provided no evidence against the hypothesis of
suicidality running in families, independent of depression
and other psychopathology."
Am J Psychiatry 2005;162:1665-1671.
September 5, 2005
Q "You
commented before on asthma. Do you truly believe it is a
psychological condition?"
A
Absolutely not. Asthma is a
respiratory disorder but "Psychological stress has been
shown to have an effect on asthma flare-ups" (and a
recent study) used functional MRI to determine the brain
regions linking emotions with asthma flare-ups.
In the study, six patients with mild allergic asthma were
exposed to ragweed or dust-mite extracts. The subjects were
visually showed three different categories of words:
asthma-related (e.g., "wheeze"), non-asthma negative
("loneliness") or neutral ("curtains").
The anterior cingulate cortex and insula showed increased
activity when the asthma-related words were heard compared
with the other types. Moreover, this enhanced activity was
specifically linked to physiologic signals from the test
allergens.
"In individuals with asthma and other stress-related
conditions, these brain regions may be hyperresponsive to
disease-specific emotional and afferent physiologic signals,
which may contribute to the dysregulation of peripheral
processes, such as inflammation." Proc Natl Acad Sci
USA 2005.
August 29, 2005
Q
"My daughter is married now, but she has had little periods
of depression several times in her life, twice recently.
Is she more likely to have major depression some day?"
A
An investigator recently reported: "Patients who have
even one episode of minor depression have an increased risk
of having a subsequent episode of major depression...So much
focus has been on major depression, but physicians need to
know that if a patient has signs that qualify for minor
depression, it should be treated, both to prevent the
current episode from progressing to major depression, and to
prevent a major depressive episode later on.
Subjects who were younger than 45 years and women were more
likely to have major depressive disorder. Among the medical
variables, only having a stroke was predictive, with these
individuals being 7.99 times as likely to develop major
depressive disorder. The symptoms most associated with risk
were suicidal ideation, appetite and weight issues, and
sleep difficulty."
August 22, 2005
Q "My
wife has difficulty with intercourse. It is called something
like vaganismes or something similar...is there any
psychological treatment?"
A "Biofeedback, in combination with
sexual cognitive-behavioral therapy, is effective in treating vaginismus. The
findings come from a small study involving women who were unable to engage in
sexual intercourse, but were able to do so after therapy.
Several uncontrolled studies have reported encouraging results with various
treatments for vaginismus, the authors explain in the July issue of Urology, but
little evidence is available from controlled trials of any method.
All women participated in 12 sessions of biofeedback aimed at learning pelvic
floor muscle relaxation. Then, with their husbands, they had 8 sessions of SCBT
with progressive introduction of fingers or dilators into the vagina. They
refrained from attempting intercourse until the treatment was completed.
All 12 couples completed the program, after which the women were able to
tolerate vaginal insertion of larger sized probes and were able to achieve
satisfactory vaginal intercourse, the authors report.
All 12 couples reported consummation of their marriage at the end of the
program," the investigators write, "and detailed questioning suggested that full
penetration and ejaculation had occurred.
FES-biofeedback with SCBT is an effective aid for patients with vaginismus to
learn muscle control; therefore, it may increase the success rate of treatment
of vaginismus. The combination therapy of FES-biofeedback with SCBT is an
effective and clinically acceptable treatment of vaginismus."
Urology 2005;66:77-81.
August 15, 2005
Q "Our
daughter has had recurrent failures in treatment programs
for her eating disorder. Are there better programs or
are there better predictors?"
A
This may be of some help:
"Japanese researchers have found that glucose tolerance may
be a useful predictor of short-term refeeding outcome in
women with anorexia nervosa. There is a "close relationship
between pretreatment glucose responses, therapeutic progress
of desensitization to fear of energy intake, and refeeding
progress."
The identification of factors associated with the success of
weight restoration is "clinically important for anorexia
nervosa, because previous studies have shown that weight
gain during hospitalization is an important prognostic
factor for disease outcome...However, little is known about
biologic predictors of refeeding outcome in this disorder."
..."the most important findings" were that, in both subtypes
of anorexia nervosa, both flat-type and impaired glucose
tolerance-type glucose responders had difficulties in
desensitization to fear of energy intake and showed reduced
daily energy intake during nutritional rehabilitation
compared with normal-type glucose responders, who had a
faster rate of weekly weight gain during refeeding.
"Clinicians should consider careful monitoring and
assessment of glucose metabolism early in the treatment
course which could provide useful data to predict responses
to an oral refeeding program in patients with anorexia
nervosa."
...the researcher emphasized that "abnormalities in glucose
metabolism in anorexia nervosa may be influenced by many
biobehavioral, psychological and nutritional factors. Thus,
we deem that future research regarding these parameters is
necessary for determining more useful biologic predictors of
refeeding outcome in this disorder."
Psychosomatic Med 2005;67:669-676.
August 8, 2005
Q "My
husband is one angry dude...constantly yelling in
traffic...he yells at the television. I tell him that he
will have a stroke or something...so he yells at me.
Is his health at risk?"
A
Individuals with metabolic syndrome and high hostility
levels have a four-fold risk of having an MI compared to
those without these cardiovascular risk factors. While
evidence suggests that the metabolic syndrome and hostility
are independent risk factors for the development of coronary
heart disease (CHD), the combined effect of these two
factors on the incidence of myocardial infarction (MI) has
rarely been studied.
To investigate, (the study) examined the combined effect of
the metabolic syndrome and hostility on the incidence of MI
in 754 men (mean age 59.7 years) who participated in the
Normative Aging Study. At baseline, the subjects were free
of coronary heart disease, cancer and diabetes mellitus.
