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From Bruce to Caitlyn Jenner… And Why Gender Dysphoria is No Longer a Disorder

Caitlyn Jenner’s transition is, what we would call in this day and age, “trending” in social media. But the transgender struggle has existed long before the times when it would have graced the cover of Vanity Fair. Many transgender trailblazers have come before Caitlyn: World War II era Army draftee Christine Jorgensen, former professional tennis player Renée Richards, LGBT advocate Chaz Bono, Hollywood actress Laverne Cox. We live indeed in a different world. A world more accepting about diversity, yet with deeply engrained prejudices. Let us not forget Brandon Teena.

But, What is Gender Dysphoria?

Dysphoria, from the Greek “difficult to bear,” is a sense of discomfort or distress. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5):

Gender Dysphoria refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.”1

In other words, people with gender dysphoria are not happy with the sex they were born, identify themselves as members of the other sex, and have significant distress because their sexual characteristics are in conflict with how they view, think, and feel about themselves and their gender.

Previous versions of the DSM used the terminology Gender Identity Disorder, which was included in the “Sexual and Gender Identity Disorders” chapter together with sexual dysfunctions and paraphilias. But gender identity disorder is neither a sexual dysfunction nor a paraphilia. Furthermore, DSM-5 recognizes that gender identity is not the clinical problem and shifts the focus of clinical attention to the distress experienced by the individual. The problem is not the identity but rather the mental anguish that the individual may face when dealing with the thoughts and feelings about their gender.

SEX ≠ GENDER ≠ SEXUAL ORIENTATION

Not that sexuality and gender identity are this simplistic, but let us think of sex as the anatomical characteristics we have from birth (generally speaking, vagina vs. penis, XX vs. XY chromosomes), sexual orientation as the person to whom we are sexually attracted, and gender as our internal sense of self (as male, female, neither, or both).

Gender dysphoria may begin in childhood but may also be seen later in life. It is more commonly seen in men than women, although these statistics are greatly contested. The level of distress caused by gender dysphoria places the individual at higher risk for behavioral problems, substance use, depression, anxiety, and suicide.

Gender reassignment surgery may not necessarily be the personal goal for all individuals with gender dysphoria. Regardless of the decision, it is important to seek help from an experienced mental health professional in order to deal with the distress caused by the gender incongruence, to treat any resulting or co-occurring mental health problems, and to assist the individual in the transition. While family and peer support is essential, family members may also need psychological assistance to deal with their feelings and the perceived loss of their transgender family member.

Caitlyn is not the first and certainly not the last transgender individual. While her life in the public eye will hopefully bring more attention to this important issue, we need to be mindful of the double-edge sword that comes with her fame. Living under the social microscope, with its heightened level of scrutiny, and in our ever-connected world where comments are unfiltered and, at times, intolerant and insensitive, may not only be damaging to Caitlyn’s journey but may actually hurt the transgender cause.

We have come a long way as a society and it is amazing that we are having this conversation. We must continue to educate ourselves because knowledge is not only power but it also fosters awareness, tolerance, acceptance, and respect.

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

De Bruce a Caitlyn Jenner … Y Por Qué la Disforia de Género No es un Transtorno

La transición de Caitlyn Jenner está, lo que llamaríamos hoy en día, “trending” en las redes sociales. Pero la lucha transgénero ha existido mucho antes de los días en que hubiera engalanado la portada de la revista Vanity Fair. Muchos pioneros transgénero han forjado el camino antes de Caitlyn: la soldado de la era de la Segunda Guerra Mundial Christine Jorgensen, la ex-tenista profesional Renée Richards, el activista LGBT Chaz Bono, la actriz de Hollywood Laverne Cox. De hecho, vivimos en un mundo diferente. Un mundo más tolerante de la diversidad, y aún así con profundos prejuicios. No olvidemos a Brandon Teena.

Pero, ¿Qué es la Disforia de Género?

Disforia, del griego “difícil de soportar,” es una sensación de malestar o angustia. De acuerdo con el Manual Diagnóstico y Estadístico de los Trastornos Mentales, Quinta Edición (DSM-5):

Disforia de Género se refiere a la angustia que puede acompañar a la incongruencia entre el género expresado y el género asignado de una persona”.1

En otras palabras, las personas con disforia de género no están contentas con el sexo que nacieron, se identifican como miembros del otro sexo, y experimentan gran malestar debido a que sus características sexuales están en conflicto con la forma en que se ven, piensan y se sienten sobre sí mismos y su género.

