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Medical Causes of Anxiety-THINC MED

Posted by Margaret Donohue on August 16, 2015 at 8:40 PM Comments comments (0)

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.

Test Scores

Posted by Margaret Donohue on July 26, 2015 at 8:45 AM Comments comments (0)

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.


Indications for testing

Posted by Margaret Donohue on June 14, 2015 at 9:35 AM Comments comments (0)

I did a presentation for a local networking group on neuropsychological testing.  Here's a recap:

Neuropsychological testing looks for problems and deficits in functioning localizable to the cortex.  Much of the purpose of neuropsychological testing has been replaced by neuroimaging.  MRI's or CT Scans.  But there are still several purposes for neuropsychological testing.


1.  Likely etiology for neurological impairment.


If you think your symptoms are due to a head injury and not a brain tumor, it might be nice to get that confirmed.  If you have musical hallucinations, get neuroimagry.  Different types of brain tumors show up at different ages.  Sometimes following a head injury with concussion, people have more symptoms.  Worsening headaches five years post injury is NOT from the head injury.  Worsening other symptoms 3 years post injury is NOT from an injury.  Head injuries improve with time. Orthopedic injuries can worsen over time.  There's some worsening for the first 3 years as the brain adapts to the injury, and headaches of migraine like intensity will continue for up to and including 5 years from injury lessening in intensity and severity as time passes.  So if you are past tose time markers and symptoms are worsening, you can get either neuroimaging or neuropsychological testing.  Many people don't like neuroimaging, especially people with claustrophobia, because it's a small tube and it's noisy. So to differentiate neurological symptoms neuropsychological testing can be done.  Brain injuries generally show a fairly wide specific area of impairment in two places, one smaller than the other.  Brain tumors generally show a small specific area of impairment.  Neuropsychological testing is used most often to show strengths and impairments folowing a known brain injury or illness.


2.  Functional strengths and impairments of a known neurological condition.


Anyone with a recent brain injury would benefit from neuropsychological testing to get a baseline for functioning.  If you were in an accident and are pursuing litigation, it's best to ask your attorney for a referral as many personal injury attorneys have specific neuropsychologists they work with for this purpose.


If you have a known neurological condition, neuropsychological testing can document what strengths and weaknesses are present. Neuropsychological testing can also help with strategies for accommodations.  It can be used to evaluate capacity for certain types of tasks such as managing funds, living independently, taking medication, etc.


3.  As part of a battery of tests, neuropsychological testing can be used to help with differential diagnosis.


This can be true for dementia versus depression, types of dementia, clarifying types of attentional problems. Or other issues.  In right handed people right hemisphere neurological impairment can show up as anxiety.  In right handed people left hemisphere neurological impairment can show up as depression.  (The same is true 80% of the time for left handed and ambidextrous people, but 20% of the time it's the opposite.)  


4.  It can be used to document the formal need for accommodations under ADA.


ADA testing follows a legal standard established by the California State Bar Association for accommodations for learning disabilities, ADHD, or neurological conditions.  These evaluations are lengthy and have substantial documentation of how someone performs with and without desired accommodations.  That allows for a functional evaluation of the need for accommodations.


There are a lot of conditions where neuropsychological testing will not be productive and general psychological testing or even just a clinical interview will be sufficient.  I can consult on cases over the phone.  The consultation is free.  If you'd like to be tested, feel free to contct me at 818-389-8384.

When did we stop?

Posted by Margaret Donohue on May 28, 2015 at 9:15 AM Comments comments (0)

When did we stop?

Eating real food that was cooked from fresh ingredients.

Letting children play unsupervised outside.

Having a doctor visit that was longer than 15 minutes.

Gardening.

Talking to people face to face.

Writing letters.

Having a legible signature.

Questioning authority.

Reading books made of paper.

Sleeping enough.

Having schools pay for supplies like paper.

Expecting students to read the assigned readings.

Learning clinical symptoms of disease.

When did psychology as a profession stop.

Focusing on relationships in favor of evidence based treatment.

Psychological testing in favor of therapy.

Neuropsychological testing in favor of neuroimaging.

Long term growth based psychotherapy.

