Appointments
Primarily, appointments are scheduled via referral from other medical and mental health professionals in the community. However, patients are accepted without a referral. To schedule an appointment, please call the office.
Clinical Practice
Nathan E. Lavid, MD, DLFAPA
Welcome To My Clinical Practice
Dr. Lavid cares for older children, adolescents, and adults providing general psychiatric evaluation and treatment. He works as a sole provider, however, typically psychiatric care is integrated with the care of other mental health professionals including physicians, psychologists, social workers, and therapists.
Below are brief descriptions of some common psychiatric conditions and are used by many mental health professionals as a framework to apply the explosion of new knowledge concerning brain function and mental illness. These descriptions are provided as a starting point for the layperson to better understand the meaning of these terms from a psychiatric viewpoint. By no means are these descriptions comprehensive, intended as medical advice, or to be used as a substitute to speaking with a mental health professional. Consulting with a mental health professional is the only valid means by which to explore treatment options, of which there are many successful approaches for each of the conditions listed, so such options are not presented in this format.
Nathan E. Lavid, MD, DLFAPA
Hours
Hours are by appointment. Typically, clinical patients are seen Mondays, Wednesday and Thursdays. Tuesday and Friday are typically reserved for his forensic practice. Every attempt is made to schedule convenient appointments for patients.
Remittance
Remittance is due at the time of service. Health insurance is not billed. For patients who want to use their health insurance, a superbill (medical receipt with codes) is provided that can be submitted by patients to their insurance company for reimbursement.
Emergencies and Urgent Matters
Emergency call is provided 24 hours a day. All clinical patients are provided with Dr. Lavid’s emergency pager number. If a life-threatening emergency arises, please call 911 immediately.
Common Psychiatric Conditions
Addiction
Addiction is marked by compulsive substance use, in spite of psychological, social, and health problems, that is coupled with episodes of substance craving. However, the key concept in substance abuse is that, followed over the long-term, it has a chronic course marked by symptoms that wax and wane. Addiction can be best thought of and treated as a brain disease. For example, if one has a family history of diabetes, one then has a greater chance to become diabetic. One did not decide this, it is just a susceptibility passed on from one’s parents. If one is diabetic and does not receive treatment, the diabetes will run its course, and one will have complications that will affect almost every organ system in the body. Analogously, if one has a family history of substance abuse, one then has a greater chance to become an addict. One did not decide this, it is just a susceptibility passed on from one’s parents. If one uses substances of abuse, the disease will run its course, and one will have complications that will affect almost every organ system in the body.
To understand the motivation that addicts endure in their addiction, it is necessary to outline the specific areas of the brain that characterize the “reward” and “craving” that are involved in the disease. Once an individual has been sensitized to a substance of abuse the brain areas involved are powerful. To appreciate the power of the brain it is best to conceptualize brain function as following a sequential order of importance. The brain keeps important functions simple, so they are not easily disrupted. (This is in contrast to relatively non-important functions, such as deciding which shirt to wear in the morning, in which higher areas of the brain that are very complicated are utilized.) An example of something simple for the brain to orchestrate is breathing. It is a simple act that is very important, and it needs to be done constantly. The brain centers that control simple, important acts tend to be primitive, i.e., they are found in most animals and have persisted through evolution, and the primitive structure that controls breathing is the brain stem.
At the rostral end (closest to the nose) of the brain stem is an area called the midbrain. Housed in the midbrain are the origins of brain cells that utilize the neurotransmitter dopamine. These cells project throughout the brain, and the role of dopamine has been implicated in many brain functions and diseases. For example, Parkinson’s disease is due to loss of dopaminergic brain cells housed in the midbrain. Stimulation of these dopaminergic neurons in the midbrain can cause a release of dopamine in a certain small area, approximately one centimeter, of the brain called the nucleus accumbens. The nucleus accumbens can be thought of as the “pleasure center” of the brain and is used to reward behaviors. Natural behaviors such as sex and eating utilize this reward pathway. How this pathway relates to addiction is that most, if not all, substances that are abused by individuals tap into this primitive pathway. This pathway reinforces the drug-seeking behaviors and craving that characterize addiction. Since this pathway is primitive and relatively simple, it is difficult to disrupt. Hence, the nature of addiction, which is marked by continued substance abuse in the face of self-destructive behavior.
As the addiction progresses, increasingly more of the substance of abuse is needed to produce the reward in the brain. This occurrence is called tolerance. Tolerance drives addicts to use more, and contributes greatly to the toxicity of abuse. Even though the addicted brain is a powerful force, there are other aspects to the phenomena of addiction. The mind and environment play an important role in the course of the disease.
Anxiety Disorders
Anxiety
Anxiety is characterized by physical and psychological symptoms. The physical symptoms include rapid heartbeats, deep breathing, sweating, muscle tension, restlessness, and nausea. The psychological manifestation of anxiety is heightened awareness and apprehension. The brain mechanisms that mediate include many circuits and areas of the brain. The interplay of these diverse brain systems converges to dictate the basic sensations of anxiety.
In psychiatry, the focus of anxiety is the relation of the state with disease. Basically, in contrast to anxiety clearly provoked and amenable to control, pathological anxiety arises spontaneously or is produced out of proportion to what should be expected. It is important to note that physical and psychological sensations of anxiety are symptoms. Anxiety, in itself, is not a disease. Rather, it is a marker for a multitude of diseases – some of which exhibit anxiety as their predominant symptom. These disorders are “anxiety disorders,” and some of the common anxiety disorders are presented below.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is used to describe patients with chronic anxiety – the term “chronic” in this sense denotes a presence of the symptoms for at least six months. Patients with GAD complain of persistent worry, irritability, and difficulty concentrating. The physical symptoms of GAD include restlessness, muscle tension, and insomnia. Usually, there is no specific stressor that can be attributed to causing the anxiety. The anxiety persists no matter what is happening in the person’s life. This frustration leads patients to complain that they have no control and that they “just want to relax.”
This type of chronic anxiety has been recognized for some time: Sigmund Freud termed it “anxiety neurosis.” Current study of GAD reveals that about five percent of the population will develop GAD during its lifetime.
Study reveals that the onset of GAD is gradual. While patients usually begin to notice symptoms in adolescence or young adulthood, GAD can present earlier or later in life. Also, the course of GAD is long and about forty percent of patients report constant anxiety over five years, with the average duration ranging from six to ten years. Few studies have examined GAD patients over many years, but it is suspected that GAD can reoccur multiple times during an individual’s life. Moreover, GAD has a predilection for females and there are about twice as many cases in women as there are in men.
Panic Disorder
The hallmark of panic disorder is the occurrence of unexpected panic attacks. A panic attack is a sudden, spontaneous episode of acute anxiety. Palpitations, increased heart rate, sweating, nausea, abdominal distress, trembling, dizziness, shortness of breath, and a feeling of choking are some of the physical symptoms noted in panic attacks. Psychological symptoms include fears of losing control or “going crazy,” feelings of detachment, and even fears of dying. The symptoms of panic attacks develop quickly and usually reach a peak within ten minutes. To the sufferer, a panic attack may seem like an eternity – fortunately, these attacks rarely last more than thirty minutes.
Panic attacks have been described in literature for centuries and entered the medical sphere during the U.S. civil war. A physician named Jacob Da Costa described a condition that resembles the current description of panic attacks in Civil War soldiers. He termed it “irritable heart.” While the name and specific criteria for these panic attacks have changed over time, the central theme of a sudden intense anxiety that is unprovoked has remained intact.
The study of panic attacks has revealed that they are quite common, and roughly seven percent of individuals will experience panic attacks during lifetime. Panic attacks tend to be recurrent and about one half of panic attack sufferers will have additional symptoms of concern towards additional attacks occurring in the future, worries about the implications of the attack, and changes in behavior related to the attacks. If an individual has these additional symptoms, then he or she subsequently meets the criteria for the illness known as panic disorder.
Panic disorder may further be sub-classified by using the modifying term “with agoraphobia” or “without agoraphobia.” Agoraphobia is derived from the Greek word ageirein (meaning “place of assembly,” commonly a marketplace) and phobos (meaning “fear.”) Agoraphobia, in the medical sense, is a term used to describe the development of anxiety in places or situations from which one might have a perceived difficulty in escaping during the attack, and consequently feel embarrassed. Patients with agoraphobia will therefore avoid public places, and even traveling, in an effort to quell this anxiety. About one half of patients suffering from panic disorder have agoraphobia.
The course of panic disorder is of recurrent panic attacks followed by periods of remission. While panic attacks usually present in adolescence and young adulthood, they may present at any age. As a person with panic disorder ages, the panic attacks become less intense and less frequent. Studies also show that panic disorder is more common in females.