Versiones anteriores del DSM utilizaron la terminología Trastorno de Identidad de Género, la cual fue incluida en el capítulo de “Trastornos Sexuales y de la Identidad de Género”, junto con las disfunciones sexuales y las parafilias. Pero el trastorno de identidad de género no es ni una disfunción sexual ni una parafilia. Por otra parte, el DSM-5 reconoce que la identidad de género no es el problema clínico y cambia el foco de atención clínica al malestar experimentado por el individuo. El problema no es la identidad sino la angustia mental que el individuo puede enfrentar al lidiar con los pensamientos y sentimientos acerca de su género.

SEXO ≠ GÉNERO ≠ ORIENTACIÓN SEXUAL

No es que la sexualidad y la identidad de género sean tan simplistas, pero veamos al sexo como las características anatómicas con las que nacemos (en términos generales, vagina vs. pene, cromosomas XX vs. XY), a la orientación sexual como a quien nos sentimos atraídos sexualmente, y al género como nos vemos y sentimos internamente (como varón, hembra, ninguno, o ambos).

La disforia de género puede comenzar en la niñez, pero también puede verse más tarde en el desarrollo personal. Se observa con mayor frecuencia en hombres que en mujeres, aunque estas estadísticas son muy debatidas. El nivel de angustia causado por la disforia de género aumenta el riesgo de problemas de conducta, uso de sustancias, depresión, ansiedad y suicidio.

La cirugía de reasignación de sexo no necesariamente es la meta personal para todos los individuos con disforia de género. Independientemente de su decisión, es importante buscar ayuda de un profesional de la salud mental experimentado para lidiar con la angustia causada por la incongruencia de género, para tratar cualquier problema de salud mental resultante o co-occurrente, y para ayudar a la persona en su transición. Si bien el apoyo de la familia y amigos es esencial, los miembros de la familia podrían también necesitar ayuda psicológica para lidiar con sus sentimientos y con la pérdida percibida de su familiar transgénero.

Caitlyn no es la primera y sin duda no será la última persona transgénero. Mientras que su vida en el ojo público posiblemente traerá más atención a este importante asunto, tenemos que ser conscientes del arma de doble filo que viene con su fama. Vivir bajo el microscopio social, con su mayor nivel de escrutinio, y en nuestro mundo cada vez más conectado, donde los comentarios sin filtro y, a veces, intolerantes e insensibles, podría ser perjudicial no tan sólo para el recorrido de Caitlyn pero podría afectar la causa transgénero.

Hemos avanzado grandemente como sociedad y es maravilloso que estemos teniendo esta conversación. Pero debemos continuar educándonos porque saber no es tan sólo poder sino que también fomenta conciencia, tolerancia, aceptación y respeto.

Recuerda…

Sé Inteligente. Sé Precavido. Sé Saludable. Sé Fuerte.

¡Hasta la próxima!

Dr. Félix

Death of a Doctor – Another Victim of Cyber Bullying?

The death of Puerto Rican doctor Gloria Ortiz González is an unfortunate reminder of the power of social media, cyber bullying, the poor conditions of a public health system affecting both patients and their providers, the level of stress and the need for attention to the emotional well-being of healthcare workers, the Hippocratic Oath, and the doctrine “primum non nocere” (“first do no harm”).

Dr. Ortiz González gained notoriety and grew in infamy after a verbal altercation with patients in the emergency room waiting area of Bayamon Regional Hospital in Puerto Rico was recorded on a mobile phone and uploaded to social networks in August 2014. In the video, which clearly begins in the middle of the discussion and does not show the preceding interactions, a patient who is off camera can be heard instigating the physician to the point that she loses her composure and uses language like:

  • “And you’re ignorant, read a goddamn newspaper.”
  • “Who pays for “la reforma de la salud” [Puerto Rican Medicaid] in this country? I do with my taxes.”
  • “Damn it. I have busted myself studying me in the damn Medical Sciences Campus to have to come here and deal with you.”
  • “Bunch of ignorants.”
  • “That is why this country is a mess because what you do is listen to Daddy Yankee. Pick up a goddamn book you ignorant. Pick up a goddamn book.”

The life of Dr. Ortiz González took a huge turn after the video went viral. The doctor was suspended from duty and investigated by the Department of Health of Puerto Rico; an investigation which ceased once she resigned. Although she would later be exonerated of any wrongdoing by the Office of the Advocate for the Patient, the degree of personal harassment and devastating cyber bullying on social media were inescapable.