Having psychological testimony be anything but objective.

#TakeBackYourLife

 

Social Security Disability

Posted by Margaret Donohue on May 15, 2015 at 7:20 AM Comments comments (0)

I provide objective evaluations for the State of California for people who have applied for Social Security DIsability.  These evaluations are referred to as Consultative Evaluations.  I provide the same kind of limited evaluation privately at my office in Glendale, CA.  The only difference between the evaluations I do in my private practice than the evaluations I do for the State of California, is that I'll help someone ensure they have provided an adequate history.  There's no difference in the reports, the psychological testing, or my role other than that.


There are several misconcentualization about Social Security Disability.  The first is that everyone is entitled to get it.  Not true.  

Social Security Disability is available to people:

  1. Who have been employed with sufficient employment credits within the past 10 years, were incarcerated and out of the labor market,  or were never employed because they were supported by someone else-housewife, domestic partner, dependent child that's now an adult.  
  2. It's also available to children who are not able to be in a regular classroom due to a severely disabling condition or collection of conditions and whose family meets income limitations.  
  3. Adults under category 1 above must also be no longer able to do simple work.
  4. Adults under category 1 above must be expected to be disabled for 12 months or longer.

Most people think that it's for people who are not able to do their usual and customary job.  Not true.  Private disability insurance is what will cover someone for the inability to perform their usual and customary job.  Social Security Disability covers any job in the labor market.  Walmart Greeter, gas station attendant, person who bags groceries at a supermarket, these are all examples of relatively simple work.  The fact that your prior employment was as a Wallstreet broker, rocket scientist, teacher, physician, soldier, or ran a corporation ill only make it lmore likely that you will be able to find some job you could theoretically do and thus would NOT qualify for Social Security Disability but qualify for private disability.  

So if you are currently relatively healthy, get private disability insurance to ensure that when you become disabled that source of income is also possible.

Disability often happens suddenly.  Car accident, sudden onset of disease, heart attack, stroke are all events that people can become disabled by.  There's a rush of medical treatment and the hope of complete recovery.  Most private disability policies have a waiting period of 6 months or more before benefits kick in.  It's important to notify a disability company as soon as possible that you are no longer able to perform your usual and customary job.  If you are no longer able to perform ANY job, then it's time to apply for Social Security Disability.  Social security should be applied for the moment someone realizes that they are no longer able to perform simple work.  The process of applying for Social Security Disability is long and may take years to be approved.  The application process starts the clock and ensures that the less than ten years post employment window is not missed.

When I evaluate individuals for Social Security Disbility, I presume they are disabled.  I don't need proof of their disability.  I'm not evaluating people to show they are disabled.  I'm evaluating them to be able to describe to an Administrative Law Judge working for Social Security and the State of California, the nature of functional limitations and what impeeds their ability to perform simple work.  I'm a disabled person.  I've been disabled for decades.  I run a company. I teach. I do art work.  I can't walk long distances.  I can't carry heavy items.  I have a combination of physical limitations and illnesses that allow me to have a handicapped placard.  I do not qualify for Social Security Disability nor for private disability insurance.  I can do my usual and customary job.  I can certainly do simple work.  So being disabled is NOT the criteria for getting Social Security Disability.  What's needed is the documentation of the functional limitations that prevent someone from either functioning in a regular classroom, or from performing simple work.

If you need an evaluation, feel free to contact our office.

Day off

Posted by Margaret Donohue on May 7, 2015 at 10:05 AM Comments comments (0)

I have a day off.  Not really.  It wasn't scheduled.  I was supposed to go to court on a case and testify but the case was settled, leaving me time in my schedule.  That's not really a day off.  but it's not work.  I could have scheduled work, as late as yesterday, I could have worked instead.  So it's time off of a sort.


Like most people I have a list of to do items that never really get done.  It's a long list.  It's been posted on the pantry door for the past decade.  Every once in awhile I'll start on an item, get overwhelmed by the scope of it, and decide it's too much.  They aren't small items to be fair.  Like remodeling the kitchen, living room, dining room.  Replace the carpet and add lighting throughout the house.  And some items get done several times but aren't completed.  Reduce clutter.  Tend to the garden.  Clear off the countertops.  Those things get done often but never fully.  


