Health and Psychology

According to the Academy of Medical Psychology (AMP), there are two educational paths to becoming a medical psychologist. One is to complete medical school and earn a license to practice medicine in the United States. The other is to complete an American Psychological Association-accredited Doctor of Philosophy (Ph.D.) in Psychology or Doctor of Psychology (Psy.D.) program, followed by a post-doctoral master's degree or certificate program in clinical psychopharmacology (www.amphome.org).

I have my Ph.D. in clinical psychology and spent 23 years working in a pharmacy as a pharmacy technician. I then spent two years working with a general medical practitioner in his office with his patients. In the process of all that I learned clinical medicine: the ability to evaluate and diagnose medical disorders based on clinical symptoms and physical signs. The "art" of clinical medicine is being lost. It requires considerable time and, in essence, a mentorship with a physician to notice and understand what is being observed. Unfortunately that training in clinical medicine is becoming rare. Instead of clinical medicine leading laboratory medicine, laboratory medicine has ineffectively replaced clinical medicine. The physicians who know clinical medicine are older. The impact of managed care on the ability of a physician to take a history has led to nurse practitioners and medical assistants getting that information as a more cost effective method. But it’s more costly to the patients and adds to the level of misdiagnosis being significantly high. It’s also led to concierge medical services outside of managed care.

Medical psychology effectively bridges the gap for a physician in providing medical education, ensuring compliance with treatment plans and getting that needed history. Unfortunately, there are few medical psychology practitioners and fewer still know what we do. I have to explain my role to physicians and psychologists alike. Most equate what I do to “Dr. House” from the television series. I just think of it as saving people’s lives.

photo credit: Stethescope via photopin (license)

Some of you know I used to work with and train cats.  This infomation is put out by the International Veterinary Academy of Pain Management http:https://ivapm.org/for-the-public/animals-and-pain-articles/how-we-assess-your-felines-pain-level/" target="_blank">//ivapm.org/for-the-public/animals-and-pain-articles/how-we-assess-your-felines-pain-level/

I remember being in Kindergarten when I figured out that the other children in my class were different from me.  By age five I had already had two surgeries for unusual medical problems and I was being routinely followed by six treating physicians.  So when I walked up to Nadine and asked her how many doctors she had, she looked at me like I was crazy.  She explained she didn't have any doctors.  She only got shots for immunizations.

That was when I realized my condition was likely genetic.  My kindergarten class had a garden and we planted vegetables.  We were also told about how plants grew from seeds.  I don't know how many students in my class figured out that the same process also applied to people, but I did.  So it was just a matter of waiting for science to identify all the genes to be able to figure out all the genetic anomolies I have.

Not every person or their parents want to know.  "I just want my son to be normal."  The mother told me.  I told her that genetic disorders tend to result in syndromes.  Many of the syndromes have complications that can be addressed early or monitored for so the person can stay healthy.  I've been able to avoid many of the complications of my syndromes because I know what to do to lessen my risk factors.  My siblings haven't been as fortunate.

A large percentage of individuals with genetic anomolies have something called facial or cranial dysmorphism.  In less medical language it means there's something unusual about the shape or size of their head or the size and structure of their facial features.  In other cases the genetic anomilies are more noticable on the hands or feet.  In other cases medical problems crop up early and are unusual. At age 6 months I weighed a pound less than I did at birth.  My head size is slightly smaller than normal.  It makes it hard to buy a hat. But it's just enough to know it's a likely genetic disorder.  Tracking down my biological family was difficult but I was able to trace my line back two to three generations.  that allowed me to do a medical genogram and document all the medical conditions that people were known to have.  It also documents any genetic predispositions to types of illness.

If you think you or your child has an unusul medical condition, we can help you connect to the right people to determine what is wrong and help you avoid possible preventable complications. Feel free to contact us. 818-223-4116.

Laboratory medicine: blood tests, urine analysis, imaging, scanning, x-rays, biopsy are all relatively new in the field of medicine. Clinical medicine goes back to when laboratory medicine didn't exist. Clinical medicine involves looking at people and really noticing them and understanding how medical illness presents clinically. That understanding allows a physician to order the correct lab tests, images, scans, or biopsy a tissue or growth. Without clinical medicine, it's difficult for a physician to know what to do.

Back prior to 1980 or so, before managed care dramatically changed how medicine works, a physician would take a history and do a physical examination of the person noticing what they look like, how they move, and take their pulse for a minute or so. They would talk to the person and listen to what the person said was going on and what prompted the visit. the visit would last 30 minutes to more than an hour and would include a consultation at he end of the visit to review the plan. They would then, on the basis of that clinical evaluation, order needed tests.

