drmargaret

There are lots of various types of hallucinations. A hallucination is a sensory experience without the usual sensory cause. Hallucinations can be visual (seeing things not present), auditory (hearing things not present), tactile/kinesthetic (feeling things not present), olfactory (smelling things not present) and gustatory (tasting things not present).

The most common types of hallucinations have to do with sleep disturbance and are auditory or visual in nature and occur at the onset or ending of sleep. These experiences are disturbances in dream states. While the person believes they are awake when this occurs, their body is actually asleep and dreaming.

Some types of hallucinations are related to neurological disorders. These include tactile hallucinations and a specific type of auditory hallucination of music.

Hallucinations related to mental illness often relate to associated sleep disturbance. Depression and manic states include symptoms of significant sleep disturbance. Problems falling asleep, staying asleep, and waking several hours too early can contribute to hallucinatory phenomena. Medications designed to help improve the loss of energy associated with depression incorrectly taken at bedtime will worsen the sleep disturbance and worsen the hallucinations. Maintaining good sleep hygiene will go a long way to improving hallucinations that are the result of sleep disturbance.

Many people can experience hallucinations as a side effect of medication. Antibiotics, pain killers, and medications that are sedating can cause hallucinations. Substance abuse causes hallucinations in several ways. The actual substance can produce hallucinations. The substance can disturb sleep. And when the substance wears off the withdrawal can cause hallucinations. Alcohol can cause visual, auditory and tactile hallucinations. Seeing pink elephants are likely occurring at the onset of sleep or waking. Hearing your name called or hearing whispers. Getting confused and having the sensation of bugs on skin or snakes wrapping around your arms or legs is a late stage of nerve problems from alcohol abuse and alcohol withdrawal.

There’s a difference between hallucinations and illusions. Illusions are things you experience that seem outside of you but you are producing. They are not a sensory experience. These are dissociated experiences. Traumatic events produce problems encoding cohesive memory. People feel unreal at the time of the event or outside themselves. When similar things trigger the memory of the event the person has an illusion. They may replay the event again in it’s entirety. This is a flashback. They may have only parts of the visual picture as a flash. This is a visual illusion. They may have only the auditory soundtrack. This is an auditory illusion. They may hear a commentary on the event. They may hear conversations of others present at the event. These are fragments of the event that occurred that haven’t been adequately processed. By identifying the triggers for the illusions, the information from the trauma can be more adequately processed.

Some traumatic events cause head injury. Often people hit the back or front of their head. The olfactory bulb which controls smell and 85% of the sense of taste sits right over the bridge of the nose. If this area is damaged by an impact either being hit in the face or head from the front, or hit in the head in the back and having the brain bounce to the front can damage this area. Smell and taste hallucinations can occur as a result of impact. Nerves heal over a long period of time. The sense of smell and taste may return to normal years after the accident or injury.

Infections especially dental or sinus infections can cause inflammation which disturbs the sense of taste and smell causing hallucinations or illusions.

Hallucinations associated with mental illness have unusual qualities to them. There are other symptoms that go along with the hallucinations that correlate with the illness. Delusional material goes along with schizophrenia. Sad mood goes along with depressive psychosis. Grandiosity goes along with manic psychosis.

Extrasensory experiences are not hallucinations although they may include delusional material. Seeing ghosts or dead people are often part of a cultural experience. These events may be experienced by a number of people who report the same phenomena. A trained psychologist or psychiatrist should be able to evaluate the experience and differentiate one phenomena from another.

For most people, hallucinations are an annoying or scary event that quickly passes. Large percentages of people have a single experience of a hallucination. It’s common. Hallucinations that interfere with daily life and interpersonal relationships should be professionally evaluated.

Baxter was our 9 year old Dalmatian. We had him since he was a puppy of almost a year old. We got him from the Glendale pound. He had been raised with cats. He had stomach problems and had already had some type of intestinal surgery. He was passive. He talked to me when I came home. I have no idea what he said but it was a long conversation. He died two days ago of complications of interstitial lung disease. It’s an autoimmune disorder. He was our third of four Dalmatians. Zoey, our first, died in 2001. Archie was given back to Dalmatian Rescue after he bit my husband. Cinnamon remains. We aren’t getting any more dogs. Cinnamon missed Baxter for less than 24 hours. She doesn’t respond to his name and doesn’t look for him. She’s now the dog in charge of the house. It’s her rightful place. She’s thrilled.

