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Complex Trauma

Posted by Margaret Donohue on April 14, 2016 at 8:00 PM Comments comments (0)

I explain complex trauma to my students by telling the story of my cat Tatum.  I met Tatum through a cat rescue organization.  Tatum was described as a fragile medically ill cat.  I picked her up in my arms and she jumped out of my grasp.  The rescue group had me sign several forms and gave me her medical history.  Three foster homes in her six months of life.  Countless medical visits.  Found in a cardboard box in a McDonald's parking lot in Lancaster, California.  She was prescribed multiple medications, creams, pills, a special diet, and she couldn't get along with other animals.  She was "slow to warm up."  "She's not to go outside.  She gets terrified.  She responds quickly to being sprayed in the face with water if she's doing something you don't want her to do."


The first time she ripped open her face I assumed what everyone had, that she had mites, or an infection, or some sort of parasite.  The first vet didn't find anything but prescribed medication anyway.  The second vet didn't prescribe because she was already on medication and nothing was changing.  So I asked if it was possible it was just self-injurious behavior.  "Oh, we call it delusional parasites"  the vet said.  So I did research.


Post Traumatic Stress Disorder occurs commonly in animals. 

PTSD symptoms in pets can include:

  • Uncharacteristic aggressiveness
  • Fearfulness, trembling
  • Increased agitation
  • Decreased appetite and weight loss
  • Reduced interest in playing, going for walks, or interacting with other pets and/or people
  • Hypervigilance (an intense, “on guard” awareness of surroundings)
  • Tendency to be easily startled
  • Urinating or defecating inside (when previously housebroken)
  • Increased neediness or attachment
  • Unprovoked whining or crying
  • Excessive barking or meowing
  • Destructive behavior
  • Extreme escape behavior to avoid a stressor (such as chewing through drywall to attempt to flee during a thunderstorm)
  • Sudden changes in temperament
  • Hiding for no reason
  • Excessive panting
  • Pacing
  • Fear of being alone
  • Sleep disturbances
  • Avoidance of people, places, or things associated with a traumatic event

Once I decided Tatum was suffering from PTSD, I changed everything I was doing.  The first thing I did was set up cardboard boxes all over the house.  She investigated all of them.  She would jump in a tall one and scratch frantically at the bottom.  Eventually I realized she was digging to try to get to her lost litter mates.  She made friends with a neighborhood cat that the neighbors could no longer keep and now lives with us.  The older cat helped Tatum go outside, calm down when there was a noise, and learn to tollerate being around another animal.  

I started taking her outside in the backyard.  It took months to get her comfortable to go outside.  Initially she could tolerate 30 seconds.  Now she can stay out for an hour or more.  

I stopped all the medication.  It was doing nothing.  I stopped the special diet.  It was doing nothing.  The face ripping lessened.  If she gets stressed she rips her face or ears open and it heals in a day or so.  She'll use the cardboard boxes if she's stressed, or hide on top of the kitchen cabinets.  When not stressed she purrs, and cuddles.  I have a predictable schedule.  She has a predictable routine.  Anything out of the ordinary and she starts ripping her ears or her face.  Those events are infrequent now.

The students will ask what made her get crazy.   And I explain that her world was a very scary place when she was a kitten.  She was with her litter mates then suddenly put in a cardboard box in a noisy parking lot and separated from them and her mother.  She was moved from one house to another.  She had lots of painful and annoying medical treatments.  Things changed constantly.  She went to a noisy rescue with lots of other cats and was terrified.  The only thing that seemed to stay the same was her food because she was put on a special diet.  So the rescue thought that was what helped.

The same thing happens in people.  They get in situations that are frightening, unpredictable and out of their control. They can't self-soothe. They revisit the trauma over and over trying to master it.  We have good treatment for people with trauma.  But trauma is exceptionally common in rescued pets.  The story helps the students understand a bit better.