Posttraumatic Stress Disorder
Posttraumatic Stress Disorder (PTSD) is a disorder in which anxiety is just one symptom of a constellation of findings that arises after exposure to a traumatic event or series of traumatic events. Simply, there are three basic clusters of symptoms.
The first cluster involves reexperiencing the traumatic event. An individual may recall (commonly described as “relive”) the traumatic event through nightmares or “flashbacks.” Flashbacks are vivid memories that are unwanted and usually provoked by a stimulus. For example, the smell of cedar may initiate the reliving of a rape of an individual that occurred in a closet.
The second cluster of symptoms pertains to avoiding stimuli that are associated with the trauma (commonly referred to as “avoidance”). Individuals will avoid people, places, situations, and activities that may trigger recall of the traumatic event. This may include the attempt to avoid any thoughts or feelings associated with the trauma. Following the previous example of a rape occurring in a closet, the victim of such horror may take extreme measures to avoid entering or even coming close to the closet in which the rape took place.
The last cluster of symptoms of PTSD is characterized by an overall increased arousal and anxiety that was not present before experiencing the traumatic event. Individuals may have an exaggerated startle response (be easily surprised), become increasingly vigilant (constantly watching and checking for danger), experience difficulty sleeping and concentrating, and suffer from irritability. Following once more the aforementioned example, the rape victim might live many years of his or her life with an unusually high amount of anxiety and terror.
The phenomenon of PTSD has been recognized for centuries. Boccacio’s The Decameron describes the Florentine people during the Black Plague, relating examples of citizens’ various reactions to the traumatic fear and loss of life experienced. The concept was revisited more carefully during World War I, during which the term “shell shock” came into the medical lexicon to describe the reaction of soldiers who continued to relive combat months after battle. More recently, studies of concentration camp survivors, war veterans, and survivors of natural disasters and accidents have shed more light on the nature of PTSD.
Studies of trauma reveal that it is a common occurrence and that around two thirds of the population will experience some form of trauma ranging from witnessing a traumatic event to rape and combat exposure in war. While everyone who is exposed to a severe traumatic event, such as rape and torture, initially develop symptoms that mimic PTSD, not all of these people develop the illness. Unfortunately however, PTSD is a common disorder, and from five to ten percent of the general population will develop PTSD during their lifetime. Once PSTD has set in, about sixty percent of the cases will resolve within months. For the population that continues to have symptoms, the duration and intensity of symptoms vary, though the course tends to be chronic without treatment.
Which population of trauma victims will develop PTSD is not yet completely understood. Several ideas about this point, however, do exist. First, the type of trauma is an important factor in developing PTSD. Events that involve interpersonal victimization, that is, trauma caused by others, such as rape and torture, have higher rates of PTSD than lower magnitude events such as natural disasters or life-threatening illnesses. Second, a history of prior exposure to trauma increases the risk for PTSD. Third, there is evidence for specific biological factors that predispose an individual to developing PTSD.
Social Phobia
Social phobia is an irrational fear of social situations in which the individual anticipates that he or she will act in an embarrassing or humiliating way. Exposure to the feared situation produces intense anxiety, and the patient will go to great means to avoid the feared social activity. The anxiety of social phobia resembles fear, and patients commonly have physical symptoms of palpitations, trembling, sweating, muscle tension, nausea, blushing, dry throat, and headache. The most frequent social situations feared in the social phobic patient are conversing in small social groups, meeting or speaking to new people or strangers, and of eating in public places.
Social phobia is different from shyness and that typical transient discomfort we have all at some time in our lives experienced in social places. The intensity of anxiety and discomfort is much higher in social phobia than in shyness. Furthermore, shy people tend to be shy in many situations, whereas the social phobic patient will only have anxiety towards the feared, specific social activity or situation. Moreover, in contrast to shyness, the anticipatory anxiety in social phobia may precede a social event by days or even weeks. Social phobic patients will go to great pains to avoid a feared social situation. For example, such a patient may constantly cancel a dinner appointment to avoid the possibility of embarrassment and humiliation.
Social phobia is the most common anxiety disorder and about ten to fifteen percent of the population will develop it during life. Females are twice as susceptible to social phobia and the reason for this is unknown. Studies of the natural course of social phobia reveal that symptoms usually begin in adolescence and tend to follow a chronic unremitting course. It is not known why people develop social phobia. However, there may be a genetic component as the disorder runs in families.
Specific Phobia
Like the association between anxiety and social situations in social phobia, specific phobias are marked by an irrational fear triggered by a specific object or situation. An individual with a specific phobia will avoid the trigger, and usually the individual is upset that he or she has this fear. Interestingly, a small number of objects and situations account for the majority of specific phobias. Some of the most common phobias, in decreasing order of prevalence, are animals, height, blood, close spaces, flying, water, being alone, and storms. The symptoms of specific phobia are intense anxiety and apprehension concerning the phobic object and situation.
Specific phobias are common – they are the second most common anxiety disorder. About ten percent of the population will meet criteria for a specific phobia during its lifetime. Like social phobia, specific phobias are more common in females. Specific phobias usually arise in childhood and adolescence. In some cases the phobia will resolve on its own; however, if the phobia continues into adulthood, the course tends to be chronic.
The exact reasons that individuals develop specific phobias are unknown. However, it has been hypothesized that there may be an evolutionary predisposition to fear certain objects or situations. For example, snakes may have been a real danger to our ancestors and those who avoided snakes were able to survive and reproduce. Thus we may have inherited a prepared fear response to snakes that enabled our ancestors to survive. This, of course, serves no present value to an urbanite, but could explain why only a small number of objects and situations account for the majority of specific phobias. Another hypothesis is that traumatic events or a series of traumatic events trigger specific phobias. For example, a snake may bite an individual on a camping trip. From then on, the individual may develop phobic symptoms when visiting the snake exhibit at the zoo or seeing snakes on television or magazines.
Although, specific phobias are a common occurrence, only about twenty percent of sufferers will seek treatment. This may be explained by the possibility that sometimes the object or situation of the phobia is easy to avoid, and hence does not require medical evaluation and intervention. For example, snakes are uncommon in urban settings, so a businessman working in a city and living in a nearby suburb might never have to come into contact with a snake. However, the fear of flying in an international businessman would be impossible to avoid and would interfere greatly in his life.
Attention-Deficit/Hyperactivity Disorder
Attention-Deficit/Hyperactivity Disorder (ADHD) is a cluster of behaviors that emerge in childhood. To be diagnosed as ADHD one has to demonstrate inattention with hyperactivity or impulsivity. These behaviors have to be noted before seven years of age and last greater than six months. Also these behaviors have to present in two or more settings, such as home and school and cause impairment in social, academic and occupational pursuits.
Approximately three to five percent of school-age children are affected with ADHD and it develops in boys three times as often as in girls. Also, ADHD tends to be a chronic disease and most children continue to have symptoms as adults.
In contrast to most psychiatric conditions, ADHD has only been recognized recently. In 1902, the British physician George Still published the first descriptions of inattentiveness and hyperactivity in children with normal intellect. He attributed these behaviors to a lack of “inhibitory volition,” which simply stated is will power. He postulated that brain damage was the culprit for this lack of will power.
The concept of brain damage as a cause of childhood inattention and activity was furthered by observations of children who recovered from the encephalitis (a viral infection of the brain) pandemic after World War I. Some of the children who recovered from these infections had behavior symptoms that resembled Still’s findings. It was thought that the encephalitis caused some residual damage to the brain and was responsible for the children’s behaviors. Thus, these children were termed suffering from “minimal brain damage.”
However, in the late 1960s, the number of children diagnosed with minimal brain damage increased, and physicians could not find evidence of any brain damage in the majority of these children. Thus, the diagnosis changed to “hyperkinetic syndrome” to emphasize the symptoms rather than hypothesized cause. Later, specific criteria were outlined, and hyperkinetic syndrome evolved to “Attention Deficit Disorder” (ADD) to reflect these criteria. Due to that hyperactivity was noted in varying degrees in ADD patients, the diagnosis was changed to the current term, “Attention-Deficit/Hyperactivity Disorder.”
Recent study of ADHD has revealed a genetic link in that if a family member has ADHD then the other family members have an increased risk of developing ADHD. Genetic studies have not implicated a specific gene as a cause, but most genes that have an association with ADHD help regulate the distribution of the neurotransmitter dopamine in various areas of the brain that are thought to regulate attention, planning and executing tasks, and impulsivity.
