Protect Your Brain

“Dr. Denise, you need to see the movie, Concussion, with Will Smith. It depicts exactly what I have experienced living with depression and dementia, ” encouraged Gary Goodridge, legendary MMA UFC and Pride fighter.  That is exactly what I did before interviewing him this week. I didn’t stop there. I read his book “Gatekeeper: The Fighting Life of Gary ‘Big Daddy” Goodridge”, researched the NFL’s as well as the MMA’s policies on dealing with head injury, and read countless articles on CTE (Chronic Traumatic Encephelopathy).  In 2012 Gary was diagnosed with early onset dementia and depression and his doctors said that he was exhibiting symptoms similar to other professional athletes that on autopsy were diagnosed with CTE.

What is CTE? Dr. Bennet Omalu and colleagues in the Department of Pathology at University of Pittsburgh together published in the journal Neurosurgery in 2005 an article called, “Chronic Traumatic Encephalopathy in a National Football League Player.”  Dr. Omalu’s autopsy of former Pittsburgh Steelers Mike Webster in 2002 revealed large accumulations of tau protein in Webster’s brain, affecting mood, emotions, and executive functions similar to the way clumps of beta-amyloid protein contributes to Alzheimer’s.

According to the Brain Injury Research Institute founded by Dr. Julian E. Bailes, M.D.,Dr. Bennet  Omalu M.D. and Robert P. Fitzsimmons in 2002 ( protectthebrain.org ):

“Since the 1920’s the term dementia pugilistica or “punch-drunk“ syndrome has been known as it has occurred in boxers. Dementia pugilistica is actually a variant of chronic traumatic encephalopathy (CTE), which is itself a serious type of brain damage resulting from repeated concussions and is found in many professional athletes and military personnel who have been subjected to multiple impacts to the head.

Severe concussions and mild traumatic brain injury are both capable of causing CTE, and the likelihood of developing this condition is increased with the number of impacts.”

“Big Daddy”, Gary Goodridge has a true samurai spirit both in and outside of the ring.  He reports his medication is helping with aggression and depression. He has been given cognitive strategies to help him keep sharp with his recent cognitive decline: keeping a day planner to help with short-term memory and maintaining structure to his day.  Walking his dogs, and spending time with his daughters and family give him the most joy.  “The gym really helps me~my own workouts as well as teaching children keeps me inspired.” He spoke about this on the interview.  He also spoke about the need for rest in between fights and other tips he thinks could have helped him to minimize repeated head trauma.  “I would have had second thoughts about fighting if I knew then what I would be experiencing now,” he mentioned during another discussion. He and I spoke about his desire to provide for his family as well as his natural ability as a fighter keeping him engaged in the sport. Gary’s love of his daughters and his desire to be a role model and advocate for mental health awareness is giving him the hope and inspiration to fight on while living with depression and dementia.

In Discover’s July/August 2016 article by Jeff Wheelwright, “Ahead of the Hit,” it was pointed out that the science is still gray on CTE and predicting the effects of impacts.  Dr. Ann McKee and her group at Boston University continue to define and help with the consensus of the definition of the neurodegenerative disorder CTE.

In my professional opinion as a Mother and as a Doctor my consensus opinion is “Protect your brain and your child’s brain.” That is it.  It is common sense.

• Avoid or minimize head trauma.
• Avoid or minimize substance use.
• Seek out treatment for mental health and focus on lifestyle habits that promote well-being.
• If you or your child play a contact sport and are having any changes in behavior or changes in cognition contact your physician at early onset to prevent any long-term neurodegenerative consequences.

Routine physicals are mandatory for optimal health.

Our children need us to be advocates for their health and well being. If we can encourage participation in sports and extracurricular activities that minimize head trauma and concussions we are doing our job to protect our children.

Thank you, Gary Goodridge for sharing your story, you have taught me a lot and have inspired me in many ways.

Dr. Denise

Medication and Child Psychiatry

I am personally grateful that I went to medical school and became an Adult and Child Psychiatrist. Why? Because mental health is the most important part of a person’s well-being. Happy individuals with healthy thoughts create a society in which we can all thrive. We need to think of our children and our future. We need to get rid of the stigma of mental health and focus on mental wellness.

Did you know there is a shortage of Child Psychiatrists in the U.S.A.?

According to the American Academy of Adult and Child Psychiatry, there are approximately 8,300 practicing child and adolescent psychiatrists in the United States — and over 15 million youths in need of one.

I just attended an amazing MasterPsych conference presented by the American Physician Institute in Laguna, California last October. Guess what discussion I engaged my “kindred spirit” child psychiatry colleagues in during our lunch breaks?

Integrative mental wellness and collaborative care.

Using the least amount of medications.

Spending time with our patients.

We talked about the importance of tools such as solution oriented therapy, cognitive behavioral therapy (CBT), nutrition, exercise, yoga, meditation, parent training, and psychoeducation.   As doctors, we know how and when to prescribe medication and value all of the clinical trials that have been done to support the treatment when needed.

I believe that a Child Psychiatrist is the best person to decide if a child would benefit from being placed on a medication for behavioral issues. The dilemma we have is that there are not enough of us. We need to solve the problem of shortage of well-trained child psychiatrists and be a part of the solution for our children getting the proper treatment.

WE NEED A PARADIGM SHIFT. NOW.