The Zika Virus Probable Complications

Posted by Margaret Donohue on February 2, 2016 at 10:35 PM Comments comments (0)

The new information on the Zika virus is that there is a confirmed case of sexual transmission of the virus in Texas.  This means that anyone, male or female, traveling to an area where the virus is epidemic, or anyone who has flu like symptoms following being bitten by a mosquito should:

  1. Not donate blood.
  2. Not engage in sexual activity without using a condom.
  3. Be closely monitored if you or your partner become pregnant following symptom development.  An ultrasound at 20 weeks to check head size for microcephaly may be indicated.

It would be appropriate to ask the CDC to do something to protect the blood supply.

It would also be important to identify anyone that has tested positive for the Zika virus and develop a data base to evaluate long term sequela.  Zika is a virus that can be expected to produce long term complications following infection.  For many people this may simply be arthritis and may be quite mild.  However, given the affinity of this virus for nerve cells in fetuses causing microcephaly, it would not be a stretch to expect that it may produce complications in nerve cells in adults.  

Possible complications:

  1. Arthritis.  This has already been found in people with the virus.
  2. Neuropathy, that sensation of pins and needles people experience when their arm or leg falls asleep.  
  3. Multiple sclerosis like symptoms from changes in nerve cells.
  4. Guillain-Barre syndrome, an ascending slow paralysis or weakness already associated with the virus.
  5. Muscle pain and weakness, already associated with the virus.
  6. Since the virus and vector are similar to Dengue fever, hemorrhage, thrombocytopenia, or other blood disorders may also be complications. 

The Zika Virus

Posted by Margaret Donohue on January 27, 2016 at 9:25 AM Comments comments (0)

For most people the Zika virus is a mild case of flu like symptoms if they notice anything at all.  For others, like pregnant women it can result in their children having abnormally small heads and brains, known as microcephally.  For others it may produce joint pain, or progressive symptoms of paralysis known as guillain barre syndrome.  Fever, rash and runny eyes are common. 


Zika virus is a viral infection of the blood carried by mosquitos.  Aedes aegypti, the mosquito that carries the virus, lives in tropical and subtropical areas throughout the world.  The mosquito strain is in the United States but their aren't enough infected people living in the United States to serve as hosts.   It originated in Uganda Africa and was found in a rhesus monkey in 1947. In 2013 it caused significant human outbreaks in French Polynesia.   It is likely also able to be sexually transmitted.  I say likely because blood borne viruses are usually also sexually transmitted and the virus has been isolated in semen.  The disease is most prevalent in South America, but it's also present in other countries.  If it's not already in the United States, it will likely be here soon.  There is no cure.  Prevention measures are to avoid pregnancy in countries where the infection is in epidemic proportions and to avoid mosquitos.  Treatment with antiviral medications have limited impact.  Several pharmaceutical companies are working on a treatment or preventative medication.


In the meantime, if you can avoid traveling to tropical areas, especially if you are pregnant, then do that.  Preventative treatment will likely be available within the next 2 to 5 years.  


If you ever have any questions about illness, disability or clinical trials, feel free to contact me.  818-389-8384.

Headaches

Posted by Margaret Donohue on January 1, 2016 at 9:10 AM Comments comments (273)

Headaches are a common phenomena.  It's one of the most common problem I treat in clinical practice with exceptionally good outcomes.  The first step in treatment involves identifying the type of headache somone has.


There are multiple types of headaches.