One of the more interesting hypotheses that has arisen as a result of these genetic discoveries is the concept that ADHD is much older than one hundred years and its existence could have served an adaptive function in human society. Hyperactivity, restlessness, and impulsivity are traits that would serve an explorer well. These traits may have served the general purpose of human migration and settlement. In sedentary contemporary society, these traits are not necessarily a boon and can cause havoc to individuals. Quelling this disruption is the goal of management of ADHD.
Bipolar Disorder
Bipolar disorder is a mental illness that is characterized by one or more episodes of mania. Mania was first recognized by ancient Greek physicians and described as a state of hyperactivity and agitation. In fact, the word mania is derived from the Greek mainesthai, which literally means “to rage.” The current psychiatric use of the term mania is used to describe a spectrum of elevated moods. Mania can range from mild elation to grandiose delusions: e.g. “I’m going to walk the two miles to the train station. I don’t mind leaving early;” versus “I am the king of Siam! I have the right to drive alongside this train as it barrels through the mountains.”
Classic symptoms of mania include persistent elevation of mood coupled with lability (ups and downs) and irritability, high energy, decreased need for sleep, the sensation that one’s thoughts are racing, rapid speech, and impulsive, risky behavior. Mania can start abruptly, with the development of symptoms occurring and escalating over several days. Alternatively, mania can develop more gradually, with symptoms developing over a period of a few weeks. The initial state of well-being in patients changes to irritability, grandiosity and, in some cases, false beliefs of extraordinary powers. The manic person can furthermore engage in very high-risk behaviors: activities such as exorbitant spending, impulsive sexual behavior and drug use are typical.
Some drugs can trigger or mimic the state of mania. Amphetamines, antidepressants, cocaine, and corticosteroids are some of these drugs. Also some medical conditions, such as hyperthyroidism and multiple sclerosis, can present and masquerade as mania. When a manic patient is evaluated, part of the essential diagnostic evaluation is to ascertain if there is a specific cause; e.g., if the patient is under the influence of drugs or has an exacerbation of a known medical condition. If a causative agent is not found, the diagnosis of bipolar disorder is then explored.
In bipolar disorder, it is common to have an episode of mania that is followed months or years later by an episode of depression. Thus, the term “bipolar,” which conveys the two opposite ends of the mood spectrum, is used. Psychiatrists further differentiate the mood disorder into other classifications based on the severity and the duration of the mania. Bipolar I disorder is characterized by manic episodes, and sufferers of this subtype of bipolar disorder may or may not have depressive episodes. Bipolar II disorder patients have at least one depressive episode along with at least one episode of “mild” mania (hypomania). Cyclothymic disorder describes patients who, for years, have many periods of hypomania and mild depression that are not severe enough to be mania or major depression.
The manic period of bipolar disorder can last from days to months. The depressive episodes tend to be longer, ranging from weeks to months. The period between manic and depressive episodes can vary: it may be months or even years. Predicting when a recurrence will happen is difficult. The best clue is to review past patterns of episodes. Also, a family history of bipolar disorder may be indicative of more recurrences.
Approximately one percent of the population has bipolar disorder, and the rate as well as the presentation is similar across different countries. The onset of bipolar disorder typically occurs in a person’s early twenties, although children can suffer from the illness. Bipolar disorder can also present later in life. Both men and women are affected with bipolar disorder at the same rate.
It is not known why people get bipolar disorder, although several observations about its occurrence have been noted. First, it tends to run in families, and the more people in a family with bipolar disorder, the greater the chance of another family member expressing the illness. These observations lend a genetic component to bipolar disorder. Second, studies of brain function show that there could be a disturbance of certain neurotransmitters. While many neurotransmitters have been implicated in bipolar disorder, there is presently no clear consensus on how their interaction causes the condition. And, third, stressful events predispose people to having bipolar episodes. A person under stress, for example, might use a drug that could cause him or her to forgo sleep, thus prompting a manic episode.
There are many different, successful treatment options for patients with bipolar disorder. One of most important interventions is education. A patient who has the insight to recognize the first symptoms of mania or depression is more apt to seek treatment, which is usually more successful when engaged at the onset of a manic or depressive episode.
Dementia
Simply, dementia is a progressive decline in an individual’s ability to think and remember. As this decline is progressive, it is noted as people age; but old age does not cause this decline. There are elderly individuals who remain intellectually intact until the day they pass on. This observation has become more apparent as human life span increases. However, also noted in the aging population is the increased frequency of memory loss and subsequent loss of intellect that interferes with day-to-day functioning. Aging does not cause this decline, but age is the biggest risk factor for developing dementia.
Dementia was first documented by ancient Egyptian physicians around two thousand BC. Throughout antiquity, physicians identified this decline, yet this observation was not described as it is now until the late eighteenth century. In 1797, the French psychiatrist, Philippe Pinel coined the term dementia (démence). Dementia is derived from the Latin de meaning “out of” and mens meaning “the mind.” Pinel’s medical description of dementia was quite accurate; however, the name he used is not reflective of the disease process. Dementia is not being “out of one’s mind.” Dementia is the slow deterioration of mental capacities that is a direct result of a disease process in the brain. Dementia first emerges as mental changes, which may be subtle. Then, dementia further affects the brain so that bodily functions diminish. Unfortunately, this process can progress to death.
The first symptom of dementia, typically, is memory loss. Memory loss is frequently first noticed, not by the patient, but rather those close to him or her. Misplacing items, forgetting names and dates, and getting lost in familiar places are all signs of memory loss. This memory loss may also emerge as deterioration in an individual’s ability to perform a familiar task, such as forgetting how to tie one’s shoes or difficulties with conversation, such as forgetting words or repeating sentences. When these symptoms increase in frequency or are considered a change in behavior, dementia should be suspected.
Once dementia is suspected, the next step is to determine what could be causing the symptoms. There are many different diseases that lead to dementia. Lewy Body disease, Pick’s disease, alcoholism, HIV disease, head trauma, Parkinson’s disease, Huntington’s disease, Creutzfeldt-Jakob disease, vitamin B12 deficiency, among others all cause dementia. Some of these types of dementias affect the young, but the majority present later in life and vast majority of individuals with dementia are old. Also, some dementias are reversible when the underlying cause is treated, for example, when due to a deficiency in vitamin B12. However, the majority of patients with dementia have irreversible, but treatable forms. In the old, usually defined as greater than sixty-five years old, the two most common dementias, both of which are irreversible, are Alzheimer’s disease and vascular dementia.
Alzheimer’s Disease
Alzheimer’s is the most common recognized form of dementia. It accounts for about two-thirds of all cases of dementia and affects all ethnic groups. Also, it approximately affects men and women at the same rate.
The differentiation of Alzheimer’s disease from other forms of dementia was first described in the early twentieth century. In 1907, the German psychiatrist Alois Alzheimer published a case study of a patient who had a progressive decline of mental functioning that lead to death. Dr. Alzheimer performed an autopsy on this demented patient and discovered structural changes in the patient’s brain. Further study revealed other demented patients also had these structural changes at autopsy. Subsequently, because of his discovery, the illness was named after him, and his descriptions of brain pathology are still the definitive means to diagnose this type of dementia.
Currently, there are no means to conclusively diagnose Alzheimer’s disease in the living. When dementia symptoms are noted, physicians rely on tests that exclude other causes. For example, older patients with depression or a deficiency in thyroid hormone may become forgetful. However, these patients usually have other signs of depression or thyroid disease, and the deficiencies in memory respond to treatment when it is directed at the underlying cause. Thus, in the absence of a direct cause for patients’ symptoms, physicians make the diagnosis of Alzheimer’s disease if it fits what is known about the clinical presentation.
Studies of the clinical presentation of Alzheimer’s disease reveal that it affects the old and progresses slowly: the course of the illness ranges from five to twenty years. Most patients first develop symptoms in their seventies, though it may present early or later in life. These facts are imperative for diagnosis and shed light on what constitutes risks for developing the illness.
Old age is the most consistently associated risk factor for developing Alzheimer’s disease. Aging is not the cause of Alzheimer’s disease, but the risk of developing the disease increases as people age. Besides age, a family history of Alzheimer’s disease is a risk factor for developing the illness. It is not known exactly how this predisposition to develop Alzheimer’s disease is inherited, but one gene called ApoE/Î4 (which is a form of the alpolipoprotein E gene, which codes for a molecule that is involved in cholesterol transport) is associated with a higher risk for developing the illness. To note, having this gene just puts an individual at risk for developing Alzheimer’s disease, and one can have this gene and not develop the illness. This suggests that other genetic factors are involved in the familial transmission of Alzheimer’s disease, and other genes have been associated with the illness. Also, other factors have been associated with Alzheimer’s disease, but do not have as high an association as old age and family history.
There are treatments that can slow the progression of Alzheimer’s disease. As Alzheimer’s disease affects the elderly, a treatment plan must include family members and other caregivers – so treatment extends the quality of life for all.
