Tag: emotions

Sometimes it’s hard not to get jealous

Being a cancer patient definitely has it’s challenges. I think we all can agree. Feeling sick, fatigue, nausea, loss of appetite, hair loss, shortness of breath are the things that we tend to think of first as the top issues that cancer patients face. However, there is another challenge that insidiously creeps it’s way into your life: envy and resentment. It’s not good. It affects your mood and your relationships. It is just as unpredictable as the cancer itself. It can make you wallow in self pity, even when you don’t mean to. It can make you lash out at the people that care about you and are trying to help you. What am I talking about exactly? I am talking about that feeling of jealousy and resentment that creeps up on you over time that you misdirect toward anyone in the way. What do you become jealous and resentful of?: anyone that is living a full life and doing what they want when you can’t! You become like that puppy dog at the window hoping to go for a ride in the car somewhere, anywhere. The real you spends your time encouraging everyone around you to keep living and do what they love, even if you are sick. Then the other you starts muttering under your breath, crying and cursing them as they leave you. It is completely ridiculous I know and it’s unfair both to you and the people in your life. It basically boils down to emotional abuse for all of you. Nothing good can come of it. I have done it myself.

However, as I sit chastising and judging myself for doing it, I also have to realize that some of these confusing emotions have to come with the territory. It is only natural for you to feel out of control emotions in a pretty out of control situation. I mean c’mon, the cancer is already unpredictably calling most of the shots when it comes to day to day physical living. Why wouldn’t your emotions be all over the place? I think the key is not that those emotions are there, but what you do with them. You can’t erase your feelings, but you can try to control yourself so they don’t run other people over like some kind of freight train. Don’t bite the hand that feeds you. Don’t lash out at the people trying to help you. That won’t help resolve the feelings and only leaves you feeling bad about yourself. That certainly won’t help you heal any faster. Here is where therapy has come in very handy, at least for me. I highly recommend it and I think every patient facing serious illness should have it. It is a much better option to let out those feelings to a paid professional who is trained in how to help you deal with them, rather than blasting your family who is only trying to help you. It might just save your relationships.

Dr.Katz

Does my pain have street cred even if you can’t see it?

Image result for Chronic Pain

It started off innocently enough…..some serious car accidents that I was not supposed to be able to walk away from. So, right off the top, I already know I am a blessed woman. I have not forgotten that. Then, the residual injuries slowly and insidiously crept in and invaded my bones and nerves, but that was to be expected over time. It’s not the kind of thing that you consider very much at the time because you are just lucky to be alive, right? A few aches and pains are nothing compared to losing your spot on Earth. Gotta keep it in perspective.

However, fast forward 20 years and words like stenosis and spurs and compression dominate my latest MRI. Right now as we speak, I am thanking my lucky stars that I did not have any patients today because I am having the granddaddy of all fibro flares. Being able to be at home allows me to take my Motrin, stay in my pajamas, drink a ton of water, and lay back in my ice helmet all day if I need to. I don’t have to show off my unsteady gait because of the inner ear inflammation. I don’t have to struggle just to move my arms and legs while hot pokers of pain are sticking through them as I am faking a smile. I don’t have to worry that my head and neck may blow right off my shoulders at any minute. ( Ok. Just kidding on that one. I know that is not going to happen. It just feels like it is.) I don’t have to be afraid that someone will want to show me affection with a hug that I might stiffen during, afraid to offend them because their display of kindness will only translate to pain for me. I can run to the bathroom as many times as I want with the temporary IBS symptoms that I get. Please do not misunderstand. If I had patients today, I would get myself to the hospital somehow because that is the job that I love and I would just spend the day worrying about who I let down that day anyway..lol. There is no question about it. I am just saying that I can get through this flare a little faster if I am able to concentrate at home. I consider myself lucky at this point. I am not on any chronic pain meds. That is largely because I am ferociously stubborn and the fact that I realize that, with my family history, that would potentially be a move with more risk than benefit. I still go to work. I live my life as fully as I can. I struggle but am mostly successful in maintaining an empowered attitude, which I truly feel impacts the severity of my disease. But, there are some days like this one when I need to just stop a second and breathe.