Baxter had been incredibly sick for about four days prior to our decision to have him put down. He was hallucinating. His kidneys enlarged. He had a prostate infection. He had an enlarged heart and spleen. He was vomiting frequently. Although he could have some treatment to ease his suffering, it was just the beginning of a series of infections and illnesses he would have had to endure. We decided it wasn’t good for him. His death was peaceful. He had lost 15 pounds in 2 days and was down to 85 pounds when he died. He had developed an autoimmune thyroid disorder with no functioning thyroid gland. He had problems breathing and coughed and wheezed all day long despite medication. We’ll get his ashes back in a few days and he’ll be buried in the garden. We’ll miss him for much longer than Cinnamon.

There is a lot of confusion about the concept of reinforcement for people not in the field of psychology. Reinforcement is doing something that causes a behavior to increase. This isn’t restricted to positive reinforcement. It includes negative reinforcement.

A small boy was in my office with his even younger sister and their mother. The mother wasn’t able to get either child to sit in a chair. The mother wasn’t issuing commands or reinforcing commands. It was dangerous for the children to run out of the office or to climb up onto chairs and stand on them. So I intervened.

I commanded the children to sit down in their chairs. The boy sat down. I said “good.” The girl ran over to the door. I picked the girl up and put her in the chair and said “sit here.” The boy started getting up from the chair and I stood up and he sat back down. So did I.

Reinforcement takes place prior to a behavior occuring. It increases the likelihood that the behavior will increase. Saying “good” is positive reinforcement. Standing up by me, is a negative reinforcer. It also increases the likelihood that the child will sit down. It doesn’t involve praise or rewards. It involves my doing something the child wants to stop, like me coming over to him and putting him in the chair. It happens before he sits. It increases the likelihood of his sitting.

Children reinforce their parents as well. The girl started screaming. The mother reached for her. I prevented the mother from removing the child from the chair. The mother complained that the child screamed often. Of course she did. Every time she screamed she got stuff. If that happened at my work I’d scream all the time too. Initially, without getting her usual scream based reward, the girl screamed more and louder. When it didn’t work, she sat crying softly, but she sat. The boy sat without crying. He got to play with toys in the office. I gave the girl a couple of plastic blocks to play with as she remained seated. Eventually the mother couldn’t tolerate the child sitting down and crying and felt it was necessary to pick the girl up. She told me the girl couldn’t remain sitting in a chair. I pointed that the child had been seated for almost five minutes and the boy was seated for almost ten minutes. There was no problem in getting either child to sit down. There was a problem with getting them to stay seated for long periods of time, because they hadn’t practiced the behavior. That would require more training.

The mother put the children on the floor and they ran around again. An office assistant came into the office and told the children to sit down. Both children sat down on his command. They understood and could follow directions for this stranger. They had been trained by their mother not to follow her directions. She would need to change her behavior and reinforce commands to get the children to listen to her.

Negative reinforcement is not the same as punishment. Punishment happens after a behavior has occurred. It’s a slap on a wrist, a removal of some wanted item, a critical remark, the dreaded word “no.” It happens after the behavior has already taken place. It is very ineffective at changing behavior because it happens too late. Punishment increases lying and sneaky behavior. People attempt to avoid punishment. Because the behavior has already occurred and can’t be undone the only thing to do is to deny the behavior or change the evidence.

Reinforcement trains behaviors that are desired. It works.

I was at my nieces fourth birday party on Sunday. It was delightful. It was held in a large store designed to provide music classes for children. There were about 25 children and their parents all taking photos or running videos. There was plenty of food. The children were given a bag of inxpensive musical instruments like a tonette, rhythm sticks and a tamborine. The party lasted two hours. There was a play area and all the children got a brief music lesson.

I helped my brother and his wife serve food and clean up. Some people came up to him and made comments. I was appalled by their disrespect and outright gall. One person told him that they should not have mixed sex parties. That boys and girl should not be at the same party and that next year they should only invite girls. Another person said in the back, loudly enough to be heard by several people, that he had spent too much money on the party, that there was too much food that would be wasted, and that the party was too extravagant for a child. He had, in fact spent less money this year than he had renting a jumper filled with balls and a pool slide last year. He had bought less food and had brought carry out boxes. All the food was eaten or given away at the end of the party. There was no waste. Extra sodas were taken to his business for his employees. The party was hardly extravagant by today’s standards. My brother is in the music industry. He had no professional entertainers there. He spent a few hundred dollars to rent a space and to cater food and to give away toy bags. He spent about what I do on a fine dinner out for a party of 10-12 adults. It doesn’t break the bank.