Vascular Dementia
Vascular dementia is the second most common type of dementia. It accounts for about ten to fifteen percent of dementia in the old and affects men at a higher rate then women.
The reason it affects men at a higher rate, is that vascular dementia is caused by damage to the brain by stroke, and men at are a greater risk for stroke. Men have higher rates of hypertension, hypercholesteremia, alcoholism, and smoking. All of these conditions are risk factors for stroke and subsequently vascular dementia.
Since strokes cause vascular dementia, the course of mental deterioration follows a “step-wise” fashion. In contrast to the gradual course of Alzheimer’s disease, vascular dementia patients have abrupt periods of mental deterioration that are followed by periods of minimal deterioration. This course is a reflection of the sudden damage of the brain by stroke.
Currently, like in Alzheimer’s disease there is currently no intervention to repair the brain damage in vascular dementia. However, there are preventative measures and treatments that are used to lessen the chance for further progression.
Classic symptoms of mania include persistent elevation of mood coupled with lability (ups and downs) and irritability, high energy, decreased need for sleep, the sensation that one’s thoughts are racing, rapid speech, and impulsive, risky behavior. Mania can start abruptly, with the development of symptoms occurring and escalating over several days. Alternatively, mania can develop more gradually, with symptoms developing over a period of a few weeks. The initial state of well-being in patients changes to irritability, grandiosity and, in some cases, false beliefs of extraordinary powers. The manic person can furthermore engage in very high-risk behaviors: activities such as exorbitant spending, impulsive sexual behavior and drug use are typical.
Some drugs can trigger or mimic the state of mania. Amphetamines, antidepressants, cocaine, and corticosteroids are some of these drugs. Also some medical conditions, such as hyperthyroidism and multiple sclerosis, can present and masquerade as mania. When a manic patient is evaluated, part of the essential diagnostic evaluation is to ascertain if there is a specific cause; e.g., if the patient is under the influence of drugs or has an exacerbation of a known medical condition. If a causative agent is not found, the diagnosis of bipolar disorder is then explored.
In bipolar disorder, it is common to have an episode of mania that is followed months or years later by an episode of depression. Thus, the term “bipolar,” which conveys the two opposite ends of the mood spectrum, is used. Psychiatrists further differentiate the mood disorder into other classifications based on the severity and the duration of the mania. Bipolar I disorder is characterized by manic episodes, and sufferers of this subtype of bipolar disorder may or may not have depressive episodes. Bipolar II disorder patients have at least one depressive episode along with at least one episode of “mild” mania (hypomania). Cyclothymic disorder describes patients who, for years, have many periods of hypomania and mild depression that are not severe enough to be mania or major depression.
The manic period of bipolar disorder can last from days to months. The depressive episodes tend to be longer, ranging from weeks to months. The period between manic and depressive episodes can vary: it may be months or even years. Predicting when a recurrence will happen is difficult. The best clue is to review past patterns of episodes. Also, a family history of bipolar disorder may be indicative of more recurrences.
Approximately one percent of the population has bipolar disorder, and the rate as well as the presentation is similar across different countries. The onset of bipolar disorder typically occurs in a person’s early twenties, although children can suffer from the illness. Bipolar disorder can also present later in life. Both men and women are affected with bipolar disorder at the same rate.
It is not known why people get bipolar disorder, although several observations about its occurrence have been noted. First, it tends to run in families, and the more people in a family with bipolar disorder, the greater the chance of another family member expressing the illness. These observations lend a genetic component to bipolar disorder. Second, studies of brain function show that there could be a disturbance of certain neurotransmitters. While many neurotransmitters have been implicated in bipolar disorder, there is presently no clear consensus on how their interaction causes the condition. And, third, stressful events predispose people to having bipolar episodes. A person under stress, for example, might use a drug that could cause him or her to forgo sleep, thus prompting a manic episode.
There are many different, successful treatment options for patients with bipolar disorder. One of most important interventions is education. A patient who has the insight to recognize the first symptoms of mania or depression is more apt to seek treatment, which is usually more successful when engaged at the onset of a manic or depressive episode.
Eating disorders
Anorexia Nervosa
In the late nineteenth century two physicians, the British Sir William Gull and the French Ernest Charles Laseque, independently published observations of self-starving in adolescent girls. This condition was termed “anorexia nervosa.” The term “anorexia” (derived from the Greek an meaning “without” and orexis meaning “desire for”) was used to describe the starvation and “nervosa” was used to imply involvement of the brain rather than dysfunction of the gastrointestinal tract in the illness.
Anorexia nervosa is actually a misnomer. Anorexic patients do not lack a desire for food. Their starvation causes hunger, yet their illness will not allow them to eat. Anorexic patients will reduce food intake or increase physical activity that overrides their hunger and causes a serious decline in weight. Presently, there are four criteria used to diagnosis the condition. The first two are physical observations: bodyweight that is fifteen percent below normal and loss of menstruation. Starvation impairs the regularity of the menstrual cycle in women. Obviously, this criterion is not used for males. The second two criteria are assessments of patients’ perceptions. Patients need to have an intense fear of gaining weight or becoming fat, even though underweight. Also, patients have a misperception of their physical appearance in that they may even perceive themselves as overweight even though they are emaciated. This misperception contributes to the denial that many anorexic patients have. Many patients really do not believe they are ill.
Anorexia nervosa usually develops during the teenage years and affects about one half of a percent of adolescents. Around ninety to ninety-five percent of the cases are in females, though the disorder is being recognized more and more in males. Interestingly, anorexia nervosa is only found in industrialized nations. However, studies have revealed that when immigrants move from an unindustrialized society to an industrialized one, they have an increased risk for developing anorexia. This observation gives some insight into the possible causes of anorexia nervosa. Social factors contribute to an individual’s predisposition to developing anorexia nervosa. This is easily demonstrated by the above mentioned immigrant observation and the presence of the illness almost exclusively in Westernized cultures where dieting is common behavior. Recently, Westernized cultures have acclaimed thinness. The media and other societal influences use thinness to promote and advertise. It represents accomplishment, beauty, and desirability. This portrayal of the feminine ideal may instill a desire to reach such a state. This ideal is impractical and unhealthy in most and has nothing to do with accomplishment, beauty or desirability. It is a cultural convention that has become more and more prominent and is thought to be contributing to the increase of anorexia nervosa that has been observed in the past decades.
Westernized culture is not the only contributor, as study reveals other factors that play a role in the onset of the illness. Genetic studies show a familial factor, in that risk for developing anorexia is increased if one has a family member with the illness. Also anorexic patients may have a biological predisposition to eating deficits. Psychological factors may include poor recognition of the normal increase in body fat that accompanies puberty. It is not know which factors are most important, but all need to be taken into account when diagnosing and recommending treatment for an anorexic patient.
Bulimia Nervosa
Bulimia is derived from the Greek boulimos literally meaning “ox hunger” (bous meaning “ox” and limos meaning “hunger.”) In the medical literature, dating all the way to the ancient Greeks, ravenous hunger has always been considered a symptom of other diseases. This observation has continued, as hunger and associated binge-eating behavior is noted in conditions, such as, diabetes, depression, and Kleine-Levin syndrome (A rare episodic illness that is characterized by periods of excessive binging and sleeping, which usually resolves by early adulthood and is thought to be caused by disruption of the hypothalamic system). However, not until the late twentieth century has medicine recognized binge eating as a core symptom of a disorder. The hallmark of bulimia nervosa is binge eating.
Bulimia nervosa consists of episodes of binge eating that are characterized by a sense of a lack of control of what or how much one is eating. This is followed by a maneuver to try to prevent weight gain after the episode. Self-induced vomiting, the misuse of laxatives, diuretics, and enemas, fasting, and excessive exercise are typical means to compensate for the binge eating physically and emotionally. Similar to anorexic patients, bulimic patients have misperceptions concerning their body weight and shape. However, unlike in anorexia nervosa, the weight of bulimic patients is usually normal; though patients may have marked fluctuations in weight. Making the diagnosis more difficult is that bulimic patients are often embarrassed about their eating habits and rarely binge or purge in the presence of others.
Bulimia nervosa develops somewhat later than anorexia nervosa, and most cases develop during the late teens and early twenties: affecting about two percent of this population. Like in anorexia nervosa, most cases are in females, and it is only noted in Westernized cultures. Due to the similarities between the two conditions, it is thought that the share the same predispositions to development. To note, the binge eating and/or compensating of bulimia nervosa may be seen in some anorexic patients. The difference between the two conditions is that anorexic patients will be underweight.
