Health and Psychology

The Omicron Variant of Covid-19 was reported November 11, 2021 in South Africa. It has spread across the globe to multiple countries. It was labeled a variant of concern by the World Health Organization a couple of days ago due to changes in the spike protein that is targeted by the vaccines.

This variant is likely transmitted by droplet, so distance measures and mask wearing are likely to be effective. Because of the mutations in the virus thus far (there are millions of mutations, most are insignificant) there are likely to have mutations that are more or less transmissable and more or less lethal. This appears to be more transmissable. There are questions about illness severity that have not been answered yet.

The governments of several countries are closing their borders to countries with reported cases. This has been described in scientific circles as putting up a picket fence to stop mosquitoes. It's unlikely to work, and because the US doesn't do much genetic sequencing, the virus mutatioon is likely already here. Wear a mask. Stay away from other people as much as possible. I've turned down meeting with friends and relatives over the holidays. We can always meet by zoom or facetime.

If you haven't been vaccinated go get vaccinated. The technology has been around for decades and isn't new. You will likely need additional shots as the virus mutates and the vaccines lose potency over time. It will take 3-4 months for companies to gear up for a new vaccine to hit a different spike protein, but with mRNA, that's very quick.

The coronavirus COVID-19 is showing a propensity towards neurological symptoms.  This is similar to other coronaviruses that infect people.  There are 7 corona viruses that infect people. 

• 229E
• NL63
• OC43
• HKU1
• MERS-CoV
• SARS-CoV
• SARS-CoV-2

The novel Coronavirus now known as COVID-19 started in Wuhan in the provence of Hubei, China.  This is a slow onset, significantly contageous illness, believed to originate from bats and perhaps pangolins and morphed to infect humans.  It is fatal about 10% of the time.  at this time there are more than 100000 cases in the United States and 1,000,000 worldwide.

Contagious illnesses are referred to by the letter R and a subscript.  COVID-19 has between an R 2.5 and an R 4.2.  influenza A or B has an R 1.4 to 2.8.  The common seasonal flu kills 70,000 unvaccinated, older or infirm people annually.  Each infected person infects two others on average.  COVID-19 has no determined treatment or vaccine and each infected person can infect 3 people on average.  The main difference is the latency of onset of COVID-19 and the fact that it can kill otherwise healthy people.

In the United States the rate of infection has been limited to an R of just 1.  That is due to the quarantine and screening and isolation procedures.

It is unlikely COVID-19 will stop and disappear with seasonal changes.  The possible transmission routes of airborne, droplet, fomite (surfaces), and bodily waste combined with a long viral life of up to 14 days, make it likely to be around seasonally, or transmitted through other vectors besides humans.  It is far more likely that the infection will mutate and eventually become less fatal over time. 

The best defense against the virus is to be as healthy as you can be.  Get a seasonal flu shot for some antiviral protection. Stay home from work when you are sick.  Wash your hands and avoid touching your face.  in the United States, unless you've had direct contact with an infected person, you are unlikely to contract the illness and more likely to get the flu.

I want to let you know about the Sleep Help institute.  They have a lot of information on sleep, resources, medical conditions and sleep.

www.Sleephelp.org/sleep-deprivation  has articles about sleep deprivation.

www.Sleephelp.org/autism-asd Sleep and autism Spectrum Disorders. 

Here's a link to their full collection of resources:

www.sleephelp.org

I don't believe I know any woman over the age of 15 that hasn't been sexually assaulted, inappropriately gropped, fondled or touched without her consent by someone.  So I'm not surprised that when @kellyoxford asks women on twitter to share their first sexual assault stories that there are more than 1 million responses with most of the events starting in childhood.

While the tipping point in the conversation about the prevalence of assault against women may be the latest video clip about Trump, it started earlier with the story of the rapes on campuses across the country, the victim letter from the Stanford rape case, the film The Hunting Ground, and the dozens of women talking about Bill Cosby assaulting them.   It started with Anita Hill talking about sexual harassment at work before congress and that conversation about how a reasonable person and a reasonable woman might have different perspectives.  

On Friday President Obama signed into law the Sexual Assault Survivor's Rights Act that allows rape kits to be preserved for up to 20 years or the State's maximum statue of limitations.  It also lets survivors be advised in writing 60 days before their rape kit is destroyed and lets them request preservation beyond the scheduled destruction date.

Sexual assault is one of the most unreported crimes.  Reading through the responses to Kelly Oxford's post on twitter, men apologize, point out that Bill Clinton did bad things too, or talk about how people are innocent until proven guilty.  They blame the media and point out that men are sexually assaulted as well.  

To men out there, you don't need to apologize or deflect.  What you need to do is to speak out.  The conversation Trump had in 2005 is common.  It's not okay and it normalizes inappropriate behavior.  It's your turn to speak out against the men that talk like this.  Get offended.  The men that talk this way prey upon your mothers, sisters wives and daughters.  Talk to the women that have been assaulted.  Find out for yourself that it's almost every woman you know and often most girls you know.  You have to get horrified before you support tremendous change.