Even the world famous reggaeton singer Daddy Yankee countered in social networks and through the song “Palabras con Sentido” [“Words with Meaning”], the video of which recreates the moment when the doctor’s outburst was recorded in the waiting room. A young doctor who, in a moment of frustration, lashed out at her patients, whom she swore to treat with “warmth, sympathy and understanding.” A doctor who fell victim to persecution and cyber attacks, chasing her out of her home, affecting her mental health, and possibly contributing to her death.

Although Dr. Ortiz González’s behavior in that moment of anger was unacceptable and unprofessional, we must remember that we are all human and the burnout caused by poor working conditions in a crowded health system marred by inefficiencies, poor pay, and little appreciation, have their weight. While I do not excuse her conduct, as a medical student who walked the floors and hallways of that same regional hospital in Puerto Rico, I understand how difficult it can sometimes be to remain composed under so much pressure.

Now, we should reflect on the impact of the news of her death, the emotional footprint carved out by harassment, and the rampant use of social media to perpetuate a persecution by anonymous abusers behind a keyboard. Many people have fallen victim to this cyber hunt. Harassment, both in person and through social networks, can have lifetime effects on the victim’s personality. The power of demoralization is monumental and erodes at the victim’s self-worth. Anxiety, depression, suicides, and murders. When will it all end?

I hope the death of Dr. Gloria Ortiz González has not been in vain and makes us think twice before casting our hatred on social media, considering the irreversible damage that we may cause.

Rest in Peace, Doctora!

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

Suicide: Faces We See, Hearts We Cannot Know…1

The recent suicide of actor Robin Williams is a tragic reminder of one of our society’s epidemics. Many have been left wondering, “How can such a talented and funny man end his life?” Robin Williams’ struggles with substance use and mental illness may have been public but, like many people around the world, his private turmoil and demons won the battle.

According to the latest data provided by the Centers for Disease Control and Prevention (CDC), suicide represented the tenth leading cause of death in the United States in 2011. If this were not alarming enough, suicide was the second leading cause of death among our teenagers and young adults (ages 15 to 34).

Recognition of warning signs, early prevention, and immediate assistance for anyone who expresses thoughts of suicide or attempts suicide are of great importance.

WHAT ARE SOME OF THE WARNING SIGNS?

Many warning signs for suicidal behavior are similar to symptoms of depression:

  • Feelings of sadness or hopelessness
  • Behavioral changes
  • Irritability
  • Anxiety
  • Trouble sleeping
  • Changes in appetite
  • Loss of interest in pleasurable or enjoyable activities
  • Poor hygiene
  • Feelings of guilt
  • Isolation from friends and family
  • Giving away or throwing out objects of personal value
  • Drug or alcohol abuse
  • Talk/verbal threats of suicide
  • Suddenly recovering from a period of depression (maybe after having decided to put an end to their suffering by ending their life)
Even in the presence of all these warning signs, it is extremely difficult to predict with certainty who will attempt suicide. We do know that the most important risk factor for the prediction of suicide is past suicidal behavior. In other words, a past suicide attempt is the best predictor of a future suicidal act.

RISK FACTORS FOR SUICIDAL BEHAVIOR:

Risk factors for suicide vary greatly from person to person depending on the severity of mental illness, personality strengths and vulnerabilities, and support system. The following list is not meant to be all-inclusive.

  • Sudden stressful life events (i.e. humiliating events, financial ruin, job loss, death of a loved one)
  • Interpersonal conflict
  • Economic problems
  • Legal problems
  • Mental illness
  • Medical problems (acute and chronic)
  • Intractable physical pain
  • Poor support system

WHAT CAN WE DO TO PREVENT SUICIDE?

It is important to recognize the above warning signs and risk factors as well as the symptoms of mental illness and alcohol/drug abuse. Early intervention is the most effective way to prevent suicide. Any statement of suicidal thoughts or suicidal behavior must be taken seriously. Anyone who expresses thoughts of suicide requires immediate medical evaluation.

WHAT ARE THE EFFECTS OF SUICIDE ON THE SURVIVORS?

The effects of suicide on friends and family can be devastating. People who lose a loved one to suicide tend to feel guilty for the death of their family member or friend, wonder what they could have done to prevent it, and may even feel rejected by others.