The smaller daily to do lists are easier.  Do laundry.  Cook.  Clean up after the cats.  Go to the bank.  Update banking for the house and the business.  Get all the appointments doctor, opthalmologist, and labs done.  


Work provides me with a degree of structure.  I think it does for most people.  It also provides structure for the cats.  Tatum woke me up today by knocking over the lamp on the nightstand.  Because on a normal work day I'd be "late" waking up after the sun came up.  I've already done several things on my to do list.  Put files in the garage.  Clear off the table.  Let the cats in.  Let the cats out.  Let the cats in.  My email is all done and it's before 7 am.  So the looming to do list on the pantry door gets looked at.  I'm not slacking by any means.  But the list on the pantry is still overwhelming.  Maybe I'll clean out my closet.



Coping with difficult feelings

Posted by Margaret Donohue on April 21, 2015 at 11:50 PM Comments comments (0)

A couple of friends and I were supposed to get together tonight.  We do this about once every 2 to 3 months.  It's nice and relaxing.  Nothing much changes.  We talk about our lives.  It's low to no drama.  But today, things got postponed and we're still tweaking schedules.  And I was looking forward to it.  So I'm sad.  So I went shopping for some needed work clothes.  Tried about 50 things on and bought three.  I had sales people tell me I was wonderful, looked great and was smart.  I had someone tell me I was too big for a size 10 and someone else tell me I was too small for a size 10. I had someone try to sell me a blouse large enough for a family of four to go camping in.


In a completely different context I had someone tell me I was stupid, insensitive, and should mind my own business.  I had someone else tell me I was thoughtless.  Another told me I was thoughtful.  If I tried to listen and believe what I was told by people each day, it would be difficult to figure out who I am.


We get tons of messages every day from people telling us who we are.  The messages aren't generally about us.  They are about the people that send them.  We get to choose which message to acknowledge and what to let in.  If some crazy guy screamed things at me, I wouldn't be inclined to believe what he said.  So I can choose what I want to listen to, to take in, acknowledge, and believe as well with people I know.  Yes it can go too far, and if everyone is saying the same thing you might need to take stock, but in general it's not so much about you.


Therapy teaches people methods to cope.  You can change your thoughts and behaviors to change your feelings.  You can look for the reasons why some statements impact you while others don't.  You can learn a wide variety of coping skills, some helpful like meditation, mindfulness, acceptance and commitment, listening to music, doing art, distracting yourself in some fashion.  Or interacting with people that enrich you.  That helps give you a choice about how to respond, or even if you should respond at all.  After all it's about them.


If you need help coping, feel free to contact one of my psychological assistants.  If you need help coping with a medical issue or medical symptoms, feel free to contact me.

Stop Celebrating Tragedy

Posted by Margaret Donohue on April 7, 2015 at 10:35 AM Comments comments (0)

She counted off the events of the week. "It was a year ago on Monday when I had my accident.  Tuesday four years ago my husband filed for divorce.  On Wednesday six years ago my sister died.  And on Saturday three years ago I was robbed. It was a bad week."


"How do you remember all those?"  I asked.


"Oh I put them on a calendar." She said.


Why?  


To feel depressed look to the past, focus on everything that goes wrong, what you can't do, make things impossibly big in your mind, think in absolutes, and expect the worst.  


To make things better, look to the future, find evidence to support your beliefs, think realistically, focus on what you have control over and what you can do.  Review your prior successes.  Remember and celebrate people's lives, not their deaths.






Patient privacy

Posted by Margaret Donohue on March 28, 2015 at 11:15 PM Comments comments (0)

I usually tell patients upfront that they have limited privacy.  Therapy notes are priviliged and confidential except when they aren't.  There's a long list of circumstances when they aren't.

The times people expect:

 

  • Suicidal
  • Homicidal
  • Gravely disabled
  • Harming a dependent child
  • Harming a dependent adult
  • Billing insurance

Less Expected:
  • Any litigation
  • Any criminal activity
  • Any suspected criminal activity

The following information is from http://www.Patientprivacyrights.org.