Step one is getting rid of the stigma of mental health in our society. Doctors of all specialties and subspecialties need to respect and hold mental health in high regard. In medical school I excelled in many rotations as a third year medical student, even surgery. When I declared psychiatry as my residency choice there was a definite stigma from my colleagues. I moved forward with passion and strong conviction that psychiatry was the right fit for me. I believe that mental health is the foundation of all health and wellness. It should be integrated into all health care.

As Child Psychiatrists we need to be open to being part of the solution of attracting more medical students into our profession. We need to be thought leaders in supervising pediatricians on mental health diagnosis’. If we have a proper system in place then I believe the children will get the right treatment and be put on the least amount of medication.

Dr. Denise

 

Obsessive Compulsive Disorder and Anxiety

Did you know that Obsessive Compulsive Disorder  (OCD) affects 2-4% of adolescents and that 80% of people who have OCD experience symptoms before age 18?

It is important to point out that most mental health challenges start in childhood.

I value science and the need for a uniform way of discussing mental health, yet feel the term “disorder” (when discussing mental health) really puts a distance to someone embracing their “neurostyle”. We need to identify children who need extra mental health support and integrate wellness thinking and acceptance of neurodiversity in our society. Let’s discuss OCD now.

Did you know that the World Health Organization (WHO) ranks OCD as one of the ten most disabling diseases?

The OCD cycle usually starts with an environmental trigger that leads to an obsession described as intrusive, repetitive, negative images, thoughts or impulses. This causes distress as manifested by anxiety, fear, disgust or shame, followed by compulsive behavior as represented by repetitive thoughts, images, or actions.

The OCD cycle

(Trigger >>Obsession >>Distress>>Compulsions >>Negative Reinforcement)

It is a myth that OCD is an Adult disorder.

The two common onset peaks for OCD include earlier for boys that have the triad of OCD, ADHD and Tic disorder, and early puberty for girls.

In child psychiatry it is common for children to present with more than one behavioral disorder. OCD exists in combination with one other behavioral problem ¾ of the time and with multiple problems 1/3 of the time.

How do we identify and begin to treat OCD?

A diagnostic interview is done which includes parent and child interviews, a review of rating scales, report cards and if OCD is present a clinician scores the severity of OCD with the Yale-Brown Obsessive Compulsive Scale (YBOCS). The 10-item (each item rated from 0 (no symptoms) to 4 (extreme symptoms) Y-BOCS scale evaluates the severity of obsessions and compulsions separately and is the standard scale used in treatment outcome studies of obsessive compulsive disorder (OCD).  The severity of OCD is based on total core: 0-7,is subclinical; 8-15 is mild; 16-23 is moderate;24-31 is severe; 32-40 is extreme.

Do you want to know the good news? Pediatric OCD is usually responsive to treatment with the goal of a score of <8 on YBOCS .

“Exposure therapy is the secret sauce in treating OCD,” UCLA Scientist and Professor James McCracken M.D. would say during our child psychiatry clinic. Exposure therapy is a behavior therapy that involves the exposure of the patient to the feared object or context without any danger in order to overcome their anxiety. An example would be an individual with fear of contamination. The exposure would be putting their hands in dirt and not allowing them to wash their hands for a period of time.  The patient ranks their fear level before and after the exposure and realizes that the fear reduces over time after exposure.

The first line treatment for OCD is Cognitive Behavioral Therapy with  Exposure and Response Prevention (ERP).Children who lack insight, have ADHD or depression, have a family history of OCD, or high family conflict tend to have challenges with response to behavioral therapy alone. From a medication standpoint the Selective Serotonin Reuptake Inhibitors are the first line of treatment, the four FDA approved SSRI”s are Clomipramine, Fluoxetine, Sertraline and Fluvoxomine.

Sertraline is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Sertraline affects chemicals in the brain that may be unbalanced in people with depression, panic, anxiety, or obsessive-compulsive symptoms. Zoloft (sertraline) is used to treat depression, obsessive-compulsive disorder, anxiety disorders (including panic disorder and social anxiety disorder), post-traumatic stress disorder (PTSD), and premenstrual dysphoric disorder (PMDD). Find out how much is zoloft without insurance in our licensed pharmacy.

The well known POTS study (Pediatric OCD TREATMENT STUDY JAMA 2004:292(16) reveals that  combination treatment was consistent with a 53.6% remission rate and CBT alone 39.3%, Zoloft alone 21.4%. It was also noted that those with family history of OCD had more than a 6 fold decrease in response to CBT alone.

Combination therapy yields the best results for moderate to severe OCD.

Let me give you a clinical example of a sixteen-year-old girl, Christina (pseudonym) who I worked with whose trigger to her obsessions was watching television and witnessing motor vehicle accidents, or driving over speed bumps. Her obsession was that she had fatally harmed someone as her obsessive image and thought. Her compulsive behavior was getting in the car and retracing her route to make sure she had not actually injured someone.  She would call hospitals to make sure no one had been hurt.  She came to see me for help with her OCD.

Her YBOCS score was in the extreme range (>32). She did not respond initially to CBT-ERP alone. A combination of Prozac and exposure therapy yielded great success for Christina! Her YBOCS was less than 8 within a year of treatment. She and I drove in her car and we would ride over bumps and not go back to the site to see if anyone was ok or call hospitals to make sure no one was in the emergency room. Christina is now in her mid twenties successfully working and is not on any medication for OCD! She utilizes her tools from therapy, exercises regularly, eats healthy and meditates routinely. This is a great thrive story-right? This is why I love what I do.

Dr. Denise