There is a place to make comments if someone doesn’t think something is appropriate. There is a way to make such comments. Someone at the party pulled me aside to do the right thing. They had “concerns” about some people at the party. They were worried the person was mentally ill and not getting treatment. Pulling me aside to talk about the situation in private away from anyone who might overhear is an appropriate method of handling a sensitive situation. The person is mentally ill. I did tell this concerned person that her assessment was corrent and that the hosts of the party were well aware of the person’s mental illness. She’s been mentally ill for years and is opting not to have treatment. She is high functioning. Apart from inappropriate comments and paranoid delusions she can live and function. She can no longer live independently. I do not consider her harmless, however and I question how much longer she should be allowed to attend these types of functions and have children be exposed to her. For now, the children do not understand much of what she is rambling on about. In another year or so they will and then it may be a problem. She is a relative, so it’s hard to exclude her from these functions. It is her choice about whether or not to seek treatment. It is my brother’s choice to invite her or not. She has asked him not to invite me. He has refused. I haven’t asked him not to invite her.

Party behavior is relatively simple. You go there to have a good time. You mingle. You eat food. You engage with activities. You enjoy the spirit of the occasion. you are a guest. You offer to help out. You don’t criticize the host, the event, the expense, the situation, the time, the people invited, what people are wearing, the food, or the activities. You can do that later on our own time. At the event you are gracious and thankful. You model being polite, kind and pleasant to others in front of your children. You try to get along. You exhibit social decorum. You behave in ways that you want your children to mimic.

My sister-in-law was hurt by some of the comments that were made to her by some of my relatives. So I explained my childhood. I had lavish birthday parties. We had the Oscar Meyer weiner car rented for rides in the neighborhood. We were on the Sheriff John show and had him out for a party. We had marionnettes and clowns and ponies in the neighborhood rented for birthday parties. We had mixed boy and girl parties until I was 12 years old. These parties from my past were far more extravagant than what they had been throwing for their daughter in both time and expense. Their parties were fine. In one of the neighborhoods where I live parties go on for hours for preschoolers and include mariachi bands and end up with block parties and the children staying up until 2 and 3 AM. That seems a bit much. In some circles 10’s of thousand’s of dollars are spent to close down a theme park for a day for a celebrity child. That seems a bit much too, but it may be the only way the child can experience a theme park without photographers. So I think the party my brother did was just right. He had little to clean up and got a great experience for his child. The business he rented got a lot of referrals for their music classes so it worked out well for them too.

Given the fact that many people overheard the inappropriate comments that were made, maybe several people will go back to my brother and his wife and mention their concerns to him about her mental illness in private as is appropriate. Maybe he’ll be able to have the strength not to invite her or to understand that she’s quite limited and needs some further limitations and spell out some rules for her behavior at public events more clearly. It’s surpirsing to me how she can get prople who are not mentally ill themselves to repeat some of the preposterous things she says.

I am a forensic clinical neuropsycholgist. What that means in English, is that after I completed a doctoral degree in clinical psychology, I went on to complete two training programs. My first was in forensic psychology. Forensic is misinterpreted (thanks to television) to mean either working with dead people or with the police as a crime scene investigator, but what it actually means is with the law. I write reports for people to have in court. I’ll get back to the types of evaluations I do in a minute and the types of reports I write. I generally do not go to crime scenes. I never conduct investigations of crimes with police. I went through an additional training program following my forensic training program. I learned how the brain functions and how it impacts behavior in a variety of ways. I learned how the brain works when it is damaged from accident and disease. My ability to study the brain through psychological tests in this manner makes me a neuropsychologist. When I apply this to legal matters, I’m a forensic neuropsychologist.

All in all it’s about 24 years of training. It’s a lot of school. Areas of law are quite vast. They involve knowing cases specific to the local, state or federal judicial system. It involves keeping up with rules of evidence and what will be admissible in court or not. The rules change over time with judicial rulings. My training started off with evaluating individuals who were admitted or convicted sex offenders as part of their ongoing treatment and presenting reports to the parole and probation departments.

I left clinical psychological training with the misinformation that I should like the people I was working with. My work with sex offenders changed that. My role was to evaluate their treatment and to ensure compliance with treatment. I was an extention of their court order. I needed to treat them with respect and dignity. It was fine if I did like them, but it wasn’t a requirement. The most violent of the offenders were brought into the office in chains with armed guards. I knew their offenses. They primarily offended against children. I could respect them; it would be hard to like some of them. It was surprising to me when I did like them. It was heartbreaking when they were not following their treatment, or were reoffending and were having to be sent back to jail or prison. Evaluation involved psychological testing with mental status questionniers, tests specific for sex offender populations, and showing slides or movies or listening to audiotapes of sex offenses and wating for arousal patterns on a penile plethismograph–think of it as a lie detector for a man’s penis. So if they were saying they were no longer aroused by children, I could actually show them pictures of children and tell. The men sat behind me in a small room with a door closed. I just watched the numbers on the dial and listened to dialogue on headsets or saw the slides or the movie as he did. There was a microphone attaching the man to my headset. Sometimes he would make comments to me. Almost always the comments were inappropriate. The comments would go into my report.