A total of 208 participants (27.6%) met the criteria for the
metabolic syndrome. The subjects were categorized as having
high or low hostility levels using the Cook-Medley Hostility
scale. The subjects were followed for an average of 13.8
years. During that time, 85 patients (11.3%) developed a MI.
Subjects with high hostility levels and the metabolic
syndrome had the highest likelihood of developing a MI.
"Psychological factors need to be assessed by primary care
doctors and cardiologists, since hostility and other
negative emotions (e.g., depression) seem to play a role in
the development of heart disease in otherwise healthy
individuals...Individuals who notice that they experience
feelings of anger and hostility often, should mention these
feelings to their doctor and seek help."
This study was
conducted in older males, so we are not sure these results will generalize to
women." Am J Cardiol 2005;96:221-226.
July 24, 2005
Q "Rather
than take all these drugs with their side effects, is that
not surgery or some brain device that would treat depression?"
A
Perhaps. "An implanted
stopwatch-sized device that uses electrical vagal
stimulation to treat chronic depression won U.S. Food and
Drug Administration approval. The device, known as the Vagus
Nerve Stimulation Therapy System (VNS), was cleared by the
FDA for long-term use in adults whose depression has not
responded to other treatments.
FDA officials cautioned that the VNS device is not to be
used as the first therapy but would give the sickest
patients another option. The device would carry the
strongest warning possible -- a so-called black box --
cautioning patients that the device is permanent.
An FDA advisory panel last year supported the device but
said muddled data made it hard to tell if the implant or
other factors were at work. The advisers also worried about
suicide risk seen in some study patients who received the
device.
VNS Therapy is already approved to treat epilepsy in Europe,
the United States and Canada. The device is also approved
for treatment-resistant depression in Europe and Canada in
2001."
July 17, 2005
Q "...but
was there not a recent challenge to the fact that
antidepressants do much of anything?"
A
You may be referring to this: "Published medical
evidence fails to support a clinically meaningful benefit of
antidepressant therapy...They suggest that transformation of
continuous data into categorical data, regression to the
mean, and selective presentation of data from drug trials
explain the benefits that are claimed...there is (not) such
a thing as a drug that will specifically relieve depression.
I think so-called antidepressants are just drugs that do
other things, such as sedating or stimulating people...
skeptical as to whether there is a biochemical syndrome of
depression despite the portrayal by the drug companies and
some psychiatric literature...depression as a condition that
"should be dealt with without drugs, because it's something
people need to learn to deal with themselves."
(Challenging this perception)...The interesting issue is
that it is now medical malpractice not to treat major
depression with medication. If in fact there were
nonsignificant differences (between antidepressants and
placebo), that would not be the standard of care....(in
Great Britain) somehow the brain is sacrosanct and you can't
have illness of the brain," he concluded. "It really is a
remarkably biased presentation."
BMJ 2005;331:155-157.
July 12, 2005
Q "How
effective is antidepressant medication?"
A
"Results from 3
consecutive trials confirm the effectiveness of
antidepressants in inducing remission for more than 90% of
depressed patients.
More than half the patients treated with a second-generation
antidepressant were in remission, the authors report, and 9
of 20 patients treated with a second drug. Five of 13
patients treated with a third drug were in remission.
Overall, two-thirds of the patients entered into the trials
were in remission, the report indicates. Among the patients
who either remitted or received 3 treatment drugs, 93% were
in remission.
Among patients treated with a first-generation
antidepressant, 205 of 342 were in remission after the first
drug treatment. The researchers note that 37 of 67 (55%) of
patients who received a second drug and 12 of 24 patients
who received a third drug were in remission.
Overall, then, 65% of those treated with a first-generation
antidepressant were in remission, the results indicate.
Among the patients in this group who either remitted or
received 3 treatment drugs, 96% were in remission.
"Our data suggest that correctly diagnosed depressed
patients who receive 3 adequate trials of antidepressant
medication have an approximately 90% chance of achieving a
state of remission," the authors conclude.
"We could find no systematic analysis of why patients leave
treatment," the investigators add. "A major challenge is
motivating depressed patients to continue treatment."
J Clin Psychiatry 2005;66:670-676.
July 5, 2005
Q "This
my be off-topic but when I do not sleep, I ache all over the
next day. Is there a reason for this...is it just the
alcohol?"
A
It may be the disruption to
sleep: "Rapid eye movement (REM) sleep deprivation may cause
increased sensitivity to acute pain. Healthy, pain-free
individuals demonstrated an enhanced sensitivity to acute
pain following a four-hour general sleep restriction that
included a 2/3 decrease in REM sleep.
Such findings suggest that the relationship between
disturbed sleep and pain is bidimensionsal— not only does
pain disrupt sleep, but disrupted sleep may enhance pain. We
were interested in determining whether loss of REM sleep
itself is hyperalgesic.
During REM deprivation, subjects were awakened on initiation
of REM sleep and required to remain awake for 15 minutes
before returning to bed; subjects were awakened at
corresponding times during the NR session.
Sleep disruptions were similar in the NR and RD conditions,
but did not involve REM sleep; the effects on pain threshold
observed in the RD condition were therefore due specifically
to the loss of REM sleep, not to the disruption of sleep per
se. We found that REM loss itself was hyperalgesic.
The finding is significant in that analgesic medications
have an acute REM-suppressing effect, and their efficacy may
be potentially compromised by increased sensitivity to pain
during the night.
Physicians should be aware that in an acute pain situation,
patients may experience increased pain due to sleep
disturbances, and this preliminary association between REM
loss and hyperalgesia suggests that improving patient sleep
may be an important aspect of pain management."
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