The thing is, I am not different than millions of people who are suffering from those chronic, invisible diseases every day. There are so many of them: arthritis, chronic fatigue, fibromyalgia, depression and mental illness, diabetes, digestive disorders like IBS or celiac, Lyme disease, migraines, Lupus, and Sjogrens. So, what the heck do I mean by a chronic, invisible disease? An invisible disease is one that does not show obvious external signs or symptoms. They may cause symptoms like dizziness, pain, fatigue, or mental health issues. None of these are things that a person walking by would notice. If they look ok, they must be ok, right? Wrong! Occasionally, we get excited about one of these conditions if they get featured in an article about a celebrity that was affected. But, the vast majority of the time, they go unrecognized and misunderstood by both health care providers and the general public. This really adds to the mental weight of these conditions for the patient and paves the way for feelings of isolation and hopelessness. Did you know that the U.S Department of Health and Human Services estimates that by the end of 2020, 157 million people in the United States will be affected by a chronic illness? In addition to that, the United States Census Bureau estimates that 96% of these chronic illnesses are invisible. That is a huge number! Did you also know that many studies have been done as far back as the 1990s that looked at the lack of validation( belief that the patient was really suffering) as a factor in their disease. The vast majority of patients in the focus groups said that lack of validation was their most significant challenge in managing their condition. It makes sense though, doesn’t it? We all want to be believed. When someone doesn’t believe us, it actually has the power to cause it’s own kind of pain, beside the physical pain we are already experiencing.

There are so many misconceptions about invisible chronic illness. The first one we have already discussed. A person must feel ok if they look ok. We already know that is incorrect. Most patients with these conditions have spent a great deal of time developing coping mechanisms to allow them to enjoy regular daily life. I do it every day. The second one is the conception that the person just needs to rest and they will feel better. I can tell you first hand that all the sleep in the world is not going to break or cure a fibro flare. Sometimes, you can’t even sleep because the pain gets so ridiculous. A third misconception is that all people with chronic invisible illness are really drug seekers. Labelling all of those patients as drug seekers once goes back to the lack of validation of their symptoms that I mentioned earlier. The implication that they are drug seekers indicates that their symptoms cannot be real and they cannot be in any kind of true pain. Wrong again. Another misconception that I hear is that those patients that unable to work because of their pain must “have it made” because they get to stay at home all day and goof off. I actually have heard people say this with an obvious tone of jealousy because they truly think that those homebound patients have a dreamy lifestyle, doing whatever they want all day. Let me paint you a picture: You are trapped at home, in pain, unable to work and support yourself and unable to do the things that you enjoy on a regular basis. Does that actually sound dreamy to you? I think not. Last but not least, I have heard that stress reduction is all that these patients need to get better and that their pain is “all in their head” and they need to “get over it.” Stress is definitely a factor in pain severity, as is emotion. As stress invokes emotion, pain is heightened. Emotion and perception of pain signals are biologically intertwined. However, stress does not CAUSE pain. You can be just sitting somewhere, minding your own business watching butterflies and a flare can envelop you before you know it. That kind of thinking is far too simplistic to explain chronic pain. It really boils down to another type of lack of validation.

The real question to ask is how do you support these patients, not how to cure them. There are no cures as of yet for any of the diseases that I mentioned. There may be treatments, but not cures. Many of these treatments have side effects that need to be weighed against the symptoms of the disease itself. This is important to keep in mind. So, how do you support them? You support them by listening and believing them and throwing away your preconceived biases if possible. Try not to get frustrated because you can’t cure them or that there is no obvious external marker for you to pick up on and follow. Be supportive when they need it and back off when they need space. These patients are challenging to say the least. I always use a multi-disciplinary approach that addresses the physical and the mental aspects of their condition. The team approach has worked the best in my practice. These patients are going to need pain control options, whether it be massage and acupuncture, anti-inflammatorys, Lyrica or narcotics. Their pain is real. Be ready. Most of all, you need to believe them. Sometimes the very key to their path to a reasonable quality of life may just be getting someone to listen. Have a fantastic day everyone!

Dr. Katz

You can never be “too Allen.”