Suicide survivors may experience:

  • Sadness for their loss
  • Anger towards the deceased family member
  • Feelings of guilt
  • Depression
  • Anxiety
  • Posttraumatic stress disorder, especially when a witness to the suicide or finding the family member after a completed suicide
  • Suicide attempts to reconnect with their lost loved one
As the aftermath of family suicide may have long lasting effects, it is important for survivors of suicide to seek help in dealing with their loss.

HOW TO HELP?

Anyone who expresses thoughts of suicide or attempts suicide should be evaluated immediately:

  • Calling 911,
  • Taking the person (yourself) to the nearest emergency room, or
  • Looking for help from a mental health professional
Psychotherapy and counseling can help the suicidal person deal with his/her feelings or negative thoughts, identify stressors, and strengthen coping skills. Psychiatric medications may also control symptoms of depression, anxiety or any other mental health condition.

Help is also available through telephone hotlines. In the United States, the National Suicide Prevention Lifeline (1-800-273-TALK or 1-800-273-8255) is an excellent source of support. It is for people in crisis, not just when thinking about suicide. The call is free and confidential and a mental health professional will be available to listen to you and provide information about mental health services in your community.

There is no shame in seeking help and it can save your life!

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

Simply Irresistible? – Impulse Control Disorders

Luis Suárez, soccer player with the Uruguay National Team representing his country at the 2014 FIFA World Cup in Brazil, has recently gained some notoriety. Not so much for his abilities as a soccer player but for the bite seen around the world. And this is reportedly the third time in his career when he has bitten an opponent on the field. The unsportsmanlike behavior has left many soccer enthusiasts wondering, what is wrong with Suárez?

One of the mental health diagnoses being thrown around by sports commentators, and even mental health experts, has been that of impulse control disorder. While displaying aggression at the height of a stressful event, like biting another human being, may be characteristic of a lack of impulse control, making a diagnosis without evaluating a person, whether a public figure or not, is neither responsible nor ethical. But since the topic has been on the news, I think it is important to have a discussion about impulse control disorders, how they manifest, and how to treat them.

First of all, impulse control disorder is not an actual diagnosis recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Together with disruptive and conduct disorders, they describe a set of different diagnoses characterized by “problems in the self-control of emotions and behaviors,”1 which include oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania. These disorders involve the violation of the rights of others and/or “bring the individual into significant conflict with societal norms or authority figures.”2 They tend to be more common in males than females, initially manifest in childhood or early teenage years, and are generally rare.

Here is a brief overview of these disorders, all of which must cause distress in the individual or impairment in his/her level of functioning:

Oppositional Defiant Disorder

Usually begins in preschool years.

How common: About 3.3%.3

Signs/Symptoms: Frequent loss of temper, anger/resentfulness, arguments with authority figures, defiance of rules, blaming others for mistakes/misbehavior, vindictiveness.

Intermittent Explosive Disorder

Usually begins in late childhood or adolescence.

How common: About 2.7%.4

Signs/Symptoms: Behavioral outbursts characterized by a failure to control aggressive impulses and manifested through verbal aggression, damage/destruction of property, or physical injury against others/animals. The outbursts cannot be premeditated and are grossly out of proportion to any provocation or stressor.

Conduct Disorder

Usually begins in mid-childhood to mid-adolescence.

How common: About 4%.5

Signs/Symptoms: Violation of the rights of others or society norms/rules manifested by bullying/intimidation of others, use of a weapon that can cause serious harm, physical cruelty towards people or animals, destruction of property, deceitfulness, theft, and serious violations of rules.

Antisocial Personality Disorder

Never diagnosed before age 18 but symptoms of conduct disorder must be present before age 15.

How common: 0.2 to 3.3%.6

Signs/Symptoms: “Pervasive pattern of disregard for and violation of the rights of others”7 manifested by unlawful behavior, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard for safety, consistent irresponsibility, and lack of remorse.

Pyromania

Insufficient data to determine when it usually begins.

How common: Not known.

Signs/Symptoms: Deliberate fire-setting; tension before the act followed by pleasure, gratification or relief once a fire is set; and fascination/attraction to fire.

Kleptomania

Variable age of onset.

How common: 0.3 to 0.6%8; females outnumber males 3 to 1.

Signs/Symptoms: Failure to resist impulses to steal things that are not needed for personal use or for their value; tension before the act followed by pleasure, gratification or relief once the theft is committed.

Other Disruptive, Impulse-Control and Conduct Disorders

Presentations in which symptoms of emotional or behavioral dysregulation cause clinically significant distress or impairment to the individual but that do not meet full criteria for any of the disorders above.