After that I worked on injury and accident cases for people claiming they were hurt emotionally or suffered head injuries. They called the emotional injuries damages to their “psyche.” It’s a very different population. The reports are for alleged, not determined, injuries. A judge, arbitrator or a jury would have to determine if the person was in fact injured and the monetary value of the injuries based on the reports.

There are different rules for people injured at work than for people injured elsewhere. I worked with this population as well. There are tables to determine the monetary value of parts of people and whole people in various levels of education and ages. In years past, the industry of Worker’s Compensation, especially in California, was rife with fraud. There were lots of clinics set up to process people with very questionable injuries. People were plucked out of unemployment lines to file for psychological injuries from their last employer for simply having been laid off. In some cases the people had legitimate injuries and simply didn’t know about the system. In other cases there were no injuries present and the person was just told it was a way to get money. In more recent years the laws have tightened. Fraud laws have been put in place and clarified. Most people have legitimate injuries but some still exaggerate the nature and extent of their difficulties trying to get more money.

Finally, I got called in to testify at court. The court cases have been of a wide variety. I testify in court based on how the attorney knows me. If the attorney knows me from my treating sex offenders I may get called in to testify on behalf of a sex offender. I do not like these cases and am no longer taking them. I don’t believe psychology has tools available to adequately treat offenders and I don’t believe we can differentiate who will offend from who will not offend. The most recent studies are showing that the treatment programs the prisoners are volunteering for are not doing anything for the offenders. For career sex offenders, I don’t think there is anything much we can do for them. There may be a few sex offenders who benefit from treatment. I have met them. They go on and live normal lives. These are people who are offending in their family and aren’t offending against stranges. Violence or coersion isn’t involved. People abusing substances during offenses may also benefit from treatment. Once the substance abuse is stopped, the offense may stop. The vast majority of sex offenders are adult men molesting young girls.

I do take cases where there are personal injuries with psychological damage or possible head injuries. I do evaluate people who have had injuries where the people may have had something wrong with them when they were injured to start with and the degree of injury is unclear. I have worked with criminals and police officers. I have given testimony in court on behalf of both in different cases. If a police officer does something wrong I will say so. If a criminal is injured wrongly I will say so. If a police officer is following the rules set down by the department I will say that too. If the criminal was injured prior to coming into contact with the police in a prior incident I will say that as well.

Some attorneys know me from my ability to testify about rules and regulations in health care. I did quality assurance. I know what health care agencies are supposed to do. This applies to doctors, their notes, their office procedures, the hospitals where they work, authorizations, managed care organizations, appeals and grievance procedures, pharmacies, labeling of pharmaceuticals, prescription writing, and handling of sample medications. So I can tell an attorney to hire a pharmacist specialist because the prescriptions and the process of prescription management is wrong in a case. Or I can tell an attorney that the chart notes are wrong and not standard and to hire a medical doctor to comment on that for that speciality. Or I can explain to the attorney that the hospital is governed by the JCAHO and to contact someone on the standards because the organization doesn’t seem to be in compliance and to pull the most recent report.

One of the things I worked on as a forensic psychologist was compliance with regulatory agencies for large organizations. This involved making sure that all aspects of an agency were in correct compliance with all local, state, national and federal regulations. It involves a lot of paper. There are tons of lists. I actually got called in to fix problems because the organization was not in compliance with some aspects. Usually there are timetables involved in fixing the problems. I did a couple of these “projects” and got noticed by some attorneys and testified in some cases at depositions and in court.

Another area of forensics is competency. The ability to understand things. I have done two areas of competency. The ability to understand the legal documents someone is signing and the ability to provide legal testimony in court and to understand the charges against the person and to aide in their defense. Competency to sign legal documents means having the ability to read and comprehend what is written adequately enough to make an informed decision about signing or not signing the document. In the case I worked on the person did not have the reading level for the document, was corersed into signing the document, and even had she read the single words individually she would not have understood them. In the case on competency to stand trial I was asked to evaluate the individual independently because the court had already found him competent and the individual wanted a second opinion. I was the second opinion. He was charged with a felony case and was facing possibly 10 years in prison. He had no recollection of the crime due to his use of drugs at the time of the offense. He completely understood the charge against him. He spoke English although it was not his first language. He was fully able to participate in his defense. He understood all the major participants in the court-the judge, the prosecutor, the jury, his attorney and what heir respective roles were. He was above average intellectually. I too would find him competent to stand trial. I told him so. And he said “but I don’t feel competent at all. I think I’m going to lose this case.” So I then explained that “competent” means to understand the legal process and “confident” means to think you might win the case. He might benefit from a dictionary during the trial. I don’t know how the case came out.