Major Depressive Disorder
Major depressive disorder (MDD) – sometimes referred to as clinical depression – is one of the oldest diseases recognized in medicine. Since antiquity, physicians have recognized a condition of severely depressed mood that arises acutely, persists, and then lifts as quickly as it started. From reviewing the chronicles of this illness in literature, one finds that the course of the illness remains the same now as it has in the past. Present day studies have revealed several findings. First, the average duration of a depressive episode is six months, although an episode can last longer. Second, the average age of patients at the onset of the illness is in the fourth decade of life, though MDD can present at any age. Third, the illness affects about twenty percent of the population; that is, one-fifth of the population will suffer a depressive episode in their lives, and all ethnic groups are affected. Fourth, the illness tends to affect females more than males. Fifth, it is a chronic illness. There is an eighty percent chance that a person will have another episode of depression during his or her lifetime and the average number of episodes in such patients is four. Last, individuals with a family history of MDD are more apt to have depressive episodes than the general population.
MDD is an illness of that presents with psychological and physical symptoms. The psychological symptoms include persistent sadness, irritability or feelings of emptiness, loss of interest in pleasurable activities, a decreased ability to concentrate, feelings of worthlessness or helplessness, and, most troubling, recurrent thoughts of death and suicide: a particularly important point, since these later symptoms are not normally found in people suffering from bereavement or grief. (To note, the depression associated with bereavement or grief is always related to a loss or perceived loss, and the severity and length of depression is proportional to the precipitant. This is in contrast to MDD where there may not be a precipitant.) In severe cases of depression, a patient may have psychotic symptoms. These can be of a delusional nature, for example, “I should kill my self because it is Tuesday and Tuesday is the day of all deaths.” or even present as hallucinations of hearing voices advocating suicide.
The physical symptoms of a depressive episode include a change in sleep patterns (usually insomnia, although oversleeping is also seen), a change in appetite with weight loss or gain, and fatigue. There is, interestingly, a cultural component to the expression of depression. If the pervading culture stigmatizes the psychology of depression, a patient may have vague physical complaints instead of psychological complaints. For example, the presence of emotional disturbances in some cultures may be considered taboo, and consequently, a patient suffering from MDD might present with an upset stomach, muscle aches, and headaches, instead of complaints of feeling sad, removed, and tired. These complaints do not respond to treatment, unless that treatment is directed towards the underlying depression.
It is known the brain mediates mood, and the current theory for depression postulates there is an alteration in brain chemistry that changes the way brain cells communicate with one another. This theory is supported by a wealth of brain imaging studies, as well as observations of illness and chemicals that affect brain function. For example, hypothyroidism can cause depressive symptoms. With the replacement of thyroid hormone in the hypothyroidic patient, the brain chemistry reverts back to normal and the depression lifts. In addition, drugs and some medications that target the brain have been found to precipitate depressive episodes: this includes alcohol, street drugs such as heroin, and even prescription medications.
In contrast to the depressive episodes associated with the conditions listed above, MDD is thought to be an endogenous phenomenon; that is, it originates internally. The depression of MDD causes specific changes in brain function and a number of neurotransmitters and circuits are involved. Once an episode of MDD has arisen, the depression will run its course, approximately six months, even if a possible trigger for the depression is removed. This course of depression is specific for MDD, and differences its depression from other causes of depression.
The obvious detriment of MDD is a miserable existence (morbidity) and the real risk of suicide (mortality). Fortunately, MDD is a treatable illness and approximately ninety percent of patients will respond to treatment – of which there are many, different successful options.
Obsessive-Compulsive Disorder
Making lists and stringently following rules are all personality characteristics of people who are obsessed with organization and compulsive in finishing tasks. These traits are common in American culture and are often associated with occupational and economic success. Obsessive-compulsive individuals usually have usually displayed these traits since young adulthood and consider them as a component of their personality. People who display these traits are usually not distressed by them and acknowledge them as an aspect of their personalities that helps them cope with life. Having obsessive-compulsive personality traits is not considered a mental illness.
Obsessive-compulsive disorder (OCD) is an illness and a different entity than an obsessive-compulsive personality. The obsessions in OCD are unwanted, intrusive, and by no means help the sufferer cope with life. These thoughts arouse anxiety and are experienced by the patient as inappropriate, foolish ideas.
Interestingly, the obsessions in OCD tend to be similar across different cultures. The most common obsession worldwide is that of contamination. Howard Hughes, the famous American aviator, had this obsession. He would demand that all materials brought to him be wrapped in volumes of paper. The next most common obsession is that of harm. An individual will have the overbearing fear that he has done or is about to do some act to harm someone or something. An example of this obsession would be of an individual driving over an irregularity in the road and having extreme distress that he had just run over someone. The individual recognizes that this concern is senseless; that is, the sufferer knows he drove over a speed bump, yet he cannot rid himself of these thoughts. The only way he is able to relieve the thought is through the performance of a ritual.
The compulsions of OCD are the acts done to decrease the anxiety of the obsession. These acts tend to be repetitive. Common compulsions include acts of cleaning or checking. For example, the above individual who thinks that he has driven over someone may stop the car and check under it to make sure that no one has been injured. The person without OCD would then continue to drive on, with the assurance that he had not injured anyone. In contrast, a patient with OCD may have to stop his car repeatedly to check that he had not injured someone. These types of rituals may last for hours. The compulsions alleviate the anxiety of the obsession and, like the patients’ perceptions of their obsessions, are known to be senseless. In OCD, the urge to carry out the compulsions is overwhelming and is difficult to resist.
OCD has been recognized since the late fifteenth century and has been considered a rare phenomenon. That is, until recently. Worldwide studies have shown that two percent of the population has OCD. A possible reason for the discrepancy is that individuals with OCD are apt to hide their compulsions from others out of shame and humiliation, as well as out of fear of being stigmatized as mentally ill. OCD patients are usually embarrassed about their symptoms, feeling frustrated that they cannot avoid and control them, and seldom reveal them unless asked. Another factor disguising the true prevalence of OCD is that, until recently, there were no effective treatments.
Fortunately, many more patients with OCD are seeking treatment, and much more information is known about the disorder today. Studies show that OCD usually presents in late adolescence and early adulthood and affects men and women equally. Once OCD emerges, are a variety of different courses for the illness to take. The symptoms may dissipate over time, wax and wane, or become progressively worse. In addition, the intensity of the obsessions and compulsions vary among patients
Over the past twenty years, there has been an explosion in the understanding of brain function in patients who have these obsessions and compulsions. Recent advances in brain physiology, immunology and brain imaging have revealed that the neurotransmitter serotonin and brain circuits housed in the basal ganglia – a cluster of neurons deep within the brain involved in the regulation of motor movements – are involved in the pathogenesis of OCD.
The neuroscience research implicating involvement of the basal ganglia is particularly interesting because this finding fits what is observed clinically about the condition. There is an increased incidence of OCD in patients who also suffer from Huntington’s disease, Parkinson’s disease, Sydenham’s chorea, and Tourette’s syndrome – which are all disorders of movement. The diseases have different causes; however, the common factor among these disorders is that they all involve the basal ganglia.
The basal ganglia, in addition to regulating motor control, has been recently found via neuroscience research to be involved with planning movements and digesting and storing new rules via its connections with higher areas of the brain. This expanded understanding of the function of basal ganglia has led to the current theory for OCD that states there is a dysfunction in the ability of the basal ganglia and its connections to regulate rules and movement; that is, there is a disturbance between the areas of the brain that control reason and the basal ganglia which can store rules and help control behavior. This explains the higher incidence of OCD seen in these disorders involving the basal ganglia and has led to a new understanding of why certain treatments for OCD are successful.
Schizophrenia
Schizophrenia is an extremely complex brain disease that has a clouded history. Unlike depression or mania, which have be recognized for at least the past 2000 years, the description of schizophrenia in historical medical literature is sparse. A possible reason for this exclusion is that patients with schizophrenia suffer from multiple symptoms that affect many aspects of sensation, emotion, and thought. The diverse and unusual presentations of schizophrenia may have contributed to its near absence from the medical literature. Also, patients with schizophrenia suffer from hallucinations and delusions that may have excluded them from medical inquiry; that is, sufferers could have thought to been possessed and evil, thus incarcerated, banished, or executed. Another possibility is that schizophrenia could be a relatively new illness.
The history of schizophrenia is still controversial. However, the recent history of the condition is well documented. In the nineteenth century, physicians began to describe an insanity that affected the young. In the early twentieth century, the term schizophrenia (a Greek derivation, literally meaning “splitting of the mind”) was used to describe this group of patients. This word was used because it was thought that the cause of schizophrenia was due to a disconnection between emotion, thought, and behavior. Although the term is still used today, the diagnosis is now based on the symptoms and the course of the illness.