  • Muscle tension headaches-These headaches are caused by muscle strain and general muscle tension.  If they occur on an occasional basis they can be relieved by stretching, massage, accupuncture/accupressure, changing position/ergonomics, or simple over the counter pain medications like aspirin, Tylenol, or Aleve.
  • Medication over use headaches--also known as rebound headaches.  If someone is taking over the counter pain medications like aspirin, Tylenol or Aleve more than twice a week, or a triptan (migraine medications like Zomig or Imitrex) more than 10 days a month, then they are likely to need assistance in detoxing from these medications.
  • Dental pain headaches--bruxism (the grinding of teeth) or temporomandibilar joint pain (TMJ) can cause headache.  A visit to the dentist can help with a fitting for a bite guard to lessen the stress on the teeth jaw and the joint of the jaw.  Popping or clicking of the jaw helps with diagnosis.
  • Cluster headaches--these are allergy related headaches.  They usually occur on one side of the head, the affected eye on that side gets red, the pain is excruciating, the nose may run.  They typically occur at the same time of day and the same time of year.  Oxygen helps relieve pain as does antiallergy medication like a histamine blocker, or a triptan.  Alcohol, cigarettes, high altitude, and pollen levels can be triggers.
  • Migraines--migraine headaches are vascular headaches in which the hands and feet get cold and the blood vessels constrict.  There may be a distinctive aura or prodrome of flashing lights, visual patterns, or neurological symptoms, that occur with the headache.  There are YouTube videos of people with complex migraine and neurological symptoms that start to resemble symptoms of stroke with loss of speech.  Migraines often have identified triggers and can be treated with triptans to lessen the intensity or severity of the headache.  Keeping a log and knowing the triggers can help.
  • Caffeine withdrawal headaches--caffeine is a stimulant that people can be dependent upon.  When attempting to cut back on heavy caffeine substitute half decaffeinated with half caffeinated products and decrease the amount by one drink per day until you reach a reasonable level.  If you are drinking more than 10 cups of coffee or are treating excess fatigue with high doses of caffeine, you need to be seen by a physician to evaluate the reason for the fatigue.
  • Orgasm headaches are pain that follows having an orgasm.  These headaches need to be evaluated by a physician with an MRI due to a rare neurological problem involving the arteries in the brain not functioning properly.  Simple orgasm headaches with no neurological symptoms may be prevented by taking medication prior to having sex.
  • Early morning headaches--these may indicate low blood sugar, changes in oxygen level due to sleep apnea, hormonal fluctuations, neck or back pain, dental pain, or caffeine withdrawal.  
  • Sinus headaches are caused by sinus pressure and sinus pain.  There may be an underlying sinus infection.  Dental infections can spread to the sinuses as well.  Often these are mistaken for migraines, but the hands and feet don't get cold, and there may be a nasal discharge.
  • Ice cream headache-also known as brain freeze headaches occur when eating something cold like ice cream.  These headaches go away when the roof of the mouth warms back up.
  • Chronic daily headaches-these are often medication overuse headaches.  They occur more than 15 days a month for at least three months.  In cases where triggers and detoxing off meddications is not effective Botox injections have been helpful.
  • Hormonal headaches--these can occur with changes in hormone levels due to menstruation or pregnancy.  They occur during the first few months of pregnancy or for a few days before or after a menstral cycle.  Changes in food to include B vitamins and magnesium may be helpful.  Evaluation of hormone levels may help reduce or eliminate these headaches.
  • Post-concussive headaches--these headaches are of migraine like severity and occur for a period of around five years following a head injury.  They frequently are accompanied by slight neurological symptoms and rarely respond to medications.  They lessen in intensity and severity over the course of five years.  Headaches following concussion that are increasing in severity over that time frame need to be evaluated by a physician with neuroimaging.  
  • Headaches with hypertension--severely high blood pressure can cause headaches.  
  • Severe headache with neck pain/stiffness and fever requires a trip to an emergency room.
  • Headache with nausea, vomiting, and difficulty with speaking or walking requires a trip to an emergency room.
  • Headaches described as the worst pain ever-requires a trip to the emergency room.
We can help you evaluate and manage headaches.  Feel free to contact us.  818-389-8384.

Sjogren's Syndrome

Posted by Margaret Donohue on December 24, 2015 at 1:30 PM Comments comments (0)

Autoimmune disorders and viral infections are strongly linked together. There are more than 80 identified autoimmune diseases. Viruses, bacteria and other types of infections are recognized as major environmental triggers for the body starting to attack itself.