How are these disorders treated?

Impulse control disorders may be treated with therapy and/or medications. Early detection and intervention are important, especially when some of these disorders may bring the person in contact with the legal system. A mental health expert may evaluate the individual’s history and current presentation to determine the presence of a disorder and to establish the best treatment plan. There are different behavioral therapies that have proven effective for the management of these disorders and which should only be performed by a licensed provider.

We may not know what, if anything, is wrong with Suárez, but at least his behavior has given us the opportunity to talk about these important topics while the world is watching.

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

Los Peligros de Molly

“Molly” se ha popularizado recientemente en canciones de Miley Cyrus y Kanye West. Con letras como: “We like to party / Dancing with Molly / Doing whatever we want” [We Can’t Stop] and “Let’s take it back to the first party / When you tried your first molly / And came out of your body” [Blood on the Leaves]1, el uso de la droga “Molly” se ha idealizado y hecho mas atractivo.

Pero, ¿qué es Molly?

Molly es una forma pura de MDMA, o 3,4-metilendioximetanfetamina por su nombre químico. MDMA es uno de los ingredientes de otra droga popular, Éxtasis (la cual puede ser mezclada con cafeína, LSD, ketamina, talco, y aspirina). Independientemente de su composición, la ingestión de MDMA puede ser peligrosa y hasta fatal.

La MDMA fue sintetizada por primera vez por la compañía farmacéutica alemana Merck en 1912. Fue utilizada en la década de 1970, sin la aprobación de la Administración de Alimentos y Medicamentos (FDA, por sus siglas en inglés) como una ayuda en la psicoterapia y la terapia de pareja. A partir de 1985, la Administración para el Control de Drogas (DEA, por sus siglas en inglés) ha categorizado a la MDMA en la Lista I de Sustancias Controladas, debido al alto potencial de abuso y la falta de un uso médico reconocido.

La MDMA es similar al estimulante amfetamina y el alucinógeno mescalina. Ingerida por la vía oral en forma de tableta o cápsula o inhalada en forma de polvo, la MDMA produce aumento en el nivel de energía, estado de ánimo elevado o euforia, percepción distorsionada, y aumento en el sentimiento de empatía. Estos efectos “deseados” son los que llevan a la gente, en su mayoría adolescentes y adultos jóvenes en los clubes y “raves,” a probar e incluso abusar de la droga, a veces sin conocer los peligros, tanto a corto como a largo plazo.

El número de visitas a la sala de emergencia relacionadas con el consumo de la MDMA se ha más que duplicado en los últimos 7 años. De acuerdo con el reporte del 2011 de la Red de Advertencia del Abuso de Drogas2 (DAWN, por sus siglas en inglés) de la Administración de Salud Mental y Abuso de Sustancias (SAMHSA, por sus siglas en ingles), se estimó el número de visitas a la sala de emergencia en 22,498 (en comparación con 10,227 en 2004). Y los números continúan en aumento…

La MDMA provoca la liberación de químicos en el cerebro (neurotransmisores), como la dopamina, la serotonina y la norepinefrina. La liberación masiva de serotonina, así como su eventual agotamiento, causan el sinnúmero de efectos negativos de la sustancia, como se detalla a continuación:

Efectos sobre el Sistema Nervioso Central:

  • Alteración del estado mental (confusión)
  • Hiperactividad
  • Convulsiones
  • Ansiedad
  • Paranoia
  • Depresión
  • Visión borrosa
  • Alucinaciones
  • Hemorragia intracraneal
  • Derrame cerebral

Efectos Cardiovasculares:

  • Taquicardia (aumento del ritmo cardíaco)
  • Presión sanguínea alta o baja
  • Dolor de pecho
  • Arritmia fatal
  • Fallo cardiaco (el riesgo es mayor en los individuos con enfermedad cardiaca preexistente)

Efectos Gastrointestinales:

  • Resequedad de la boca
  • Náusea
  • Vómitos
  • Calambres/retortijones abdominales
  • Pérdida de apetito

Efectos Respiratorios:

  • Dificultad para respirar
  • Fallo respiratorio
  • Aspiración (inhalar el vómito)

Otros Signos y Síntomas:

  • Deshidratación
  • Sed excesiva
  • Sudoración profusa
  • Moler/Rechinar los dientes
  • Apretadura de la mandíbula
  • Espasmos musculares

La toxicidad por MDMA puede también conducir al potencialmente mortal Síndrome de Serotonina, el cual causa:

  • Hipertermia (fiebre peligrosamente alta)
  • Alteración del estado mental (confusión)
  • Alteraciones en el ritmo cardíaco y presión arterial
  • Rigidez muscular
  • Muerte

El tomar agua de manera excesiva (por el calor y la sed), así como el sudor profuso debido al esfuerzo físico (bailando en clubes a menudo calientes y repletos de gente), pueden conducir a la hiponatremia (niveles bajos de sodio). La hiponatremia severa puede llevar a la inflamación del cerebro, convulsiones y la muerte

La mayoría de las muertes relacionadas con la MDMA se atribuyen a los síntomas del aumento de temperatura corporal. Otras causas incluyen: deshidratación, rabdomiolisis (destrucción muscular excesiva), fallo renal, desequilibrio electrolítico, arritmias cardíacas, y derrame cerebral.

Es importante conocer los efectos de esta droga potencialmente fatal. Como si estos efectos no fuesen lo suficientemente preocupantes, la MDMA casi siempre se utiliza en los clubes y “raves” junto con otras drogas y/o alcohol, lo que podría resultar en una combinación fatal.

Conozca también los varios nombres que se utilizan para la MDMA, como: Molly, Mandy, Éxtasis, E, XTC, X, Adán, droga del abrazo, frijoles, droga del amor, rola, entre otros.

Recuerda…

Sé Inteligente. Sé Precavido. Sé Saludable. Sé Fuerte.

¡Hasta la próxima!

Dr. Félix

The Dangers of Molly

“Molly” has been recently popularized in songs by Miley Cyrus and Kanye West. With lyrics like, “We like to party / Dancing with Molly / Doing whatever we want” [We Can’t Stop] and “Let’s take it back to the first party / When you tried your first molly / And came out of your body” [Blood on the Leaves], the use of the drug “Molly” has been praised and glamorized.

But, what is Molly?

Molly is a pure form of MDMA, or 3,4-methylenedioxy-methamphetamine by its chemical name. MDMA is one of the ingredients of another popular drug, Ecstasy (which may be mixed with caffeine, LSD, speed, ketamine, talcum powder, and aspirin). Regardless of its composition, ingestion of MDMA can be dangerous and even fatal.

MDMA was first synthesized by the German pharmaceutical company Merck in 1912. It was used in the late 1970s, without the approval of the Food and Drug Administration (FDA), as an aid in psychotherapy and marital counseling. As of 1985, the Drug Enforcement Administration (DEA) has categorized MDMA as a Schedule I controlled substance due to its high potential for abuse and no accepted medical use in treatment.

MDMA is similar to the stimulant amphetamine and the hallucinogen mescaline. Taken orally in tablet or capsule form or snorted as a powder, MDMA produces an energy rush, elevated mood or euphoria, distorted perceptions, and heightened feelings of empathy. These “desired” effects are what drive people, mainly teenagers and young adults in the club and rave scene, to try and even abuse the drug, at times not fully aware of the dangers, both short- and long-term.

The number of emergency room visits related to MDMA use has more than doubled in the last 7 years. According to the Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network report of 20111, there were an estimated 22,498 emergency room visits (compared to 10,227 in 2004). And the numbers keep rising…

MDMA causes a release of brain chemicals (neurotransmitters), including dopamine, serotonin and norepinephrine. The massive release of serotonin as well as its eventual depletion lead to the negative effects of the substance, as detailed below:

Central Nervous System Effects:

  • Altered mental status (confusion)
  • Hyperactivity, restlessness
  • Seizures
  • Anxiety
  • Paranoia
  • Depression
  • Blurred vision
  • Hallucinations
  • Intracranial hemorrhage
  • Stroke

Cardiovascular Effects:

  • Tachycardia (increased heart rate)
  • High or low blood pressure
  • Chest pain
  • Fatal arrhythmia
  • Heart failure (risk increased in individuals with pre-existing cardiac disease)

Gastrointestinal Effects:

  • Dry mouth
  • Nausea
  • Vomiting
  • Abdominal cramping
  • Loss of appetite

Respiratory Effects:

  • Breathing difficulty
  • Respiratory failure
  • Aspiration (inhaling vomit)

Other Signs and Symptoms:

  • Dehydration
  • Excessive thirst
  • Profuse sweating
  • Teeth grinding
  • Jaw clenching
  • Muscle spasm

MDMA toxicity may also lead to the potentially fatal Serotonin Syndrome, causing:

  • Hyperthermia (dangerously high fever)
  • Altered mental status (confusion)
  • Heart rate and blood pressure abnormalities
  • Muscle rigidity (tightness)
  • Death

Increased water intake (from heat and thirst) as well as the excessive sweating from physical exertion (dancing often in crowded and hot conditions) may lead to hyponatremia (low sodium levels). Severe hyponatremia may result in brain swelling, seizures, and death.