What information can be found in my health record?

A: A health record is created any time you see a health professional such as a doctor, nurse, dentist, chiropractor, or psychiatrist. You could find the following in your health record:

 

  • Your medical history and your family’s medical history
  • Labs and x-rays
  • Medications prescribed
  • Alcohol use and sexual activity
  • Details about your lifestyle (smoking, exercise, recreational drug use, high-risk sports, stress levels)
  • Doctor/nurse notes
  • Results of operations and proceduresGenetic testing
  • Research participation
  • Any Information you provide on applications for disability, life or accidental insurance with private insurers or government programs
  • Driver’s License
  • Social Security Number
  • Financial information such as credit cards and payment info

 

Q. Who has access to my health records?

A. Many more people than you would ever want, including people outside the health care industry.

 

  • Insurance companies
  • Government agencies especially if you receive Medicare, Medicaid, SCHIP, SSI, Workers Comp or any local, state or federal assistance
  • Employers
  • Banks, Financial Institutions
  • Researchers
  • If you are involved in a court case, your health records can be subpoenaed and available to the public
  • Marketers
  • Drug companies
  • Data miners
  • Transcribers in and outside the U.S.
  • Many health websites collect information about you

 

Q: Can my personal health information be used and disclosed without any notice to me or without my informed consent at the time of treatment?

A: Yes.

The Amended HIPAA Privacy Rule states only that you must receive a Privacy Notice telling you how your personal health information will be used and disclosed. Section 164.520(c) (2) (i) (A).

Privacy Notices are often mistaken for consent forms, but they are simply notices telling you what will happen to your medical records.

Example: information about a depressed person’s attempted suicide and hospitalization can be used and disclosed without any notice to him/her without his/her consent and even if he/she objects.


Q: Can my insurer or employer get my health records without my permission?

A: Yes.

The Amended HIPAA Privacy Rule gives health plans and self-insured employers broad authority (“regulatory permission”;) to get information without consent that is far more extensive than is needed for billing or any other reason related to a specific individual’s health care. Other uses for which health plans and employers are authorized to obtain use and disclose an individual’s health information without consent include:

 

  • Due diligence in connection with the sale or transfer of assets;
  • Certain types of marketing;
  • Business planning and development;
  • Business management and general administrative activities; and
  • Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance. Section 164.501

 

Example: A depressed person’s health plan or employer would have regulatory permission from the federal government to obtain the information about his/her attempted suicide and hospitalization without his/her knowledge or consent if the information was needed for any of the above business purposes, as well as for treatment or payment.

Even more disturbing, the Amended Rule would authorize the individual’s health plan or employer to use and disclose that information even if the suicide attempt and hospitalization occurred before the Amended Privacy Rule went into effect on April 14, 2003.


Q. What is a “self-insured employer”?

A. A self-insured employer does not contract with an insurance company to insure their employees. Instead they have enough employees to do their own risk pooling like an insurance company would. These employers are called “Self-Insured.” During the past couple of decades, the number of employers who have become self-insured has increased dramatically, starting with large employers and spreading to those with fewer employees. Some examples of self-insured employers are: Walmart, Microsoft and IBM.


Q: I thought I signed a Privacy Notice at my doctor’s office giving consent to use my information. What’s in that Privacy Notice?

A: Those are not “consent forms” but a list of the ways in which your doctor or provider may use or share your information.

“Covered entities” are required to provide notice to individuals of the uses and disclosures of identifiable health information that may be made under the Amended HIPAA Privacy Rule as well as the rights of the individual and legal duties of covered entities. Section 164.520 (a). These notices are called Privacy Notices.

Covered entities must “make a good faith effort” to obtain written acknowledgement of receipt by the individual of the Privacy Notice. Section 164.520(c) (2) (ii). When you sign those notices you are only acknowledging that you’ve received a copy of the many ways your provider may use your information.

Privacy Notices are likely to be lengthy, because HIPAA authorizes so many broad uses and disclosures of identifiable health information. Unfortunately, your rights are quite short. You cannot REQUIRE anything of your provider. You can only make REQUESTS.