Chronic cytomegalovirus (CMV) one of a type of herpes virus that causes mild flu-like symptoms has been linked to the development of Sjogren’s syndrome. Sjogren’s syndrome is the second most common autoimmune disease in humans impacting more than 4 million people in the United States.  Sjogren's syndrome causes dry eyes, a dry mouth, and can cause joint pain, increased dental decay, swollen salivary glands, vaginal dryness, persistent cough and fatigue.


The research showing some of the mechanisms for the linkage may help with future treatments.


Research:  Anne Halenius and Hartmut Hengel, “Human Cytomegalovirus and Autoimmune Disease,” BioMed Research International, vol. 2014, Article ID 472978, 15 pages, 2014. doi:10.1155/2014/472978

Dear Doctor

Posted by Margaret Donohue on December 20, 2015 at 11:15 AM Comments comments (0)

Dear Doctor:

You don't know me and as a result my medical history will not be believed until it is.  My tests tend to come back normal in spite of obvious symptoms of illness.  I have a number of unusual medical conditions going back to birth, literally.  Many of these are genetic and rare.  They run in my family so I'm familiar with some of them, but the presentations never seem to match text book descriptions.  So I'm not believed.  I know that.  I understand that.  That doesn't make it correct.  I'm part of a large number of patients with unusual, rare or atypical medical conditions.  I am not alone.


So let me explain some things.


 

  • I'm not stupid.  If I tell you I'm sick, it's because I believe I am.  It doesn't matter what the lab tests say,  It doesn't matter what you're training says.  Nothing in your experience will prepare you for the likes of me or other people like me.  If you don't believe me, I'm not going to believe you.  Telling me I can't have the symptoms I have won't help.  I remember I was in the process of losing my airway and coughing.  The physician at the ER didn't believe a breathing treatment would help.  i think he said "it's stupid."  After three minutes into a breathing treatment my coughing stopped and I could breath freely.  He was surprised.  He did the treatment only because I insisted.

  • I live with these symptoms.  You might want to take some time to understand them.  Going with the first thing that pops in your head as a diagnosis doesn't inspire confidence.  I had severe vomiting.  The tests all came back negative doctor at the ER said "Maybe it's stress."  No. Vomiting is not a symptom of stress.  I had an atypical life threatening reaction to a medication I'd been on a long time.  Not stress.  

  

  • Look at me.  Get your face out of the computer, the chart and the lab findings, and actually look at me.  If you have any understanding of clinical medicine, it might help if you look at the patient. My labs come back normal because I have low blood volume.  I've been told I'm not anemic even when I was ghastly pale and fainting.  I've been told I have no signs of infection even with pus coming out of my eyes. Look at me it might help you figure out what is wrong. 

 

  • I avoid seeing physicians unless I already have a good idea of what's wrong.  I don't expect a physician to be able to diagnose me anymore.  I have developed a low pain threshhold and a high pain tolerance and a higher tolerance for ambiguity.   I started readng medical texts as soon as I could read.  It's why I ended up studying medicine and working with a physician after I finished my education in psychology.  It's a method for gaining some semblence of control.  The alternative is to ignore any symptoms unless something explodes and I can't function any longer.  Some people like me do that because it's easier, but we're sicker when we come to see you.  We have a greater tendency to shun western medicine and are less likely to see it as helpful.

  • Telling me, there's nothing wrong doesn't help.  Asking why I waited so long to seek treatment doesn't help. I've had these two responses within 24 hours.  I saw a doctor and said I had pneumonia.  He said I didn't and sent me home telling me I had a cold.  I went home.  18 hours later I went to the emergency room with 103 fever and both lungs full of fluid.  The second doctor said I should have come in sooner and not waited so long.  The first doctor was the chief physician at the medical group.  I showed him the chest x-ray from the second physician.