Switch to today. A nurse or medical assistant will take vital signs and enter them into a computer. The nurse or medical assistant will record in notes what the patient says is wrong and/or the reason for the visit. The physician will meet with the patient for 5 to 15 minutes. The computer will prompt any issues based on the vital signs and will suggest tests. The physician, especially if they are younger, will order a shotgun approach to diagnostic laboratory tests-blood work, urine analysis, maybe an x-ray. In many cases the patient never disrobes. In some cases the physician never looks up from the computer screen. If a lab test comes back positive they will order more tests.

The field of medical psychology was conceptualized in the early 1980's to allow psychologists trained in clinical medicine to assist physicians in their office with taking histories and assisting with documentation of symptoms and noting clinical medicine signs. In the 1990's the field of medicial psychology changed to include health psychology and to focus on compliance with treatment and coping with chronic illness and health improvement. The field of clinical medicine was left behind.

A recent medical article (Improving Diagnosis in Health Care from the Institute of Medicine) estimated that there is a 5% error rate in diagnosis at outpatient visits.  10% of these errors are serious enough to result in death.  17% are serious and life changing.  Virtually everyone can expect a medical diagnostic error over the course of their lifetime.    Clinical medicine reducess error rates.

I'm in the process of writing a book on clinical medicine for therapists.  So far it's 50 pages in length and covers taking a history, doing a mental status exam, and looking at the skin and hands.  Physicians need to be trained in clinical medicine in order to make laboratory medicine work well.  If they can't perform clinical medicine evaluations because there are too many constraints oon their time, then maybe it's time to bring back medical psychologists with clinical medicine training.

The research studies go back to the 1930's and were quite prolific through the 1970's.  Most involved individuals admitted to psychiatric hospitals as the result of severe symptoms of depression, anxiety, mania, psychosis, or neurotic symptoms.  The rates of undiagnosed medical illness CAUSING the symptoms ranged from 10% to 50% and of that population, 77% had a complete remission of symptoms when the underlying medical condition was treated.

Back in the late 1970's when I was in graduate school, the field of Medical Psychology was being created.  It was conceptualized that Medical psychologists would work in physicians' offices to assist with diagnosis and differentiation of medical and psychiatric symptoms.  We would refer back those patients with medical conditions for further evaluation and treatment and continue to treat psychiatric symptoms with psychotherapy and also address issues of compliance with medical treatment.  To that end, we were taught to take thorough medical histories, do medical symptom evaluations, perform basic vital examinations such as heart rate, respiration rate, blood pressure, height and weight, and temperature. We were also taught to recognize medical symptoms through an understanding of clinical medicine.

Clinical medicine existed at the beginning of the field of medicine.  It is the evaluation of a patient by looking at them and listening to them.  It predates laboratory medicine by thousands of years.  The field of clinical medicine is generally no longer taught in medical schools.  It's been replaced by laboratory medicine described as "more accurate and evidence based."  But it's not.

Ideally, clinical medicine should allow for an andequate index of suspicion to present for laboratory based medicine to confirm symptoms and establish a diagnosis.  But if a physician relies only on laboratory based medicine they will miss anywhere from 12-25% of cases where the laboratory findings are just under abnormal, but still indicative of disease.  In psychiatric illness, where diagnosis by general physician is based on symptom report or rating scales, the error rates skyrocket.    

I have some rare genetic condition, one of which is low blood volume.  That means my labs are normal even when I have obvious manifestations of disease clinically.  Physicians trained in medicine after 1985, have little to no training in clinical medicine and will inevitably pronounce me "normal" and "healthy" even if I'm fainting in their office, pale as a ghost, bruising easily, complaining of long muscle pain, tongue scalloping, and tongue burning--all symptoms of significant anemia.  If they finally look up from their lab sheets, they will confusedly remark "but your labs are normal!"  As a result I became invested in learning as much clinical medicine as I could.  

I started off working for a general physician right out of graduate school.  The majority of missed diagnoses were of endocrine disorders, anemia of chronic illness and malignancy, cardiac conditions, lung conditions, kidney disease, substance abuse and poor nutrition.  He was a good physician.  The difference between what he was doing and what I was doing was in taking an adequate history.  He had 10 to 15 minutes to see a patient, establish a diagnosis, order labs and tests and write a prescription.  I had an hour and, if needed, I could take 90 minutes.   It makes all the difference.

So here are the people I treat:   

• Anyone who has seen a physician for 6 medical visits and still doesn't have a diagnosis
• Anyone who has had an evidence based treatment for anxiety, depression, or other psychiatric illness, and is not significantly improved.
• Anyone who has relapsed from an evidence based treatment.