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With the launch of HBOmax the other day, my world was rocked to discover that Friends had jumped ship to HBO after disappearing from Netflix. Life was whole again! I, like much of America, still hold on to my love for that bunch of 20 somethings who modulated flawlessly into 30 somethings while still looking fabulous and maintaining a lifetime of friendships. I started with episode 1 and just kept going…for the 100th time. I go to the episode when Monica finally was dating a guy named Allen that the whole group liked…a little too much for Monica’s comfort. They couldn’t get enough of him and even hung out with him when Monica was not around. This should have made Monica ecstatic right? She had been saying for years( as far as we know, because this was only 3 episodes in…lol), that she really wanted to find someone that her friends liked. Instead, she broke up with him right away, devastating her friends and then went on to her next series of unhealthy, unhappy relationships. It seemed like she was so intent to take complete ownership of her relationship decision that she was willing to sacrifice potential happiness rather than give her friends credit for perhaps seeing something that she wasn’t able to.

This brings up several questions. Do we really want the approval of our friends as much as we say that we do? Does that outweigh our own need to make our own decisions? Are we always able to make healthy decisions for ourselves without input? Do we sometimes make a bad decision intentionally just to say that we did it on our own? Do our friends know us better than we know ourselves? Do our emotions rule our decisions?

Ok, that is a lot of questions. Let’s break this down. All human beings have an innate inclination toward having some kind of control over our lives. We like to be in charge of our own decisions, no matter how trivial they may seem. We say we want our friends’ input, but really our natural impulse is to ultimately make the decision of our choice, not theirs, regardless of the consequences, just to say that we did it. That’s who we are. Even the most collegial of humans have a need to have the final say in the topic of choice.

Psychologists all over the world have studied human decision making. There are multiple theories about the decision making process. One theory says that the decision making process involves 7 steps: 1) Identify the decision to be made, 2) Gather relevant information, 3) Identify the alternatives, 4) Weigh the evidence, 5) Choose among alternatives, 6) Take action, and 7) Review your decision. Other theories do not break down decisions into steps. They say that there are only two types of decisions: Habit decisions and Goal-directed decisions. Habit decisions are made on a more impulse-based process. Goal-directed decisions are made based on information and logical thinking, but research shows that you can’t give a person more than four pieces of information to evaluate without actually slowing down the decision making process or stopping it all together.

We like to think that we are logical in our decisions and that we carefully weigh the alternatives, we gather info and look at our options. However, it is just not possible that we are logical in all of our decisions. Our brain actually makes hundreds of decisions per day without any kind of logical think through. Here I go bringing up research again, but, it shows that the bulk of our decisions are actually unconscious and actually involve emotion over logic. Researchers have studied brain activity during decision making. They were actually able to determine what choice the subjects were going to make on average of 7 to 10 seconds before they even realized that they made a decision or verbalized it. Let’s take a look at the emotional component of decision-making. The somatic marker hypothesis also suggests that decision making is a process that depends on emotion. We know that the ventromedial prefrontal cortex (vmPFC) of our brain is key in processing emotional signals that are essential for guiding our decisions to our advantage. The vmPFC helps regulate fear. and stops you from continuing to be afraid in certain situations. It modulates conditioned fear and helps you let go of it and be able to make a decision. Our amygdala is also a key component in processing emotional signals but it’s role differs slightly from our prefrontal cortex. The amygdala is where conditioned fear responses are created and continued. Damage to either of these areas affects decision- making. There you go: more evidence that decision making depends on emotion. I will take this a step further and add that emotion plays a role in helping others with their decisions. For example, you can’t effectively help someone change their mind about something unless you begin to truly understand how they feel about it in the first place. Otherwise, you cannot really make any arguments of influence. It makes sense, doesn’t it?

I am glad that we have established that we are not robots and that we do not make cold, calculating emotionless decisions every day. I personally view this as a positive but I am in the minority. It is interesting to me that the concept of emotionally -influenced decision making is still vastly greeted with skepticism and negativity. This is exemplified in phrases like “clouded by emotion.” Gender discrimination in the work place abounds based in large part by the misconception that women are more inclined to utilize emotionally based decision making more often than men. Therefore, women are often looked over for high powered management positions if a male candidate is available. This has a negative connotation implying that the weighing of emotional factors implies a sense of weakness or irrationality somehow. Based upon what I’ve told you this bias does not make any sense. All humans make decisions based on emotional input, regardless of chromosomes and regardless of whether they are aware of it or not. It is a scientific fact. Does emotional have to equal irrational? Absolutely not. Emotions are just part of what makes us human. Emotions and decisions are intertwined and not likely to become untangled anytime soon and that’s what makes life interesting and unpredictable. Have a fantastic day everyone!