A patient of mine called me to tell me she was going to call in to a talk radio show to whine to the host “Jesus Christ” AM640 in Los Angeles and complain about her life and asked me my opinion about that. She whines about her life to everyone within cell phone radius. Occasionally she talks a poll on how miserable her life is and how devastating all this emotional angst is in her life. I’m no longer her treating psychologist. I’m the back-up. I’m not the only back-up person either. There are at least two other back-up people. This woman does not lack for support. She also has a pretty good life, all things considered. So when she asked me about getting the Almighty involved in this whining I was bemused.

A mental image from Mel Gibson’s “The Passion of the Christ” flashed in my mind. I knew she had seen the movie. So I asked her to recall the scene in which Christ was being beaten. She did. I asked her to think about it for a moment. I then asked her to recall he graphic image of the crucifixion. She did that too. So then I asked her what exactly did she intend to whine about to THAT GUY who had been through all that, about her life? She stopped completely speechless. “Well when you put it like that.” She said.

It’s about perspective. People have emotional and physical pain. Some have good reason to complain. Others just whine. They whine for every little physical and emotional “owie” in their lives. It’s these difficulties that make people stronger, that develop character, that people hold up as grace under pressure. Too many people want to do away with all the difficulties in life as too big of a demand, too big of a struggle, too big of a problem. They describe things as insurmountable or catastrophic. But from another perspective they are little owies.

I saw a person in pain. The physical pain should have been appropriately handled by an over-the-counter pain killer like tylenol or advil. The person was prescribed morphine. Morphine. So I asked why. I explained that if they get any real pain, like pain from bone cancer, or nerve disease (both of which were in their family) they would have no available pain tolerance, and no available pain medication. “Well, when you put it like that”…

I don’t doubt the physical or emotional pain. It can be quite raw at times. It can be brutal. It helps to get a different perspective. It helps to get outside yourself. It helps to do things for other people and not stay so self-indulgent.

What would Jesus say? I don’t know or sure. I told her she could call him and ask, but be prepared to have him say “Suck it up and get on with your life and stop whining.”

People come into the office and decide they just aren’t sick enough on their own so they have to make themselves seem to be much worse than they are. They complicate my job. Some do it because they have character flaws and want sympathy. Some are scam artists and have nothing wrong with them at all and are trying to get a check out of the system. Some just think the illness they have isn’t quite good enough and if they embellish they are more likely to get approved for disability. It’s hard trying to tell them apart. When they get their children involved in the scams or the embellishments or their character flaws it’s awful.

I saw a brilliant little boy yesturday. I don’t use the term brilliant lightly. He was acting up in the waiting room in a manner that was, well, intentional. When he was removed from the waiting room by staff he was fine away from his mother. Think of her as conducting and orchestrating the whole presentation of this child. My ethnicity is mixed. I have some gypsy heritage. I recognized that this was a gypsy family and heard the mother’s subtle accent as Romani, the language of gypsys. Now I have seen gypsys who do not malinger. There are a lot of genetic disorders in the community. They have a lot of legitimate needs. In addition a brilliant child needs special education services as much as a child who is well below average. The child stopped putting on any show for me and did well for me in the office. I found him delightful. The evaluation of him went smoothly. I asked him if he spoke another language besides English and he said he spoke gypsy sometimes at home. I spoke to the mother in private about her behavior with the child in the office. She has a choice for him and his life. She was educated to the 7th grade and pulled out of school. It’s the custom. Actually 7th grade is fairly high. Often it’s 5th or 6th grade. Then the children are immersed in the culture of the Romani. The rest of the world is unclean outsiders. A few gypsies go on to college but it is rare.

My great great grandmother was a village healer from Siberia, Russia. The gypsies were removed from most of Europe and expelled to the vast wastelands of Russia or forced to live in small meandering groups. She was not educated in the traditional sense. Stories about her have been passed down through the generations. She married my great great grandfather as a mail order bride. My grandfather wanted to help people and create generations of healers. Some of the ideas of the gypsy culture took hold in the family. There were secrets. There was interfamily marriage and resulting offspring. There were some criminal elements introduced.

I understand that people decide to try to get things they want with little effort. I also understand that people decide to try to get things they feel entitled to. I know that when people get sick they get frightened and that leads them to become desperate. I understand criminals and people who scam the system, some of those people are relatives of mine. I get all that. I do not understand introducing children to the idea of being entitled to get something for nothing. I do not understand intentionally teaching children how to try to mislead adults. I do not understand coaching children to malinger. It breaks my heart.