A simple way to understand the symptoms of schizophrenia is to think of them as positive or negative. A positive symptom is one that is added. The positive symptoms are hallucinations, delusions, and disorganized speech and behavior, which are collectively referred to as “psychosis.” Hallucinations are disturbances in the five senses (sound, sight, touch, smell, and taste). A common hallucination noted in schizophrenia is the hearing of voices. These voices vary in character, ranging from simple commands to intricate conversations. These voices are not a misinterpretation of sounds or talking. They come from inside the patient. Another common positive symptom is delusional thinking. A delusion is a fixed, false belief. It is fixed, because the patient will not change his or her view in the face of reason or contradictory evidence. An example of delusional thinking, then, might be a patient thinking that the CIA has secretly implanted a computer chip in his or her brain. Although the delusional patient can have a head x-ray or magnetic resonance imaging (MRI) that would prove that there is no chip, he would continue to insist and react to the notion that a chip is implanted, and that the head imaging must have been wrong, or even that the chip might have been invisible to MRI detection. Another common positive symptom seen is that of disorganized speech. Disorganized speech is characterized by strings of words expressing ideas that have no obvious connection; for example, “Doctor, I went to bed at ten because I have a pen, she doesn’t care about the rock, I need to do pushups, Hi Doc.” Also, a patient’s speech is often accentuated by long pauses, which might be a clue to something called “thought blocking.” This postulates that the patient’s normal train of thought is being interrupted, that is, “blocked,” by some internal process, for example, voices.
In contrast to a positive symptom, a negative symptom is one that is missing from normalcy. These symptoms include apathy (lack of emotional expression) and greatly decreased motivation. Patients with schizophrenia do not show the normal range of emotions. They have minimal facial expressions, and their emotions seem blunted. Also, their motivation is diminished and they do not adhere to goals, even though they may have been very goal-oriented in the past. The lack of motivation can cause patients to neglect basic personal hygiene. These negative symptoms contribute to the social withdrawal that characterizes schizophrenia, and consequently are considered a destructive part of the illness that leads to a poor quality of life for the patient.
Classically, schizophrenia develops slowly and may not be immediately recognizable to the patient and family members as an illness. Patients in the first stages of schizophrenia may become withdrawn, seem aimless, and display subtle oddities. An example might be an individual preoccupied with nuclear disarmament, yet not making progress in trying to learn about and participate in solving the problem. These “soft” signs may not cause concern to family members. However in schizophrenia this period is followed, roughly about five years later, by a florid presentation of positive symptoms. The positive symptoms, which may erupt suddenly, usually present in males in the early twenties and in women a few years later. The ages of presentations vary, however, and children or even older people may develop schizophrenia.
After the initial presentation of positive symptoms, the following ten to twenty years of illness are characterized by multiple exacerbations of positive symptoms interspersed with periods when the patient may return to his or her previous state of health. Unfortunately, some patients never return to their baseline state.
The next stage of schizophrenia is generally characterized by a decrease in the positive symptoms, while the negative symptoms continue. Roughly one-half of patients who survive to old age can function well in society and are not in need of custodial care, for example, hospitals or community institutions; and some of these patients recover completely. Unfortunately, the number of patients who recover is less than what it could be. Sadly, the rate of suicide is extremely high (approximately ten percent) in schizophrenia. Furthermore, patients with schizophrenia tend to die prematurely from other medical conditions. This might be secondary to poor access to medical care, possible unhealthy lifestyles, or inherent predispositions to various physical illnesses. What is known is that many patients with schizophrenia do not live long enough to enjoy the abatement of their worst symptoms.
Approximately one percent of the world’s population will develop schizophrenia, and males and females are affected at the same rate. Schizophrenia afflicts individuals throughout the socioeconomic spectrum, but due to the symptoms of the illness and its chronic course, most patients with schizophrenia drift down to the lower socioeconomic groups.
As with many diseases, family history lends to the development of schizophrenia: that is, there is a genetic factor involved in the expression of schizophrenia. A patient with schizophrenia may inherit a predisposition to developing the illness. Genetic studies have suggested that susceptible genes may be present on certain chromosomes. In addition, environmental causes, such as possible brain infection, immune system dysfunction, and abnormal development of brain cell connections have all been studied as contributing factors to schizophrenia. There is no consensus on which factors are important or how they exactly may cause schizophrenia. However, there is a consensus that schizophrenia is a disease of the brain and advances in neuroscience research have made an enormous impact on the treatment of schizophrenia. Now, more than ever, the chance for a patient with schizophrenia to live a better quality of life is the highest it has ever been.
Obsessive-compulsive disorder (OCD) is an illness and a different entity than an obsessive-compulsive personality. The obsessions in OCD are unwanted, intrusive, and by no means help the sufferer cope with life. These thoughts arouse anxiety and are experienced by the patient as inappropriate, foolish ideas.
Interestingly, the obsessions in OCD tend to be similar across different cultures. The most common obsession worldwide is that of contamination. Howard Hughes, the famous American aviator, had this obsession. He would demand that all materials brought to him be wrapped in volumes of paper. The next most common obsession is that of harm. An individual will have the overbearing fear that he has done or is about to do some act to harm someone or something. An example of this obsession would be of an individual driving over an irregularity in the road and having extreme distress that he had just run over someone. The individual recognizes that this concern is senseless; that is, the sufferer knows he drove over a speed bump, yet he cannot rid himself of these thoughts. The only way he is able to relieve the thought is through the performance of a ritual.
The compulsions of OCD are the acts done to decrease the anxiety of the obsession. These acts tend to be repetitive. Common compulsions include acts of cleaning or checking. For example, the above individual who thinks that he has driven over someone may stop the car and check under it to make sure that no one has been injured. The person without OCD would then continue to drive on, with the assurance that he had not injured anyone. In contrast, a patient with OCD may have to stop his car repeatedly to check that he had not injured someone. These types of rituals may last for hours. The compulsions alleviate the anxiety of the obsession and, like the patients’ perceptions of their obsessions, are known to be senseless. In OCD, the urge to carry out the compulsions is overwhelming and is difficult to resist.
OCD has been recognized since the late fifteenth century and has been considered a rare phenomenon. That is, until recently. Worldwide studies have shown that two percent of the population has OCD. A possible reason for the discrepancy is that individuals with OCD are apt to hide their compulsions from others out of shame and humiliation, as well as out of fear of being stigmatized as mentally ill. OCD patients are usually embarrassed about their symptoms, feeling frustrated that they cannot avoid and control them, and seldom reveal them unless asked. Another factor disguising the true prevalence of OCD is that, until recently, there were no effective treatments.
Fortunately, many more patients with OCD are seeking treatment, and much more information is known about the disorder today. Studies show that OCD usually presents in late adolescence and early adulthood and affects men and women equally. Once OCD emerges, are a variety of different courses for the illness to take. The symptoms may dissipate over time, wax and wane, or become progressively worse. In addition, the intensity of the obsessions and compulsions vary among patients
Over the past twenty years, there has been an explosion in the understanding of brain function in patients who have these obsessions and compulsions. Recent advances in brain physiology, immunology and brain imaging have revealed that the neurotransmitter serotonin and brain circuits housed in the basal ganglia – a cluster of neurons deep within the brain involved in the regulation of motor movements – are involved in the pathogenesis of OCD.
The neuroscience research implicating involvement of the basal ganglia is particularly interesting because this finding fits what is observed clinically about the condition. There is an increased incidence of OCD in patients who also suffer from Huntington’s disease, Parkinson’s disease, Sydenham’s chorea, and Tourette’s syndrome – which are all disorders of movement. The diseases have different causes; however, the common factor among these disorders is that they all involve the basal ganglia.
The basal ganglia, in addition to regulating motor control, has been recently found via neuroscience research to be involved with planning movements and digesting and storing new rules via its connections with higher areas of the brain. This expanded understanding of the function of basal ganglia has led to the current theory for OCD that states there is a dysfunction in the ability of the basal ganglia and its connections to regulate rules and movement; that is, there is a disturbance between the areas of the brain that control reason and the basal ganglia which can store rules and help control behavior. This explains the higher incidence of OCD seen in these disorders involving the basal ganglia and has led to a new understanding of why certain treatments for OCD are successful.
Sex and Sexual disorders
Sex
Sex enhances intimacy and connectedness, and adds comfort, security, and pleasure to loving couples. And, of course, sex is necessary for propagation. As sex is such a large component of normal life, when it is disrupted, wide ranges of problems develop. From a medical standpoint, these problems are addressed by maneuvers to mend any type of physiological or psychological disruption that may be present. This approach is not complete – human sexual behavior is too complex to be viewed only through a medical prism – but is helpful to alleviate common types of problems patients have during sex.