Dr. Katz

Perimenopause is not for pussies!

Hello all you perimenopausal power women out there! I know there are millions of you at any one time, trying to suppress labile emotions, fighting “power surges.” lamenting over vaginas of sandpaper, etc. Even though menopause is not a pathologic process per se, sometimes it sure feels like one! Fear not! You are not alone! I am right there with you!

Let’s shed a little light on the overall perimenopause and menopause process. First, let’s not get all hung up on terminology. For the sake of this blog, let’s define perimenopause as that magical period of time during which the ovary’s waning hormone levels and decreasing population of eggs to shoot out of a corpus luteal cannon cause a variety of unexpected and unpleasant symptoms. Let’s then define menopause as the point when “it’s all over.” The FSH( follicle-stimulating hormone) is consistently over 30. The last egg has left the gate. The uterus has shed its last lining, along with the last hope for babymaking. The last period is at least one year in the rear view window. Although I am going to tell you upfront that just because the last egg left the building and periods have stopped, the symptoms are not completely gone, but we will get to that later.

So, why the heck do we care about hormones anyway? What do they actually do? Do we need them? What the hell is a hormone anyway? A hormone is defined as a regulatory substance produced in an organism and transported in tissue fluids such as blood or sap to stimulate specific cells or tissues into action. It can also be defined as a synthetic substance with an effect similar to that of an animal or plant hormone. What? Heh? Let’s narrow this down and talk about the big 3: Progesterone, Estrogen, and Testosterone. These are the key hormones in our bodies, all of which are made by the ovaries. Yup, that’s right, even testosterone. It’s not just for guys anymore ladies. So now let’s talk about what each one of those hormones does. As it turns out, hormones help with over 400, that’s right 400,bodily functions. To go over all 400 would be a little bit beyond the scope of this blog, but let’s at least break some of the main ones down. I bet there are some that will surprise you.

Let’s start with estrogen. So, estrogen alone has like 400 different functions in the body. They include the following: 1) simulate the production of choline acetyltransferase( an enzyme that helps fight Alzheimers), 2) increase metabolic rate( don’t we all miss this one?), 3) improve insulin sensitivity, 4) regulate body temperature( hello hot flashes), 5) maintain muscle, 6) reduce risk of cataracts, 7) aids in formation of neurotransmitters like serotonin which decreases depression, irritability, anxiety, etc and 8) maintain bone density. Ok so you get it. There are a ton of things that estrogen plays a role in.

Now there’s progesterone. It helps with many things too, although it is not quite the rock star that estrogen is and has been vilified and then praised back and forth in many studies. Let’s talk about a few of the good things it can do. It helps balance estrogen. It helps to improve sleep. It has a natural calming effect. It helps lower high blood pressure. It increases metabolic rate. It can help the body use and eliminate fats. It is a natural diuretic. It also protects the uterine lining from excess estrogen effects. These are just some of the things that progesterone can do.

Then there is testosterone. Yes ladies. I was shocked too when I first learned that my ovaries made testosterone. Isn’t that for dudes only? Nope. We need testosterone too! Testosterone helps increase our sexual interest. It increases our sense of emotional well-being. It increases muscle mass and strength. It helps maintain memory. It helps stop skin from sagging. It elevates norepinephrine in the brain. It helps decrease excess body fat. Sounds pretty great right?

Ok, these hormones sound pretty useful don’t they? I can see why we would miss them when menopause comes and they all start circling the proverbial drain like a clump of hair in the shower. Keeping these hormones in balance is pretty key to our quality of life, if nothing else, as well as keeping some important bodily functions on track. When they get out of balance we start feeling pretty miserable. I get that some very important, although in my opinion skewed, studies have really muddied the waters as far as how to approach menopause and hormone therapy. I for one, remain a fan of hormone therapy in the right patient with the right risk profile who is also compliant.