Jarisch-Herxheimer Reaction also known more simply as Herxheimer or Herx reaction sometimes occurs after antibiotic treatment causes a large die off of bacteria, fungus, yeast, or other systemic infections. initially described by Adolf Jarisch in 1895 and later by Karl Herxheimer in 1902, the reactions have been found in syphillis, sarcoidosis, rheumatoid arthritis, chronic lyme disease, leptospirosis, relapsing fever and candidiasis starting within an hour or so of taking the antibiotic to several weeks later and can last for a few hours to weeks.  

Symptoms of a herxheimer reaction include:

• Flu like illness
• Muscle or joint pain
• Low grade fever
• Bone pain
• Nausea
• Diarrhea
• Vomiting
• Mental Confusion
• Anxiety
• Depression
• Neurological Symptoms
• High or low blood pressure
• Changes in heart rate or rhythm
• Heart palpitations
• Rashes

Jessica Jacobs died in August. She had Ehlers-Danlos Syndrome. She is also described as having Postural Orthostatic Tachycardia Syndrome. I say described because I’m not sure I believe that. I think she had Ehlers-Danlos Syndrome with Autonomic Dysregulation and postural orthostatic tachycardia syndrome is just a part of that. She lived most of her adult life in Washington, DC but moved back to Twain Harte, California when she became too disabled to continue working. She wanted to be closer to her family.

Ehlers-Danlos Syndrome has several variants. The symptoms can consist of a variety of any of the following: hypermobility of the joints, thoracic outlet syndrome, early onset of osteoarthritis, degenerative joint disease, long slender fingers with swan-neck deformity, boutonniere deformity of the fingers, tearing of tendons or muscles, scoliosis, kyphosis, a tethered spinal cord, muscle pain, joint pain, trendelenberg’s sign (balance instability), Osgood-Schlatter disease, fragile skin, atrophic scarring, easy bruising, multiple skin folds, subcutaneous spheroids, molluscoid pseudo tumors, valvular heart disease, postural orthostatic tachycardia syndrome, arterial rupture, aneurysm of the ascending aorta, Raynaud’s phenomena, heart murmur, heart conduction abnormalities, hiatal hernia, gastrointestinal dysmotility, dysautonomia, the ability to hyperextend the tongue to touch the nose, anal prolapse, collapsed lung, Arnold-Chiari malformation, platelet aggregation, pregnancy complications, sleep apnea, chronic pain and insensitivity to local anesthetics., drooping eyelids.

Jessica Jacobs was an advocate for the disabled and a blogger that wrote about her poor medical care and lack of coordination of her medical treatment. The types with dysregulation of the autonomic nervous system, and bleeding disorders are at risk for sudden death. Jessica noted all the places that were not accessible to her in a wheelchair, including her hospital room bathroom. She attempted to ensure that all her doctors could share medical records but carried around a binder of them because they couldn’t. She found her primary care physician dumping her onto uncoordinated specialist care abhorrent. Unfortunately, this is a common practice with any rare medical condition. It’s a bit more common with Ehlers-Danlos Syndrome.

She’ll be missed.

Depending on the study, somewhere between 58 and 79 percent of all psychological diagnoses have a substantial medical component.  That's a very alarming statistic.  In the 1970's the field of medical psychology was created to address this need.  By the late 1980's it had all but dissappeared, replaced by the less medically intense health psychology field or the broader behavioral medicine field.  

When I first went into practice I worked with a family practice physician.  My office was located in his office.  The referral question was simple: "This person has been seeing me (the MD) for 4 or more visits and the diagnosis is unclear" or "This person is not responding to treatment."  Of the hundred or so people I saw over the first year, I diagnosed about 30 cases of cancer, 20 cases of heart disease, and 35 cases of endocrine disorders.  The rest were a mixture of psychological conditions and non-compliance with complicated medical treatment.  My private practice geared to work with heart disease and cancer was starting to be filled by men with what would eventually be diagnosed as HIV/AIDS.  I drove to San Francisco on the weekends to be with a client who was being treated at San Francisco General.  I stopped counting the deaths at 175 and closed my practice to start working for one of the insurance companies.  

At a risk management seminar I was sitting at a table of physicians.  They presented a case of a woman with persistent neck pain.  The cardiologist at the table and I were arguing over the diagnosis. The case was presented in pieces, just like it is in a medical office.  She had been cleaning the shower and her neck started hurting.  It felt better after some rest but still didn't go away.  She thought maybe she had the flu.   I was telling the cardiologist the woman had a heart attack.  He was telling me I wasn't a doctor.  After the third visit for neck adjustment the woman collapsed at home.  She'd had three heart attacks.  I explained to the cardiologist that women experience heart attacks differently than men and they have different symptoms mainly neck and jaw pain, fatigue and muscle aches.  Almost all my heart patients were women.  Almost all were misdiagnosed in medical offices or even at emergency rooms.

The endocrine diagnoses were worse.  Almost all my endocrine patients were misdiagnosed with depression, anxiety, or personality disorders.  Some had endocrine tumors.  Some of those tumors were malignant.  Just trying to get the correct tests done or imaging studies done was challenging.  Eventually I had physicians I worked with because we knew each other, and they understood what I did.  For physicians not trained in clinical medicine, they decided I was psychic.  For physicians trained in clinical medicine, they honed their skills and trusted them more than the lab studies they treated like oracles.  