There are millions of people with rare or unusual medical conditions.  I'm not alone.  Women with these conditions are more likely to seek treatment than men with these conditions.  Women report more trauma as a result of these interactions.  Men tend to be more avoidant of treatment and there is a resulting higher mortality rate.


Thanks.



Migraines

Posted by Margaret Donohue on December 13, 2015 at 11:55 PM Comments comments (0)

Migraines are a type of vascular headache causing a variety of responses to inflammatory pain in and around the lining of the brain with symptoms of acute nausea, vomiting and severe pain.  They are different from tension headaches, cluster headaches, rebound headaches, post-concussive headaches, sinus headaches, headaches from hypertension, headaches based on changes in blood sugar, abdominal migraines, hormone related headaches, chronic progressive headaches, and mixed headaches in addition to rarer forms of headaches.  


Migraines cause the hands and feet to be cold.  They may cause a wide variety of neurological symptoms such as loss of speech, problems with vision, visual and auditory hallucinations including hearing music, and olfactory hallucinations.  They can be triggered from a variety of foods, medications, hormonal conditions, stress, genetic predisposition, and environmental conditions.  It's important to differentiate migraines from other types of headaches and other medical conditions.  


There are a wide variety of treatments for migraines.  These include lifestyle changes to reduce stress, adding meditation or yoga, physical therapy, massage and ensuring adequate sleep and exercise.  There are lifestyle changes to eliminate triggers for migraine such as eliminating caffiene or other migraine triggering foods or drinks, changing diet to a less inflammatory diet, and changing sleep and wake patterns.  There are medications taken at the start of a migraine to lessen the intensity and severity of migraine, and medications taken to prevent migraines from occurring.  In chronic migraine botox can be used.


If you are having chronic headaches feel free to contact me for evaluation.  818-389-8384.

Medical Necessity for Testing

Posted by Margaret Donohue on November 19, 2015 at 7:55 PM Comments comments (0)

Many people think their insurance covers psychological or neuropsychological testing.  Insurance will stipulate that psychological or neuropsychological testing if it meets criteria for medical necessity.  That doesn't mean that a physician or a school or a teacher thought the testing would be necessary.  It means that psychological or neuropsychological testing meets the strict criteria set forth by the insurance company.  

Medical necessity means that there is no other agency or organization that can provide testing at state or federal expense.  So that eliminates testing for:

  • educational placement 
  • disability 
  • Regional Center services
  • Gifted placement
  • ADD/ADHD

 It means that psychological or neuropsychological testing will produce a change in diagnosis or treatment plan and is the most cost efficient method of obtaining that information.  So an MRI or CT scan may be able to rule out memory problems related to brain disease or defect.

  • Schools provide psychological testing for placement in special education including gifted classes.  
  • Schools can evaluate for ADD/ADHD and learning disorders to determine accommodations
  • Regional Center provides their own testing to confirm the need for services
  • Social Security Disability provides testing to document disability for benefits

If you are interested in obtaining insurance benefits to cover psychological or neuropsychological testing GET AN AUTHORIZATION NUMBER from the insurance company.  

If you are interested in having psychological or neuropsychological testing feel free to contact our office.  We have access to a large number of psychological and neuropsychological tests at reasonable fees.  If you are eligible to use a free service we will advise you of that.  Feel free to contact us.  Our main office number is 818-223-4116.  My cell phone is 818-389-8384 Margaret Donohue, PhD.

  



Taking a history

Posted by Margaret Donohue on October 25, 2015 at 11:15 AM Comments comments (0)

I listened carefully as psychologist Anthony Zamudio, Ph.D. spoke at the 27th annual Convention of the Los Angeles County Psychological Association about his clinical practice within a primary care clinic.  He sees 30 to 50 patients a week in 30 minute intervals.  Not what I do.  He has patients he treats for psychological factors that impact physical conditions.  I see no more than 15 people a week.  I spend 50 minutes to 2.5 hours getting a history.