Human sexual behavior can be divided into four stages: drive, arousal, orgasm and resolution. Sexual drive is the impetus that makes individuals think about and want sex. The brain regulates this process through a number of mechanisms. Sexual arousal is the stage of sexual pleasure and excitement preceding orgasm. In males, the blood enters the penis, which becomes erect. In females, blood flow increases to the clitoris, labia, and vagina. Orgasm is the climax of pleasure during sex. In males, this coincides with ejaculation. In females, orgasm is accompanied by contractions of the vagina and uterus. Orgasm is a sensation in the brain. In males, impending ejaculation triggers orgasm. In females either vaginal or clitoral stimulation triggers orgasm. The last stage of sex is resolution. Five to fifteen minutes after orgasm, the body returns to baseline. In men there is a refractory period that may last from minutes to hours, in which they cannot be stimulated to orgasm. This period is not seen in women, many of whom are able to have multiple, consecutive orgasms.
Sexual Disorders
Impotence
Impotence is the inability to attain or sustain an erection to complete sexual intercourse. Impotence can be psychological in origin; however, it is also a common symptom in many physical conditions and drugs. The easiest way to sort out and treat impotence is to group the causes into physical or psychological categories.
One way to differentiate if the cause of impotence is physical or psychological is to ask when the impotence occurs. If impotence happens only at certain times, for example, only with one’s wife – not with one’s mistress – there is a strong indication for a psychological cause. However, diagnosis is not usually that simple as the insidious nature of impotence in medical conditions, such as diabetes, allows for psychological contributions. Commonly, anxiety will confound the cause of impotence in patients who have an underlying physical cause. The treatment of impotence begins by adequately treating the underlying physical or psychological condition.
Medication-Induced Sexual Dysfunction
This is the most common cause of sexual dysfunction that psychiatrists encounter. Many medications and most substances of abuse cause sexual problems. Unfortunately, many of the medications that are prescribed for psychiatric illnesses cause sexual dysfunction.
One of the most prevalent diseases in psychiatry is depression, and the most popular antidepressants, which work exceptionally well for depression, can cause sexual dysfunction. The most common sexual problems encountered with antidepressant therapy are delayed ejaculation and delayed orgasm. Also, decreased sexual desire and arousal may be seen. The effect on sex is dose-related, that is, higher doses of medication cause higher levels of dysfunction.
The first step in appraising if the antidepressant is contributing to sexual dysfunction is to ask patients if they are taking the medication. Most depressed patients respond to medication and may stop taking medicine when they feel better. A reemerging depression can decrease sexual function. If patients are compliant with medication and their depression is controlled, the next step is to assess if there are other possible causes, for example, exacerbation of a medical illness or new stressful encounters. Once the problem is addressed, most patients will respond to treatment strategies.
Orgasmic Disorder
Orgasmic disorder is the absence of orgasm following a normal excitement phase. It is more prevalent in females than in males. In the workup of a patient with orgasmic disorder it is necessary to inquire about physical and psychological manifestations associated with the orgasm. Lack of knowledge of the function of sexual anatomy, that is, the understanding of the physiology of an orgasm, decreased awareness of sexual sensations, anxiety, and distractibility can contribute to the condition. In addition, these areas are targets of treatments – which typically incorporate multiple approaches. These approaches are best applied and most successful when coupled with communication with the sex partner.
Premature Ejaculation
Premature ejaculation probably would not be considered a problem if there were no refractory period in males. One of the glaring differences in sexual activity between males and females is that females are capable of multiple, consecutive orgasms, while males are not.
So, what is the “premature” in premature ejaculation? Attempts have been made to count pelvic thrusts and measure the time it takes to orgasm. However, using these criteria as a part of diagnostic evaluation can greatly decrease sexual pleasure when males are asked to count the number of pelvic thrusts or the duration of sex.
The current criterion for diagnosis only recognizes dysfunction if the time to ejaculate causes distress in the partner. If premature ejaculation is considered a problem, then there are a variety of successful treatments. As with all sexual disorders, patients more readily respond to treatment when their sex partner is included in the treatment plan.
Vaginismus
Vaginismus is an involuntary, painful muscle spasm of the outer third of the vagina that occurs with the attempted insertion of an object into the vagina. Vaginismus can occur in nonsexual situations such as during gynecological examination or with insertion of a tampon; however it is considered a sexual disorder when the item is a penis.
The exact cause of vaginismus is unknown. Physical causes, such as infection and surgical adhesions, have been noted in vaginismus. The psychological view is that vaginismus is caused or confounded by fear from past negative sexual or imagined sexual experiences. This fear is expressed via the involuntary muscle spasms. The treatment of vaginismus consists of interventions to decrease the pain and muscle spasms, as well as interventions to address an underlying problem if present.
Sleep and Sleep Disorders
Sleep
All living organisms have a rest-activity cycle. The need for rest is essential for life and if it is prevented in animals, as shown experimentally, life-expectancy is drastically shortened. The need to sleep is unavoidable. This is unlike eating, for example, where an individual can starve himself to the point of death.
Studies of sleep have implicated certain areas in the brain that regulate the sleep cycle, which has enabled researchers to categorize the sleep cycle into specific stages. Knowledge of what occurs during the sleep cycle stages is helpful for understanding the consequences of .
Human sleep has been categorized into two distinct states: rapid eye movement (REM) and non-rapid eye movement (NREM). The flow between the two states during sleep is defined by the electrical pattern of the brain as recorded by electroencephalography (EEG) – a test where electrodes are strategically placed on the scalp to record the electrical activity of the brain. NREM sleep is the first type of sleep during the cycle and generally is characterized by a “slowing” of the body. NREM sleep is divided into four stages and the stages are separated by distinct EEG patterns. Stage 1 sleep is the transitional stage between wakefulness and sleep, and lasts about five minutes. Stage 2 has characteristic EEG patterns that differentiate it from stages 1 and 3, and it lasts for approximately forty to sixty minutes. Stage 3 and 4 sleep have similar EEG patterns and last for about twenty to thirty minutes together. These stages are important because they are required to reduce the need for sleep.
The EEG pattern during REM sleep resembles the waking state. Physically, the limb muscles become temporarily paralyzed, blood pressure rises, breathing becomes labored and the eyes move about rapidly. (Hence the name rapid eye movement.) Psychologically, this is the stage of dreams. Much has been written on the meaning of dreams: Sigmund Freud believed that dreams were a portal into the unconsciousness and a means by which to express primitive emotions that were unacceptable to address in the consciousness, and Carl Jung spent most of his career describing a framework into which the symbols of dreams could be understood. (To note, recent neuroimaging studies have supported Freud’s theory at an anatomical level. During dreams, there is high activity in areas of the brain associated with emotions and motivation.) However, from a strictly scientific viewpoint that has a worldwide consensus, the “why” of dreams is unknown. What has been repeatedly shown is that REM sleep is needed for new learning. When an individual is deprived of REM sleep, they cannot recall newly learned material.
A typical sleep cycle averages an hour and a half, and there are four to six cycles per night in an average night’s sleep of eight hours. The sleep cycle is not static and changes as the night progresses. The percent of Stage 3 and 4 sleep is highest in the beginning and decreases throughout the night, while REM periods increase in length throughout the night.
The sleep cycle is also dependent on age. Infants and children sleep more and spend more of sleep in REM. Also, as we age, the amount of Stage 3 and 4 sleep decreases, and the sleep cycle becomes fragmented and has less continuity. The need for sleep is the same, but adherence to a nightly schedule is not as strong as in the young. Thus, there is a higher frequency of daytime naps in the elderly.
There are two processes in the body that determine when it is time to sleep and they are independent of each other. The first process is called homeostasis – the medical term for equilibrium or balance. This is simply that the likelihood of sleep increases as the period of wakefulness increases. No matter how much one may try, if one stays up long enough, sleep will occur. The second is called circadian (Latin for about the day) rhythm, commonly referred to as the “biological clock.” This is a clock in the body that is set by the light of day and the dark of night. The clock is located in a specific area of the brain called the suprachiasmatic nucleus, and it receives input from the retina of the eyes. Without this input, the clock will run a rhythm of 24.5 to 25 hours. This extra length poses a problem to blind individuals. Patients with total blindness have a sleep cycle that lasts a little bit longer each day and they usually have to take medication to adjust their cycle to the outside day and night.