There is  new study out in the Journal of Clinical Endocrinology and Metabolism http://press.endocrine.org/doi/pdf/10.1210/jc.2015-2696 which found a correlation between people in Denmark using a large number of narrow specturm antibiotics matched with controls that used few to no antibiotic, and subsequent risk of developing Type 2 diabetes.  I've added the link so you can read the original study yourself and make your own conclusions.

Radio news reports have suggested that based on this study caution should be used in prescribing antibiotics.  That isn't what the study says.

What the study says is that there is a link between people who are prescribed a large number of antibiotics and subsequent development of Type 2 diabetes.  

Here is what we know and what is also mentioned in the article.  Antibiotics change the normal gastointestinal bacteria.  Infections elevate blood glucose.  Diabetics are predisposed to infection.  Prediabetes are obese.  Some gastrointestinal bacteria are linked to obesity. Obesity is linked to Type 2 diabetes. 

Here is what we don't know and are still questioning:

• Does the use of antibiotics cause an increase in the risk of obesity, prediabetes, or diabetes Type 2?  
• Does increased infection rates signal the onset of diabetes Type 2, suggesting greater need for dietary changes to prevent it's development earlier?
• Do certain types of infection cause diabetes Type 2?  This would suggest greater monitoring of types of infection.
• For the individuals with more than 5 antibiotics prescribed, were they ever infection free?  This would suggest that some types of infection requiring multiple courses of antibiotics change people to allow for their continued survival.
• Does increased rate of infection, and increased elevation of inflammation, and blood sugar, result in the body maintaining elevated blood sugar levels?  This would suggest that a greater impairment of the immune system and it's relationship to the endocrine system requires more study.

There are many medical conditions that mimic symptoms of anxiety,  All psychiatric diagnoses start with a request that medical conditions be ruled out before a psychiatric diagnosis is considered.  In addition there should be a history of symptoms of anxiety that gradually escalate over time.  Anxiety is not generally sudden in onset.  Most anxiety disorders start in childhood or by early adulthood.  Symptoms of anxiety occuring later in life are unusual.  Any symptoms of anxiety that are accompanied by neurological symptoms such as changes in smell, taste, behavior, hallucinations, headache, or unusual or paranormal experiences should be medically evluated.  Many drugs, chemicals, food additives and herbs can cause anxiety.  

The major medical causes of anxiety can be remembered by the letters THINC MED:

• Tumors. These often present with a range of psychiatric symptoms. For example, pheochromocytomas produce adrenaline and often present as anxiety or panic attacks. However, episodes of panic related to pheochromocytomas include severe headache and are not accompanied by catastrophic thinking.  Meningeomas may cause personality changes in addition to anxiety symptoms.  Anxiety symptoms with headache should be evaluated medically.

• Hormones. Hyperthyroidism, hypothyroidism, parathryoid disorders and adrenal disorders may present with symptoms that mimic anxiety disorders. Such physical symptoms as increased sensitivity to heat, weight loss, restlessness, difficulty sleeping, and tremor suggest a physical cause for the anxiety-like symptoms. In some women, estrogen can produce anxiety symptoms.

• Infectious diseases. Some infectious diseases may also present with psychiatric symptoms. For example, untreated streptococcal infection may lead to onset of tics (Sydenham’s chorea) that resemble the symptoms of obsessive-compulsive disorder. Symptoms resolve with treatment of the infection. Lyme disease can be associated with psychiatric symptoms, including anxiety.

• Nutrition. Vitamin deficiency or excess, malabsorption, and poor nutrition can mimic a range of emotional disorders. Vitamin B12 deficiency and anemia can present with anxiety symptoms and, in some cases, cause symptoms of panic attacks.

• Central nervous system. Head trauma—even when it is mild—can result in psychiatric symptoms, including those of anxiety.  Anxiety symptoms are especially common in right hemisphere brain injuries in right handed people.  

• Miscellaneous. Wilson’s disease, an inherited disorder that interferes with the metabolism of copper, can present with features similar to schizophrenia, bipolar disorder, and anxiety disorders. The psychiatric symptoms often begin during adolescence. Wilson’s disease is progressive in nature, causing damage to the liver and brain. A distinctive physical characteristic is a brownish ring surrounding the cornea of the eye. Porphyia a hereditary disorder of blood metabolism can also cause psychiatric symptoms. 

• Electrolyte abnormalities and environmental toxins. Long-term exposure to insecticides (organophosphates) can result in anxiety and restlessness.

• Drugs. OTC, homeopathic, prescribed, or illicit drugs can produce a wide range of psychological symptoms. Alcohol withdrawal, cocaine, and stimulants can also result in anxiety symptoms.