I do evaluations on people for social security disability. It’s not the best way to evaluate people. People get very little feedback about how they are doing and they have to wait weeks for results. The outcome has substantial meaning for the people involved who believe that they require their disability checks in order to survive financially. The process is full of ambiguity and creates anxiety more than psychological testing normally does. In addition the people applying are bombarded by television commercials and advertisments in doctors’ offices from attorneys suggesting that disability evaluating doctors “aren’t on their side” so they will require legal representation in order to “get the benefits they deserve.”

I, and the other doctors in all the offices where I work, are independent contractors with the State. We have sets of questions to answer about disability applicants from the State. The State evaluates people per speciality. My speciality is psychology, so I evaluate the cognitive and emotional functioning of an individual. I also ask about their medical history in detail because it’s important to know about. If a child is applying, I ask the parent or caretaker about the birth, pregnancy and delivery and developmental milestones in addition to education. I’m not expected to provide all the information to the State. The disability analysist integrates all the information and ultimately makes a disability determination. I don’t determine whether a person is disabled or not.

After I see someone, there is a four to six week wait for a letter to arrive with a disability determination. This waiting period is filled with anxiety for many people. During that time people ruminate about the evalution process, worry about what they might have done wrong or what the doctor “really thought.” Preemptive complaints to the analyst about the doctor or evaluation are common during the waiting period and simply express anxiety.

I recently had the opportunity to take the oral examination for licensure in the state of Nevada. Any test taken with litle to no feedback where you have to wait for results is a very similar process to a social security evaluation. The difference for me was that my survival wasn’t on the line. I’m licensed in California and employed. If I didn’t pass the exam, I could take it again. Of course there was a lot of pressure from a company I work for that opened a clinic in Nevada for me to pass. They want me to work there starting yesturday.

So I took the test. I’m best in the early mornings. So being tested late in the afternoon almost evening wasn’t the best time for me. Everything in the world that could have gone wrong apart from death, fire flood, tornado and earthquake, had happened in the two weeks prior to the test. My car had started showing signs of blowing a head gasket so I sold it and got a one year old car with low mileage which immediately needed the gas tank replaced. I refinanced my home with all the resultant problems that come with that process. My husband was being evaluated for surgery. Someone brought a gun into one of the clinics. Some new staff people quit some new staff people were hired. I had my taxes to finish prior to seeing my accountant. All ordinary stuff if it was spread out over a couple of months but not in a two week time frame. The test itself didn’t worry me. The timing of it wasn’t the best.

I know every trick in the book to manage test anxiety. I used to vomit prior to exams in high school and college and read some self help books that taught me some steps to relax. When I took the oral exam in California and passed I threw up. When I took the exam for doing Worker’s Compensation and started getting anxious I just controlled the symptoms and was fine. This time I stayed in my car until 10 minutes prior to the exam time. Waiting in the building makes me more nervous. In the car I can listen to music and calm down. I can talk to myself and get myself to relax. I know how to do all that.

I talked to my Aunt prior to her disability evaluation. she was nervous and didn’t know what to expect. I told her it was a doctor’s appointment only a lot simpler. She’d had three heart attacks, a stroke, emphysema, diabetes, diabetic neuropathy, and some problems with night vision. The stroke hadn’t been well documented but everything else had. I told her to bring her reading and distance glasses and either a list of her medications or all the bottles of medications, not insulin. They would take her blood pressure, hight and weight and make her read an eye chart and ask her to fill out forms about her problems and the doctor would ask her some questions and listen to her. If she couldn’t fill out the forms someone would be able to help her. The doctor might request x-rays or, in her case, a breathing test. The doctor was attempting to agree with what she said was wrong with her. The doctor was documenting what she said as well as the opinion of the doctor. The doctor didn’t make a disability determination. The doctor wasn’t there as her doctor. They might not have the best bedside manner or establish rapport to your personal liking. They can’t diagnose, recommend or treat. Sometimes it’s hell for them not to. Sometimes they actually like the people and would really want to help. That made her less anxious. When her claim for disability got denied, she called me and asked what to do. I told her to get her medical doctor to document her stroke. With that documented, her claim was approved. She didn’t need to return to see an SSDI doctor. She just needed an MRI from her own MD.

I took my oral examination in Nevada. I can’t talk about the details of the examination. I can talk about my 4 1/2 hour car ride home. I screamed about every single detail I missed. 4.5 hours of screaming. No law enforcement officer pulled me over for screaming in my car while driving. It’s an easy thing to explain. “You have to realize officer, I knew that one, I just forgot it.” I missed information from things I do five days a week. I missed things I train people to do. Because there was no feedback or responses I wasn’t sure how some answers would be interpreted. I figured all in all I was in the borderline range. I might or might not pass. I probably passed, but there was a chance I didn’t. I’d have to wait a couple of weeks.