So what happens when these hormones all start decreasing and /or getting out of balance? That’s right! The road to menopause has begun! That’s when we start getting all the traditional ones like mood swings, hot flashes, and vaginal dryness. But let’s not forget some of the lesser known symptoms like flatulence( farting too much), palpitations, hair growth on our faces, weird dreams or not sleeping at all, osteoporosis, peeing on ourselves, or forgetting what we were saying. I mean. Who doesn’t enjoy announcing your presence in a room with a not-so-silent, deadly episode of farting? Yup, we can blame menopause whenever we let one rip ladies. Enjoy!

So when can we expect this little bundle of change joy? Well, average age of onset of menopause in a non-smoking female in the United States ranges from 35 to 55. That is a huge range. Average duration of the transition of perimenopause into menopause ranges from 6 months to several years. The expectation is that once you are in menopause, you should be symptoms free right? Well, this may be true in terms of some of the symptoms like hot flashes, but I can tell ya that there are still days that I fart like a champion and can’t fall asleep despite a bottle of Benadryl. Ok. I am kidding. I do not drink a whole bottle of Benadryl, but you get the point. On the other side of the coin, I have some unfortunate patients who are still having hot flashes into their 80s and swear that they would die without their estrogen patch.

Take heart, ladies! There are options to restore your quality of life. A lot of women out there are afraid of hormone therapy, but it is a viable option. Current national recommendations say to use the lowest dose for the least amount of time, whatever the hell that means. It has always sounded a little obtuse to me. I do use hormones in my practice, after I have counselled the patient on the pros and cons, evaluated their personal risk profile and their family history, and have assured myself of their compliance. Some of my patients are on traditional/commercial hormone therapy. What I call traditional hormone therapy is the prescription hormone therapy that your insurance covers like estrace, provera, etc. Some of my patients are on bioidentical compounded hormone therapy. The differences between the two are not as extensive as one would think. I know that people like to refer to bioidentical hormone therapy as more natural, but be careful of the word natural. I think sometimes that people hide behind the word natural as if it implies some kind of increased safety. That is not necessarily the case. There are plant based products on both sides. There are possible side effects and risks on both sides. Estrogens are estrogens, whether they come from horse pee or yams. Both of them affect body receptors. Personally, I think that the one advantage bioidentical hormones have over traditional hormones is that I can individualize dosing in hundreds of different ways, as opposed to the 4 or 5 dosing regimens available with most commercial hormones.

Hormone replacement therapy really is the best option for quality of life. Having said that, some of my patients cannot take hormones because of their own personal risk profile. No biggie. We have other options. Sometimes I use herbs, vitamins and supplements. Sometimes I use serotonin uptake inhibitors like Prozac. I realize that Effexor is what is in vogue right now, but I prefer Prozac any day. It is the only one with a weight loss side effect and the weaning process is a lot less brutal when you are ready to be off of it. If I can be less emotional, less hot flashy, and lose some weight in the process? Count me in! We can protect your bones with other medicines like Alendronate or Denosumab so we have that covered as well. We will get you through somehow!

To sum up, menopause can sometimes really get you down. It’s not a disease. It’s a transition. You are still you! Those hormone imbalances can overtake you, put you on the emotional roller coaster from hell, make you sweat and win you first prize in a flatulence contest. The process is different for everyone….but we have the tools to help you get through it. Happy farting!

Dr. Katz

Crying by the dumpster outside of Olga’s

I just have to relay this story a patient told me the other day. Let me set up the scenario. So, this patient has a large family. Her children’s ages range from elementary school to college. Some of them are still at home. Some are off at college. She has always had a close relationship with her kids. You could even say that she values them even more than she values herself. She is a perimenopausal woman with let’s say more than her share of hormonal and mood lability, as all of us perimenopausal and menopausal women do. To say that she can be oversensitive at times is probably true. We all can. Let’s add to that the fact that college age kids who have moved out have a very different sense of what is appropriate and acceptable with regard to conversation and “house rules” than elementary age kids do. It’s a recipe for absolute peace and harmony right? That was rhetorical. Of course it isn’t.