These are NOT consent forms. You no longer have the “right of consent” with the Amended Rules, effective April 2003.


Q: What is a “covered entity”?

A: According to the amended HIPAA Privacy Rule “covered entity” is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Over 4 million businesses, corporations, government agencies, professionals, and individuals handle personal health information (PHI) electronically and therefore must comply with the HIPAA Privacy Rule.

Consultations between direct and indirect treatment providers are expressly permitted under the Original Rule. 65 Fed. Reg. at 82,510. The Amended Rule did not change this permission.


Q: Can I prevent my doctor from reporting a certain procedure to my insurance company?

A: No. The Amended HIPAA Privacy Rule does not provide any method for an individual to prevent any procedure, treatment, medical test, or prescription from being reported to his/her insurance company.

 

  • This is because the Amended Rule provides regulatory permission for the individual’s insurance company to obtain virtually any personal health information from an individual’s doctor as long as they can assert that they need it for treatment, payment or health care operations.
  • Even if the individual asks the doctor to not report the procedure, the doctor need not agree. Any medical treatment can be reported over the individual’s objections.
  • Even health information about procedures paid for privately can be reported. The original Privacy Rule stated that information about procedures paid for out of pocket would not be disclosed, but that statement was in the context of a discussion of the right of consent which was included in the original Rule but repealed in the Amended Rule. See 65 Fed. Reg. at 82,512.
  • Since the Amended Rule allows for the use and disclosure without consent of personal health information for the insurance company’s business operations, clearly such information can be used and disclosed regardless of whether the individual paid out-of-pocket.

 

Example: a depressed patient could not prevent the health information about his/her hospitalization from being reported by his physician to his insurance company.


Q. Are my prescriptions private?

A. No. All 51,000 pharmacies in the U.S. are wired for data mining. You cannot keep your prescriptions private, even if you pay cash. Selling prescription records is a multi-billion dollar a year industry: In 2006 IMS Health reported revenues of $2 Billion for selling prescription records (that’s just one company!).


 

Child Abuse

Posted by Margaret Donohue on March 17, 2015 at 9:30 AM Comments comments (0)

CHILD ABUSE

I come from a horrific history of child abuse.  I've had some therapists refer to my history as child torture.  It started from the day I was born and adopted out, until the time 3 days later when I went to a neonatal intensive care unit with ruptured ear drums, and my adoptive parents said they didn't want me any longer.  To the adoption agency lying about my background, history, ethnicity, religious background and medical condition to the physician signing off that I was "completely healthy" at six months even though I weighed a pound less than I did at birth.  And to the abusive adoptive couple that eventually raised me.  The abuse stopped when I was 12.  It stopped because I threated to kill my adoptive mother.  Not everyone has those experiences.  But a lot have some of them.


There is research showing there are long term medical consequences of child abuse.  This is also true with the obese, who lose weight only to gain it back.  So I assume most medical psychology patients have an abuse or neglect background.  But child abuse provides a benefit to people as well. The benefit to that history isn't discussed because it's not politically correct to do so.  How can anyone say there are some advantages to having been abused as a child?  


Child abuse provides an internal strength and an ability to endure difficult situations and to push forward that people without that early background don't quite have.  Child abuse provides a meaure of resilience.  


While other people are wondering how misfortune could possibly be happening to them, people with child abuse histories don't wonder.  Of course it's happening to me.  Who else would it be happening to?  I have the ability to deal with problems better than most people.


For child abuse survivors what's important is to stop enduring and to look to find joy.  I met someone who celebrates every bad occurence in her life as if it's a holiday.  She endures and wants to remember the struggles.  I have a friend who found out from a relative that her abuse goes back to infancy and the police, although called, did nothing.  "Who does those things to a baby?" she asked, before reflecting on how well her son is doing and how proud she is of him.  And it's that change of focus that allows for people to improve their lives, find meaning, be resilient, and to find joy.


What happens to child abuse victims very early in life is that they make a conscious decision to live.  From that decision they forge meaning, and become resolute.  While therapy helps to change the focus to improving the future and your own life, the basic building blocks are already in place.