The people who evaluated me were nice. I perceived them as nice because I actually like the concept of regulatory agencies. I think they protect the public from unscrupulous people out to take advantage of them. But some people view them as agents of the government, similar to tax colectors and IRS agents, and are fearful. They have both roles. A psychologist was recently threatening to leave without notice as required which would have resulted in cancellations and delays for about 16 people and a wait for several more weeks. That person was threatened with being reported to the Board for unprofessional conduct. They decided to uphold their end of the contract on behalf of the public. It helps to wave the stick sometimes.

Some people perceive me as nice and helpful. Some people perceive me as evil and mean. The perception can change in the middle of a sentence. A man came in with this idea expressed very clearly: “When I first met you I thought you were a Nazi, but then you seemed caring.” I didn’t change in one hour. His anxiety lessened.

In some cases the anxiety increases. I evaluated a woman. She had problems with English and spoke some Spanish which she also had problems with. She had a history of special class placement in school. I said everything first in English. I translated every sentence then in Spanish. When she left I got a call from her mother who reported the woman said the entire evaluation was conducted in Spanish and she had understood nothing, she worried she had lied. Her anxiety had increased. I explained the bilingual presentation and reassured the mother.

I spent two weeks ruminating about how I did on the evaluation coupled with friends and my work ruminating. “Have you heard yet?” During the four to six weeks SSDI applicants have to ruminate we get complaints about doctors, the office, the office staff, and anything they might need for a “do over.” I didn’t need to complain about anyone. If I wanted a “do over” I’d ask for an earlier time next evaluation cycle. I either passed or I didn’t. It isn’t life or death. The ruminative voices in my head can shut up. Time for a good CD to listen to. No I haven’t heard yet, stop asking I’ll call you. Call the Board and ask them if they have mailed out the letters. I’m not going to call I sent an email. I can wait.

Yesturday I heard. I passed.

There is news about psychiatric medications once again. Children who are prescribed stimulant medications for attention deficit disorder are at a slight possibility of risk of heart problems. Women who take medications for depression, specifically selective serotonin reuptake inhibitors (SSRIs) like Prozac can also get heart problems and their babies, exposed prenatally can have withdrawal symptoms. So what are people to do for attention problems or depression?

First, look at the information rationally as it applies to you and your situation. No one should be taking medication if it isn’t needed. So be sure that medication is required prior to starting on any psychiatric medication. Let me go a step further. How do you know if medication is needed for attention problems or depression? First, non-medication treatments were tried. For attention problems, treatments involve parenting, behavior work in the classroom and behavior work at home. Sometimes a psychologist can be involved in providing behavior specialty work. sometime a specific professional called a behavior specialist is involved. School and clinical psychologists can be used to treat comorbid problems with emotional problems and academic difficulties that often accompany attention problems. Cognitive and interpersonal therapies can be used to treat those in addition to standard counseling. For depression, cognitive therapy seems to have the most research to show it is as effective as medication for mild and some moderate depression. There are some interpersonal therapies and some other types of therapies that also report effectiveness but don’t yet have the same research support behind them. Supportive psychotherapy, where someone just asks how your day is going and tells you when to come back after listening to you, is not very effective at all for any form of depression or anxiety. Therapy requires some form of activity on the part of the therapist to be effective.

Very severe forms of attention disorders or severe depression require medication. All medications cause side effects. Very few medications are specifically researched as safe or effective for children. Risks increase the younger the child is and the higher the dose of the medication. It’s important to understand how medications work to understand what goes wrong with the side effects. Stimulant medications increase the heart rate to increase the functioning of a specific part of the brain-the frontal lobe. The medications are excreted from the body from the kidneys and processed through the liver. Several things can go wrong. The heart can speed up too much or beat wrong causing an arrythmia or heart attack. The liver can stop processing the chemical or the kidneys can shut down. All these things can be fatal. Of all the millions of children taking stimulants, 24 had heart problems and died. Lots more had liver problems and some drugs got taken off the market a few years ago. The kidney problems are far less frequent. Seizures are less frequent, and are almost never fatal. The same effects can happen with caffeinated soda for the same reason. Caffeine speeds up the heart. People die from ephedra. People in college die from caffeine overdose with cardiac arrythmia during finals and mid-terms. Sure, they had pre-existing heart problems they never knew about and they added a drug they thought was safe. No-dose and Jolt Cola and other stimulants are considered so safe they are sold over the counter. For most people Ritalin and Strattera are safe and effective. For a very small minority there are unknown preexisting problems that the medication points out. But for anyone, if they suddenly get short of breath, complain of chest pain, start sweating profusely, get pain radiating down their arms or through to their back, even if it’s a child, they need medical attention. Heart attacks happen in childhood as well as in adults.