Most MDMA-related fatalities are attributed to symptoms of heat stroke and hyperthermia. Other causes include: dehydration, rhabdomyolysis (excessive muscle breakdown), acute kidney failure, electrolyte imbalance, cardiac arrhythmias, and stroke.

It is important to be aware of the effects of this potentially fatal drug. As if these effects were not of enough concern, MDMA may be used in the club/rave scene together with other drugs and/or alcohol, leading to a possibly fatal combination.

Beware of the several names used for MDMA, including: Molly, Mandy, Ecstasy, E, XTC, X, Adam, Clarity, Lover’s Speed, Roll, MD, Mad Dog, among others.

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

Teen Suicide

Suicide is one of our society’s epidemics. According to the latest data provided by the Centers for Disease Control and Prevention (CDC), suicide represented the tenth leading cause of death in the United States in 2009. If this were not alarming enough, suicide is the third leading cause of death among our teenagers.

Recognition of warning signs, early intervention, and immediately seeking help for anyone who expresses thoughts of suicide or attempts suicide are of great importance.

WHAT ARE THE MOST COMMON CAUSES OF SUICIDE AMONG TEENS?

Adolescence is an extremely stressful period in our development. The transition between childhood and adulthood is marked by enormous changes: hormonal, physical, mental, and emotional. The stress caused by these changes can have a significant impact on the teenager’s life.

Some stressors include:

  • Normal developmental changes
  • Painful events
  • Family dysfunction
  • Physical, emotional or sexual abuse
  • School problems or bullying
  • Problems with boyfriend/girlfriend
  • Sexual orientation
  • Mental illness
These stressful factors can be very overwhelming, too embarrassing, or too difficult to overcome for some teenagers. Suicide may erroneously seem like the answer to end their problems and/or internal suffering.

WHAT ARE SOME OF THE WARNING SIGNS?

Many warning signs for suicidal behavior are similar to symptoms of depression:

  • Feelings of sadness or hopelessness
  • Behavioral changes
  • Irritability
  • Anxiety
  • Trouble sleeping
  • Changes in appetite
  • Loss of interest in enjoyable activities (hanging out with friends, video games)
  • Poor hygiene
  • Feelings of guilt
  • Isolation from friends and family
  • Giving away or throwing out objects of personal value
  • Drug or alcohol abuse
  • Suddenly recovering from a period of depression (maybe after having decided to put an end to their suffering by ending their life)
  • Talk/verbal threats of suicide
Even in the presence of all these warning signs, it is extremely difficult to predict with certainty who will attempt suicide. We do know that the most important risk factor for the prediction of suicide is past suicidal behavior. In other words, a past suicide attempt is the best predictor of a future suicidal act.

WHAT CAN PARENTS DO TO PREVENT SUICIDE?

It is important to recognize the above warning signs. Early intervention is the most effective way to prevent suicide among our children.

Any statement of suicidal thoughts or suicidal behavior must be taken seriously. Anyone who expresses thoughts of suicide requires immediate medical evaluation.

Other recommendations include:

  • Maintaining an open communication with our children
  • Making our children feel comfortable to talk to us about their problems/feelings
  • Supporting our children
  • Keeping medications and firearms away from children

WHAT ARE THE EFFECTS OF SUICIDE ON THE SURVIVORS?

The effects of suicide on the family can be devastating. People who lose a loved one to suicide tend to feel guilty for the death of their family member, wonder what they could have done to prevent it, or even feel rejected by other family members or friends.

Suicide survivors may experience:

  • Sadness for their loss
  • Anger towards the deceased family member
  • Feelings of guilt
  • Depression
  • Anxiety
  • Posttraumatic stress disorder, especially when witness to the suicide or finding the family member after a completed suicide
  • Suicide attempts to reconnect with their lost loved one

As the aftermath of family suicide may have long lasting effects, it is important for survivors of suicide to seek help in dealing with their loss.

HOW TO HELP A SUICIDAL TEEN?