Now I tend to work with more neurological symptoms, recent head injury or abnormal test results that don't seem to correlate with any illness.  When the Dr. House series was on television it was easier to explain what I did.  That was a show about clinical medicine.  I like the puzzle.  I like figuring out what's going on.

If you don't have a diagnosis and have seen your physician for more than 4 visists, or if you aren't responding to treatment, contact me.  I'm likely to be able to help with diagnosis and treatment.

Patient shaming. This time it happened to/about my cat. This happens by physicians (or vets) when they don’t know what is going on and all the treatment options they know of have been exhausted. It usually happens to people on the fourth visit either when there isn’t a diagnosis or the treatment is ineffective.

I ‘ve had Tatum since she was just under 2 years old. She was a hot mess. She was in several foster homes. The rescue organization referred to her as medically fragile. She had a couple of common cat conditions, namely cat acne, and bilateral herpes of the eyes. But she was ripping her face and ears open and the go-to diagnosis was some sort of unseen parasite. She was subjected to scrapings, dips, multiple medications and a food diet so extreme that she was only eating one brand of cat food and only turkey pate at that. She still had all the conditions. The rescue person dropped her off, did a cursory look at the house and ran out yelling “Start the car. They took the cat.”

I kept up with all the craziness for a year. Then I stopped the pills. I stopped the drops. I kept her eating out of ceramic or glass dishes. I started varying her food. No change. She ripped her face open and I took her to two vets. No parasites. It’s stress. Cat self-harm. Cat trauma. New people trigger it. Sometimes the other cat triggers it. Sometimes it’s a thunderstorm. She eventually gets over it. She’s been fine for the last several days.

She just turned five and I took her to the vet. New vet. “She should be on L-Lysine twice a day” she said.

“I did that,” I said. “It does nothing.”

“She’s ripping her face open because of the cat acne. It’s painful” she said.

“No,” I said. “She rips her face open when she’s psychotic.”

“We can treat that. There’s medication for it” she said.

“I’ve given her creams and drops for a year. It does nothing. No thank you.”

“So you want your cat to be in pain. I guess you know everything.”

“She’s here for vaccinations. Can you do those?”

“Yes,” she said.

Stalemate.

It’s annoying. It happens because doctors are taught in medical school that they have to know everything. For many it hinders later collaborative practice. They blame patients with chronic medical conditions that don’t respond to typical treatment. They blame parents for children not improving. They blame people when they can’t diagnose. They refer to therapy as a last resort rather than as a first line of options. Switching doctors happens with disgruntled patients or being referred out to specialists is the common practice for physicians. It fragments treatment, limits history, and results in poorer medical care. As more physicians integrate psychologists into their practices hopefully this will lessen.

Disability is a complex system of insurance companies, state regulations, federal regulations and governmental bodies with competing and differing codes for determination. It’s confusing to a lot of people. Our office can help with all forms of evaluation.

DEFINITIONS

A disabling condition is a physical or emotional illness or collection of symptoms that impairs the ability to function in one or more areas of life. Accommodations are methods to assist someone in performing tasks so they can function better.

Accommodations may include a device such as a computer that recognizes speech, or converts speech to text, or reads text aloud. It may be a wheelchair or a cane. It may be a device that helps to put on socks, or grab items, or button. It may be a device that helps someone hold a spoon, or fork, or pencil. It may be a cell phone or tape recorder. It may be a system of applications that says what color something is, what denomination of money someone has, or a prompting system to help with memory. It may be a medical device to test blood sugar, blood pressure, temperature, pulse. It may be extended time on exams, a private room, natural lighting, a test given on computer or a paper based test. It may be a service animal or emotional support animal. It may be voice activated door bells, light switches, smoke detectors. It’s not an advantage, but it may be an equalizer.

An off work notice. This is a letter to an employer indicating a disabled person is not able to function in their usual and customary job as a result of a temporary disabling condition. This usually needs to come from a physician (psychologists count as physicians in this regard). The person is expected to undergo some form of treatment to return them back to their usual and customary job.

Evaluation of disability by a treating provider. This is a letter or report of the symptoms and a description of functional impairments. This may be requested by an employer or by an insurance company handling a disability claim. This letter does not have to be written by a physician.

Evaluation of disability for the Social Security Administration. This is an evaluation of how an individual is able to function in their ability to perform simple work in the general labor market. The is not an evaluation of their ability to perform their usual and customary job. This is simple work. Examples would be the person who bags groceries at a grocery store and retrieves shopping carts, or the helper that waters plants at the local nursery. It involves some degree of judgment such as not putting the gallon of milk on top of the carton of eggs.

Evaluation of disability for accommodations. This is a complex evaluation involving multiple layers of documenting what is required and what is available. For conditions such as ADHD, or for tests such as licensing board tests these evaluations are lengthy and extensive.

We perform all tyes of evaluaitons on all age groups and write letters as part of those evaluations.  Feel free to contact our office.