A similar thing is true for SSRIs. These antidepressants block the reuptake of serotonin all over the body. They have a significant impact of the GI tract, the spinal cord and the brain. The impact on the brain takes several weeks. The impact on the spinal cord and GI tract is within a few days. The people who notice an almost immediate impact to SSRI’s are responding to this GI and spinal cord impact. Pain due to muscle disorders and GI problems may be medical causes of depression that may have been overlooked in the initial diagnostic workup. Significant repose to an SSRI within 2 to 3 days of onset suggests a medical, not a psychological, cause of depression. There is a very small percentage of people who have some very strange symptoms with SSRIs. Seizures, abnormal bleeding, and heart problems as well as problems with metabolism of the chemicals cause difficulties with these medications. People who have a history of these types of problems should review their histories carefully with their prescribing MDs prior to choosing these medications and monitor their ongoing treatment carefully.

Especially with the SSRIs, it’s important that the medication be taken every day without fail. Intermittant use of medications like these ensures that the medications will not work correctly to reach the brain and will limit the impact only to the GI tract and spinal cord. episodic use increases the risk of side effects that reduce with time such as nausea that primarily have their impact on the GI tract.

It’s important when reviewing medications and medical histories with a treating MD to review all over-the-counter herbs, vitamins, supplements and prescription drugs as well as medications you may be borrowing from others (not a good practice). You may also want to review them with the pharmacist when you fill your pescriptions. If possible, fill all your prescriptions at the same pharmacy. With computerized tracking systems, potential drug interactions can monitored and hopefully avoided at the pharmacy. In addition, it’s always important to eat a normal diet and drink an adequate amount of fluid (6 to 8, eight ounce glasses of fluids a day).

Eat food, drink water. MDs don’t seem to tell people that. I still see people on weird diets not drinking enough water and getting dehydrated. They get sick in weird ways. Medications don’t work and their body doesn’t work right. It’s important on stimulants and antidepressants to eat and drink fluids. It keeps the body systems working right. It helps the medications work right too.

I was evaluating a child yesturday. His behavior was so appalling with his mother I just couldn’t ignore it. I told him he was being rude. He seemed surprised. As if he didn’t know. His mother immediately jumped to his defense and said he thought he was simply being cute. I guess it’s why she didn’t stop him. It’s not “cute” for a child to be rude to an adult.

He was 9 years old. He had several rude behaviors. He talked back. He argued. He made faces at her. He hit her. He slapped her. To all of this she did nothing. Eventually she would get fed up and would scream at him. She reported he was in therapy. She had asked for family therapy but it had not been approved. She had taken parenting classes. She felt desperate. I could see why.

I don’t doubt that the child had some problems. Even if she had been a perfect parent with great skills he may have had problem behaviors. Now there is a difference with psychotherapy to focus on how a child feels and behavior work. some therapists seem to think that if a child talks about how they feel their behavior will improve. This assumes they know how to behave. This child and this mother do not have any clue about how to behave. He can articulate his feelings just fine. He can act his feeling out. He can’t manage his behavior. He needs direction.

So I explained to his mother the difference between a behavior specialist, like what people see on The Nanny television shows, and what most psychologists and counselors do, which is to focus on feelings. The child was swinging his watch around. So I talked about that. I can talk about how he feels about his watch. He can talk all day about his watch with me. Or I can tell him to put his watch back on his wrist. He started to tell me why it was off and I interrupted him and told him to put it back on unless it hurt him. He put it on. I didn’t need or want the story. I then asked him to sit correctly in the chair and corrected him until he had a good sit. Now most children know hot to sit still for about as many minutes are they are old. He should be able to sit for about 9 or 10 minutes. He was able to sit still for 30 seconds. I told him he would need to practice. It was a skill. Most kids learn the skill by age 2. He didn’t. He was behind. He would need to practice to catch up. He understood that. He can tell time I told him to get a clock and practice sitting.

Next I did some work with his mother. I told her to give commands not suggestions. I had actually done this when I took him and her into the office. He had refused to come so I took her and left with her for the evaluation of him. I didn’t say anything at all to him. as she and I left without him, he saw what was happening and he decided to come too. I didn’t argue with him. I didn’t interact with him at all. I told him he had an appointment. He said he wasn’t coming. I took his mother into the office without him. Then he decided to come. Making faces at her, but he came.

I told her when he was being rude to not interact with him. To not respond to him at all. She should only respond to him when he was being appropriate and not bizarre. She should not tolerate being hit or slapped. She should tell him once to stop. She could then move away or have him move away. Which ever was easier. No more yelling. Yelling at him doesn’t work. It wasn’t working in the waiting room. Very clear directions for what you want him to do seems to work well. Praise for what works seems to work well. He seems to try to please if he can figure out what to do. Tell him what to do. It sounds so simple but it’s very hard in actuality.