If you have concerns about your symptoms, have had prior ineffective treatment for anxiety or depression, feel free to contact our office, 818-389-8384.

I'm going to post a link to another web site that has lists of foods that naturally contain salicylates.  Salicylates are best known to people as the main chemical in aspirin.  All salicylates are reducers of inflammation.  The problem is they are common in foods and many people are either sensitive or allergic to them.  Symptoms include everything from hives, to ADHD symptoms, to OCD symptoms.  They also treat pain, headaches, inflammatory conditions, irritable bowel, depression and anxiety.  Write down all the foods you eat commonly.  See if you are either treating a medical condition with food, or are having symptoms due to foods.  Here's the link:

http://salicylatesensitivity.com/about/food-guide/

Most people think that depression is caused by either situational events or some sort of chemical imbalance.  In fact more than 70% of depression is caused by either an undiagnosed or an inadequately treated medical condition.  Here are some of the main medical causes of depression:

1. Anemia--Anemia has multiple types, but the common feature is that oxygen rich blood is not able to be adequately carried to the brain.   This may be because there aren't enough red blood cells, the cells don't have the correct shape to hold the oxygen molecules, the cells are being used up as they are being created, or the cells lack the rich red color needed to help them transport oxygen effectively.

2.  Lung and heart disease--like the problem with anemia, lung and heart problems cause depression because of the lack of transportation of oxygen molecules to the brain.  The lungs pull oxygen molecules into the blood stream while the heart circulates them through the body.

3.  Infection--infection causes a surprising number of psychological and psychiatric symptoms.  The autoimmune response to illness can cause depression and/or anxiety.    

4. Sleep impairment-sleep apena, circadian rhythm disturbances, changes in sleep schedule or just poor sleep hygeine can all cause depression, and may even cause hallucinations.

5.  Thyroid disease-hypothyroidism or Hasimoto's Thyroiditis can cause symptoms of depression, sluggishness, weight gain, mood swings, irritability, and extreme fatigue.  In late stages these illnesses can cause severe symptoms including psychosis, suicidal thoughts and behaviors, and extreme personality changes.

6.  Other endocrine disorders-parathyroid illness, diabetes, adrenal fatigue or failure, pancreatic illness can all cause depression, mood swings, or irritability.

7.  Malignancy--cancer of any type causes the immune system to activate and that can cause depression.  The symptoms of depression may vary with the location of the cancer.

8.  Gastrointestinal problems--malabsorption of nutrients, chronic constipation, gluten intolerance, or impaired large and small bowel problems may all result in depression.

9.  Antibiotic or antiviral use.  Any significant change to the immune system can result in depression.

10.  Medication side effects--depression is a common side effect of a large number of medications including medications to treat blood pressure, gastroesophageal reflux disorder (GERD), high cholesterol, acne, antianxiety medications, and many others.

In ALL cases of depression it's important to rule out medical causes for the symptoms.  Most depression at a mild to moderate level responds extremely well to 6-8 weeks of an evidence based treatment approach such as cognitive behavioral therapy.  If you have attempted an evidence based treatment approach to help your depression and continue to have symptoms, feel free to contact me.    

I’m teaching psychological assessment and it’s finals week. That means I’m explaining a lot about psychological test scores and how to evaluate them. Most psychological tests are based on the normal curve (pictured below). The normal curve is a statistically way of looking at a phenomena in a population that is believed to be normally distributed, like IQ scores. The midpoint in the distribution is referred to as the mean. This is a fixed number.

There are various rating scales that are used when discussing the normal curve. These are Z scores, Index scores, T scores, Stanines, and Scaled Scores. The method to look at how spread out the scores are is called the Standard Deviation. One standard deviation from the mean is the average range.

So an IQ score with a mean of 100 and a standard deviation of 15, means that average scores will fall within scores of 85 to 115. T Scores with a mean of 50 and a standard deviation of 10 will have average scores between 40 and 60. Z scores with a mean of zero and a standard deviation of 1 will have an average range of -1 to +1. A scaled score with a mean of 10 and a standard deviation of 3 means that scores between 8 and 12 are in the average range. A score of 7 is below average and a score of 13 is above average.

Scores are transformed to fit into a normal distribution to be able to better compare them. Another way to compare scores is through percentile rank. A percentile rank is the percentage of the population that score is above. So a percentile rank of 50 means that person is in the middle of the population and does equal to 50% of their peers. A percentile rank of 16 means they perform as well as only16% of their peers.

This helps people when looking at test scores to understand what they mean about an individual.  If you want to know what test scores mean feel free to contact me.