Sleep Disorders
Insomnia
Insomnia is the inability to fall asleep or remain sleeping for an adequate length of time. It is a very common problem, and an estimated 60 million Americans suffer from insomnia annually. Physicians use insomnia as a clue to look for an underlying cause. Anxiety, depression, drug use or a wide variety of medical conditions can cause insomnia. When the underlying cause is treated, the insomnia usually resolves. If an underlying cause is not found, the insomnia is “primary.” And, there are a number of successful maneuvers to treat primary insomnia.
Jet Lag
Jet lag is the fatigue, daytime sleepiness, insomnia, clumsiness, and lack of concentration that accompanies travelers after they have traveled through multiple time zones. The cause of jet lag is the failure of the biological clock to adjust quickly to the light-dark cycle of the new environment. Naturally, the body can adjust its circadian rhythm at the pace of around 1 hour per day. Jet travel overwhelms the body’s ability to shift the sleep cycle and thus symptoms of insomnia result. There is no specific treatment that can override the circadian rhythm, yet there are maneuvers that facilitate the re-setting of circadian rhythm to the new time zone.
Narcolepsy
Narcolepsy is a disease that affects about 0.05% of the population, which makes it about as common as multiple sclerosis. Narcolepsy is Greek for “stupor attack” and it consists of immediate episodes of sleep that can be associated with loss of muscle tone. Patients also complain of excessive daytime sleepiness, even though they may be getting adequate sleep during the night. The sleep of narcolepsy resembles REM sleep and is associated with increased respirations and eye movements. If untreated, a patient usually has from 2 to 6 episodes per day that last from seconds to more than 30 minutes. The cause of narcolepsy is unknown, however it seems to run in families. Narcolepsy also occurs primarily in males and symptoms usually start in adolescence. Narcolepsy cannot be cured, however the symptoms can be treated.
Nightmares
Nightmares are common and 80 % of the adult population occasionally has them. The incidence is even higher in children. Basically, nightmares are dreams (and hence occur during REM sleep) in which the individual or someone close to the individual is put in some deadly or humiliating situation. In some cases the nightmare can disrupt sleep and the person can awake. Once the person awakes, he or she feels relief due to the realization that the person “was only dreaming.” Why people have nightmares is unknown, but the frequency of nightmares increases with stress as well as withdrawal from alcohol and drugs. People typically do not seek treatment for nightmares as their frequency is usually low and they are tolerable. If an individual has persistent nightmares, his or her physician will look for an underlying cause to treat, such as anxiety or substance abuse.
Night Terrors
About five percent of children, experience night terrors, though adults can also have them. A night terror is an abrupt awakening from sleep that is characterized by screaming, sweating, motor movements, and fear. While this can resemble a person waking from a nightmare, a night terror is different. Night terrors occur during stage 4 sleep and are not the result of dreams. Consequently, the person has no recollection of the terror when he or she awakens. Since they occur in stage 4, night terrors usually occur during the first half of the night. Most childhood cases resolve. Night terrors in adulthood are usually associated with a concurrent psychiatric diagnosis such as depression or posttraumatic stress disorder. However, an individual may have night terrors without an accompanying psychiatric condition.
Restless Legs Syndrome
Restless legs syndrome (RLS) is an unpleasant sensation of crawling or prickling in the legs that occurs at rest. The sensation is relieved after movement. RLS presents as constant leg movement during the day and insomnia at night (Patients have difficulty falling asleep due to their need to move their legs.) The condition was first described in the 1600s and study has shown that it affects about 5 % of the population, with the elderly having the most severe cases. The cause of RLS is unknown; however some conditions are associated with it, such as iron deficiency and pregnancy. Also, there may be a genetic component to RLS. Twenty-five to fifty percent of RLS patients have a family history of RLS. Treatment of RLS is directed at the underlying cause or exacerbating factor. In addition, there are interventions directed specifically at decreasing the urge to move one’s leg.
Sleep Apnea
Sleep apnea (Greek for “without wind”) is a disorder of breathing that is a common cause of insomnia. Sleep apnea is a disruption of breathing that breaks up the sleep cycle and prevents a normal night of sleep. The majority of sleep apnea cases are due to an obstruction of the airway. This usually happens when the muscles of the respiratory system relax during sleep. Normally, this is not a problem. However, this may become a problem in certain patients with a predisposition for sleep apnea. Patients with obstructive sleep apnea are usually overweight and have fat tissue that obstructs the airway, are older and therefore more prone to having a loss of respiratory muscle tone, or have a small receding jaw or short neck that allows the tongue to obstruct the airway. Obstructive sleep apnea (OSA) is a common problem and affects approximately 4% of middle-aged adults. Patients with OSA are usually not awoken during the night and are not aware of the problem. They usually complain of insomnia, daytime tiredness, irritability, and depression. However, their bedfellows describe their partners as experiencing bouts of snoring, restlessness, and occasionally “choking” during the night. OSA is typically addressed by interventions alleviating the obstruction.
Somnambulism (Sleepwalking)
Somnambulism, more commonly known as sleepwalking, is an extremely dangerous disorder of sleep. Somnambulism is a disturbance of deep sleep (stages 3 and 4) in which the normal relaxation of the limb muscles is disrupted and the sufferer can get out of bed and walk around. Since somnambulism occurs in stages 3 and 4, most instances occur during the beginning of the night. The person suffering from this would still be asleep during these activities and would not be aware of his or her actions. This can be very dangerous because an individual may seriously hurt himself or herself: for example, fall down stairs or walk through glass. Fortunately, the majority of cases occur in children and most of the sleepwalkers do not actually walk. Instead they may make repetitive movements, e.g., sitting up or pulling at their pajamas. Most cases of somnambulism resolve by adolescence, however some arise or continue into adulthood. Somnambulism is usually addressed by maneuvers promoting a normal sleep cycle and by safety measures to prevent injury for residual episodes.
Stuttering
Stuttering the medical condition is termed “developmental” stuttering to differentiate the condition from the occasional stuttering that affects us all. Developmental stuttering is an observed disruption in the normal fluency and mannerisms of speech. Fluent speech is considered to follow socially accepted time patterns, and thus stuttering is termed a “dysfluency” of speech, in that there are breaks in the flow of speech.
The dysfluency in developmental stuttering can vary widely among individuals, and most individuals who stutter tend to have a waxing and waning course of dysfluency; that is, those who stutter tend to have times when they stutter more and times when they do not. Also, stuttering usually occurs at specific points in conversation – most commonly at the beginning of sentences or phrases.
In contrast to the occasional stuttering that affects us all, the dysfluency of developmental stuttering is associated with secondary motor behaviors, such as facial and neck tics, eye blinking, lip and tongue tremors, and other body movements. Moreover, developmental stuttering is associated with a form of anxiety termed, “anticipatory anxiety.”
Anticipatory anxiety is the anxiety associated with the fear of stuttering. The fear of stuttering is directly proportional to the self-perception of communication. For example, a person may stutter severely, but if he believes he is communicating well and the audience is not distracted, he has less fear and less anticipatory anxiety. In addition to the common symptoms of anxiety, anticipatory anxiety can significantly worsen the fluency and secondary motor behaviors of those who stutter. This anxiety does not cause developmental stuttering, but is rather a catalyst for dysfluency.
This constellation of dysfluency, secondary motor behaviors, and anticipatory anxiety that define developmental stuttering has been recognized since ancient Egypt. Contemporary study has revealed that one percent of the population stutters, and the condition affects every ethnicity and culture equally. Developmental stuttering affects five percent of children, typically emerging between the ages of two and six. Development stuttering may continue to adulthood, and for those children afflicted, twenty percent will continue to stutter as adults.
As mentioned earlier, anxiety does not cause developmental stuttering. Nor does a diseased tongue or overbearing parenting, as has been proposed in the past. Current study reveals that developmental stuttering is a brain-based condition that has a genetic contribution. Studies of brain function in developmental stuttering suggest that the condition is associated with variations in brain areas associated with language. Specifically, brain areas involved with formulation and expression of language, which in the vast majority of individuals are located in the dominant left cerebral hemisphere, appear to be expressed in the right hemisphere or bilaterally in those who stutter. In addition, familial and twin studies reveal a genetic component. However, a number of environmental factors may influence the emergence of developmental stuttering, and familial and twin studies of developmental stuttering reveal that the condition cannot be completely ascribed to genetics.
Interestingly, there are maneuvers that can induce fluency in persons who stutter. Singing, impersonating another’s voice, speaking alone, speaking in unison with other individuals (choral speech), speaking with a metronome, auditory masking (using white noise or other masking noise to prevent those who stutter from hearing themselves speak), and delayed auditory feedback (a maneuver where an individual hears what he or she is speaking approximately two to three hundred milliseconds after he or she has spoken) all can evoke fluency. Some of these maneuvers are incorporated in treatment – and are a part of the powerful armament of treatment options for patients who stutter.