When I first started in practice in a medical office, my clients were depressed and anxious with some weird medical symptom that defied diagnosis.  They were frustrated as was the physician.  It was my job to assit the patient in describing their symptoms adequately so the medical condition could be illuminated.  Cancer, endocrine disiorders, rare medical conditions, and heart disease were the commonly missed diagnoses. The idea was that by taking an adequate history in addition to noting physical symptoms the physician could cut down on unneeded tests and avoid litigation for failure to diagnose.  Most people talk about medical symptoms in non-medical terms.  There is then a problem with the translation of patient language to doctor language.  So a woman comes in saying her neck hurts.  The physician gives her a prescription for ibuprophen.  She comes back saying her neck is worse.  I would then see her.  She's been cleaning her shower on her hands and knees.  She's been moving furniture.  Her son is coming for a visit.  She cleans the shower for a bit then her neck hurts.  She can no longer clean her shower. After 20 to 30 minutes of lying down covered in sweat, the pain subsides.  When she goes back to clean the shower it starts back up.  She's nausous from the pain.  I tell the physician she needs an EKG a way to check the electrical activity of her heart.  The heart attack has already occurred and she's at risk for another one.  She has an 99% occluded blood vessel found on angiography at the hospital.  At the end of the day I review the case with the physician.  So he can see what I saw for the future.  Her coloring is ashen.  There's some mild bluing as an undertone. She's laboring to breathe.  Her jaw is tight.  She never mentioned sweating or nausea so the physician wasn't cued to look for heart problems.  She talks about neck pain, but holds her hand up to her throat first before reaching around to the back of her neck.  She arches her neck slightly to take a deep breath.   Physician's still think of chest pain, which is a common presentation in men with heart attacks. Women are more likely to complain of feeling sick and maybe having the flu, or neck pain, or feeling weak or tired.  But symptoms increase on exertion and lessen on rest. If the information isn't provided the physician can't know what's going on.  


If you are having a problem getting diagnosed for your recurrent symptoms, contact our office.  818-223-4116.


 



Breast Cancer Screenings

Posted by Margaret Donohue on October 21, 2015 at 9:00 AM Comments comments (0)

Breast cancer in women has a population spike between the ages of 30 and 70.    

 

Percent of U.S. Women Who Develop Breast Cancer over 10-, 20-, and 30-Year Intervals According to Their Current Age, 2009–2011

Current Age 10 Years 20 Years 30 Years

30 0.44 1.88 4.07

40 1.45 3.67 6.83

50 2.29 5.56 8.76

60 3.48 6.89 8.90

70 3.88 6.16 N/A

Source: Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975–2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/browse_csr.php?sectionSEL=23&pageSEL=sect_23_table.10.html, based on November 2013 SEER data submission, posted to the SEER Web site, April 2014.


So the American Cancer Society has recommended that cancer screenings should start at age 45.  That breast exams not be done by physicians due to time constraints, and that women over 50 with a negative screening should get evaluated every two years.  


If these recommendations are followed, the rate of cancer in African American women between age 30 and 45 will increase and cancers will be found at later stages when they are harder to treat.  This is a population most at risk for breat cancer between age 30 and 45.   


Global statistics to inform health policy should be a thing of the past.  More individualized treatment recommendations should be being made based on a woman's history, genetics, racial background and life expectancy.  The more someone knows about their history, the better they can be informed about health care decisions.


A young woman with a history of breast cancer in her family who is positive for the BCRA (breast cancer gene muttion) may want to be screened early.  A Caucasian woman with no family history can wait to age 45 for an initial screening.  An African American woman with a family history of breast cancer may want to get an initial screening at 30 depending on the age at which relatives developed the disease.


If you want help with health related decision making, assistance in developing a medical genogram to evaluate risk factors, or assistance with treatment planning, feel free to contact us.  818-223-4116 our main office is in Glendale.