Ok now that I have the stage set, let’s look at what happened. The college kids came home for the weekend, one of whom had not been home in months. The whole family goes out to dinner. My patient is super excited to see everybody and hang out. She has already had an emotional day and she can’t to hug the college kids and maybe even play with her daughter’s hair like she used to. She gets totally rebuffed. Now she is already hurt and trying to hide it while they are all sitting there eating, but the hurt is slowly welling up, threatening to take over just the same. Then the conversation starts and she hears her older children making conversation that is just plain uncomfortable for her. She is not sure if they are just trying to be sarcastic and funny or just plain hurtful. When she tries to interject, they just look at her like she is from another planet with that “What’s the problem” expression. Finally, she feels herself losing emotional control and announces that she is going to just go home rather than cause some sort of fight during what was supposed to be a nice family night out. They look at her and laugh and remind her that she doesn’t have a car because they drove. By then she is really embarrassed but can’t back out now and leaves the restaurant, only to find herself crying outside by the restaurant dumpster.

Oh the humanity. That story completely sucks right? It embarrassing. It’s humiliating. There is miscommunication everywhere. The kids probably didn’t realize that the mom was already emotional. The mom probably didn’t realize that the kids were just trying to act grown up and show off their intellectual prowess. It’s just a no win scenario. You are thinking to yourself, I would never do that. I say au contraire! I am willing to bet that there are a lot of moms out there that have been in a similar situation. C’mon you can admit it. Being a mom to college age kids or any kids that have moved out of the house is way harder than you think. Whatever scenarios you thought you had handles when they were teens living at home have paved the way for a whole new set of scenarios to slog through best you can. They have been living on their own without supervision.( Yes that’s right. I am saying that dorm resident advisors are not all they are cracked up to be.) They have been setting their own rules and curfews. They are probably having sex. They have linked up with all kinds of kids from all over the world with all kinds of opinions that you probably don’t share. On top of that, those opinions may or may not be based on any known facts, but they sound cool to spout out with their friends. You as the mom are no longer their primary influence and you are definitely not as cool as they once thought you were now that their horizons have widened. Ugh! Now add on top of that the fact that you are probably at least perimenopausal if not postmenopausal with hot flashes, labile moods and fluctuating hormones and, even on a good day, you could rocket from singing with the radio to screaming or bawling your eyes out in less than 10 seconds. These are the kinds of elements that lead up to the story from above. These are the kinds of elements that foster miscommunications and misunderstandings of epic proportions if you are not conscious of what’s at play. My poor patient and her family were set up from the start from both ends. She was all emotional and ready to bond ” with her babies.” . The kids were ready to joke and act like their interpretation of grown ups. It was set up to fail.

Raising college age kids sounds like a misnomer doesn’t it? A lot of people think that once they are 18, your job is over. Likewise, a lot of college age youth think that they are ready to be fully in charge. Well, neither perspective is really accurate. Our kids will always be our kids and we will always be their parents. We will always have some level of investment in how they end up in the world. That being said, we also have to be ready to modulate our mutual roles in a way that is acceptable to both parties if possible. Sometimes it is not possible, but we have to at least try. As much as I miss picking up my kids and tossing them into the air or playing with their hair and cuddling, I realize that they are just not as up for it as they used to be. I can try to resort to emotional blackmail, but it won’t get me anywhere. I have to realize that these things don’t mean that they don’t love me or love me any less. They are just evolving in how they chose to bond with me. I can sit there hoping that one of them is going to jump into my lap one day and want me to read them a story, but it is not likely to happen. Instead, we might have a conversation about politics(yuck) or what’s going on at school or I just listen to long, what they think is eloquent, speeches about what is important to them at the time. I am just kidding, I love hearing about what is important to them an I love to watch how their thought processes change over time and the evolution of their responses to certain situations. What I don’t love, is if those speeches turn snarky, satirical and hurtful without purpose. If they do, it is up to me to remind them that no matter what opinion they have, it is still their responsibility to voice it responsibly and remain a good human being. Sometimes, as they are espousing away, they don’t even realize that the person listening might think they are just being a jerk, rather than impressing the with their intellectual brilliance. In terms of voicing things responsibly, I also realize now that I am better off if I give people a heads up if I know I am having a perimenopausal emotion buffet day before I head off to any family outings. This system is not fool proof, but it is worth the effort, if you want to still bond with your kids as they get older. The old adage by Khalil Gibran says that ” If you love somebody, let them go for if they return, they were always yours. If they don’t, they never were. ” I think this means that we have to loosen the reigns and adapt a bit within reason as our kids get older. Then hopefully, they will come back some day, realizing just how cool we really were the whole time! Have a fantastic day everyone!

Dr. Katz