Anyone who expresses thoughts of suicide or attempts suicide should be evaluated immediately:

  • Call 911
  • Take the person to the nearest emergency room, or
  • Look for help from a mental health professional

Psychotherapy and counseling can help the suicidal person deal with his/her feelings or negative thoughts, identify stressors, and strengthen coping skills. Psychiatric medications may also control symptoms of depression, anxiety or any other mental health condition.

Help is also available through telephone hotlines. The National Suicide Prevention Lifeline (1-800-273-TALK or 1-800-273-8255) is an excellent source of support. It is for people in crisis, not just when thinking about suicide. The call is free and confidential and a mental health professional will be available to listen and provide information about mental health services in your community.

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

To Take, or Not To Take: That is the Question… Medications for Psychiatric Illness

My psychiatrist wants me to take this medication. What should I do?

The term psychotropic, a way to describe medications used for the treatment of mental conditions, means that the medication affects or alters the activity of the brain. While the words affect and alter tend to have a negative connotation, the changes that occur in the brain from its exposure to these medications can have beneficial and long-lasting effects on your mental condition. They are used to treat mood, anxiety, psychosis, and many other psychiatric disorders.

Being honest with your psychiatrist about your symptoms is extremely important. While your primary doctor may diagnose your high blood pressure or diabetes by checking your blood pressure or blood sugar levels, psychiatry is limited in the amount of actual tests that we can perform. Some reversible causes of depression may be detected in the blood (for example, certain vitamin deficiencies or thyroid dysfunction) but the bulk of the diagnoses made in psychiatry require a careful examination of your clinical symptoms by a trained mental health professional. Being frank and open about your symptoms will allow your psychiatrist to diagnose you with the correct mental health condition and prescribe you the right course of treatment.

All medications, regardless of the condition they are intended to treat, are foreign substances to your body. This means that side effects may occur. Prior to starting a new medication, it is important to have a discussion with your psychiatrist about the most common side effects of the proposed treatment. Some may be slightly bothersome but temporary; your body’s reaction to the new substance flowing through your system. Other adverse effects may be longer-lasting and may lead to permanent changes.

Most psychotropic medications, like those used to treat depression and anxiety, are what we call “maintenance medications.” They do not work like the Tylenol or Motrin that you reach for when you have a headache and expect to relieve your pain within an hour or two. Maintenance medications must be taken on a daily basis, preferably around the same time every day, and as prescribed by your doctor. Over the first weeks of treatment, the medication will slowly build up to a therapeutic level in your bloodstream, allowing it to reach its full potential. Your doctor may choose to “start low and go slow” with the dose, letting the medication reach that therapeutic or effective level over some time. This approach will minimize possible adverse effects and ensure you end up on the right dose. In other words, the medication may take some time to fully work but it will prevent you from taking more medication than needed in the long term.

Taking your psychotropic medication on a consistent basis will allow you to improve sooner. Taking these types of medication “only when I am down or anxious” or “as needed” may not only prolong the duration of your symptoms but may also cause you to experience side effects from the constant re-exposure to the medication. And just because you are feeling better does not mean it is time to stop the medication. I always tell my patients to treat the psychotropic medication I prescribe as they would an antibiotic. What does your primary doctor tell you?: “Finish all your antibiotics as prescribed.” Prematurely ending a course of treatment with psychotropic medications may lead to inadequate treatment response, return of your symptoms, and even withdrawal symptoms from abruptly stopping the medication.

Your psychiatrist may decide to continue your medication for depression or anxiety some months past your return to baseline. This will guarantee that the brain chemistry imbalance causing your condition is adequately managed and addressed. Your doctor may then slowly decrease the dose, monitoring you for continued stability and any possible withdrawal symptoms. Other medications, for example those used for psychosis in schizophrenia or for mood stabilization in bipolar disorder, may require long-term treatment.

And what are withdrawal symptoms? Does this mean I am addicted to the medication? Remember, psychotropic medications alter the functioning of your brain with the goal of improving whatever symptoms that are affecting you. Addiction does occur with some psychiatric medications, especially with benzos like Valium and Xanax used for the treatment of anxiety. But other medications, like antidepressants, require a dose decrease prior to discontinuation to make certain those areas of your body that were sensitized by the medication are slowly “weaned” off it.

Finally, psychotropic medications are not for everyone. Your psychiatrist may decide that a course of psychotherapy and/or counseling may be more appropriate at first. Your doctor may also prescribe medication in conjunction with psychotherapy. Whatever the decision, remember that it will be based on the information gathered along your treatment. And in the case of your relationship with your psychiatrist… Honesty IS the best policy!

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix