PTSD AND PMS...IS THERE A CONNECTION?

A woman who comes to me mentioned that every month she has intense emotions and irritability during the 5-7 days before the onset of her period representing symptoms of a premenstrual sydrome [PMS].  This person also has post traumatic stress disorder [PTSD] and I wondered if there is a connection between her PMS symptoms and PTSD. I was aware that stress and anxiety can influence hormones. I started to research the possible influence of estrogen and progesterone on PTSD symptoms. There have been a number of studies that have suggested that PTSD symptoms intensify when estrogen and possibly progesterone levels are lower and conversely PTSD symptoms are lower when these levels are higher. During the prementrual period estrogen levels rapidly decrease and it is possible that this triggers an increase in PTSD symptoms. The monthly cycle for women starts with menses when estrogen and progesterone are lowest followed by the follicular phase with an increase in estradiol that triggers the release of follical stimulating horomone [FSH] that stimulates follicle [egg] development. Then leutinizing hormone [LH] increases triggering the release of the egg [ovulation] with a rapid drop in estradiol. This is. followed by the luteal phase when estradiol increases again in preparation for fertilization of the egg. Without fertilization, estradiol and progesterone levels drop late in the luteal phase triggering prementrual symptoms followed by the onset of menses. Estrogen levels increase in the later follicular phase and then drop around ovulation with leutinizing hormone peaking and then increases again halfway through the luteal phase before dropping rapidly leading to onset of menses. The progesterone increases in the late follicular phase and then peaks and levels off during the middle of the luteal phase with rapid drop off just before menses. Leutinizing hormone and follicular stimulating hormone both peak in late follicular phase and then rapidly drop off after ovulation. 

What is the point of elaborating on the fluctuations of hormones during the mentrual cycle? Well, PTSD symptoms are reported to increase with decreasing estrogen and progesterone levels and this is correlated with later luteal phase of the cycle including the several days leading up to menses. So if PMS is accentuated by PTSD symptoms then these PMS symptoms will be increased especially during the luteal phase until just before menses. This is when my patients experience their PMS symptoms. 

So, if the PTSD symptoms increase as they are triggered by the hormone level changes and if these symptoms are lower with increased estrogen levels then they should be lower during pregnancy and other times when estrogen levels are high. Focusing on the hormone levels  would support the liklihood of PMS occuring during a signficant part of the luteal phase up until near the onset of menses. This seems to be true for the woman who came to me for treatment. 

I wonder if it is possible to reduce PMS by lowering PTSD symptoms. This would make sense if for some women PMS represents a coping mechanism dealing with traumatic memories. 

What do you think?

WHAT IS SO IMPORTANT ABOUT LETTING GO?

Recently I heard a poem entitled "let go." This poem by an unknown author repeatedly talks about why it is important to let go. What is it that we are supposed to be letting go? The poem states that it is not about stopping caring but the recognition that we can't do it for others. Also an awareness that we can't control others. Letting go is also not about caring for, but it is caring about. It is not about enabling others to not take responsibility for themselves, but it is about encouraging and supporting others to be responsible for themselves. Finally, letting go is not to judge or criticize others but for us to choose to start becoming who we were meant to be. Criticizing and judging others focuses us away from learning who we are meant to be. Freed from the burdon of critically focusing on others we have an opportunity to see ourselves and others more clearly. 

So, why is letting go so important? I believe it is because we are letting go of a need to control other people or have other people respond to us in a certain way. It is realizing that what we worry about is actually not important and it is much better to just see what happens in our lives, including being open to the possibility that when we encourage and support others, instead of judging them, we might even see them as human, just like we are.

What do you think?

HOW DO AMPHETAMINES HELP PEOPLE WHO HAVE ADHD?

I have prescribed amphetamines [Adderall, Vyvanse, Dexedrine, Ritalin, Concerta, Focalin, Evekeo and others] for thousands of people of all ages that I have diagnosed with ADHD. To diagnose ADHD I require that current symptoms meet the current DSM criteria for ADHD as they are self-reported using a scale that has been shown to be reliable and valid, comparing results to clinician determined results as part of a blinded research study. I also require that symptoms be present before 6 years of age and also have corroboration of symptoms by a spouse, parent or at times an employer. Finally, I do not prescribe these medications to people with addictions unless they have been free of addictive behaviors for more than a year. I also look for other problems separate from ADHD symptoms and will frequently treat those problems before the ADHD as people often believe that Rx for ADHD will reduce distractibility no matter what is causing it. This is not the case as other causes of distractibility that are not directly connected to poor focusing and concentrating will not be helped by medication prescribed for ADHD. An example would be that depression is often distracting and Rx for ADHD will not reduce this and will not improve mood. However, stress associated with poor focusing and concentrating can lead to brief episodes of depressed feelings that can be overwhelming and treating the ADHD can eliminate these depressed feelings and yet this is not the same as significantly reducing depressive symptoms. I believe that one reason that antidepressants have been shown to improve ADHD symptoms is that the distractibility due to the depression is reduced or eliminated and this is considered an improvement in ADHD when it is actually an improvement in mood. 

I have very frequently found that people who have their focus and concentration helped by amphetamine based medications experience very significant changes in their lives as they are able to concentrate and focus and therefore have more access to their brains, they feel more motivated as they can finish tasks now and they experience a sense of accomplishment that leads to improved self worth. Another important benefit of medication enhancing concentration and focus is that now it is possible to reflect on what they are doing and this reflection can lead to improved self esteem as they are able to recognize what they are accomplishing. 

There are still misunderstandings of the way that amphetamine based medications help concentration and focusing. People frequently assume that people with ADHD respond to the medications like other people who do not have ADHD respond to amphetamines with increased energy, very poor appetite, reduced sleep and irritability. This would make concentrating and focusing much worse even though one might feel a lot of energy and think that they are focused when they are not. This latter might be why people without ADHD abuse amphetamines to get the increased energy and the illusion of increased focusing. If people with ADHD has this reaction to the amphetamine medications their concentration and focusing would be much worse. Instead, people with ADHD respond to amphetamine medications by being more focused, having more sustained concentration, being less anxious, are more able to finish tasks and able to reflect on what they are accomplishing. 

Occasionally, one of my patients will respond to one type of the amphetamine based medications with continuing poor appetite, poor sleep, irritability and no improvement in focusing or concentration. I will then switch them to another kind of amphetamine based medication such as changing from methylphenidate [Ritalin] medication to dextroamphetamine mixed salts [Adderall type]. They will then respond to the new medication with improved concentration and attention span. For each person that I diagnose with ADHD and prescribe amphetamine type medications the dose has to be optimized. Part of this optimization process is to be sure that the concentration support does not wear off or be diminished before the next dose as many people with ADHD will require three doses a day of the immediate release form of these medications and often two doses a day with the long acting form of these medications.  It is also important to carefully titrate the optimum dose of these medications because a dose that is to high dose can lead to them becoming stuck on one focus and having significant difficulty switching focus.

Because people with ADHD [or ADD] respond to amphetamines with improved concentration, focusing,alertness and feeling calm which is so different from how people without ADHD respond to these medications, this is likely why none of my thousands of patients who have ADHD became addicted to the amphetamines that I had prescribed for them. This is important as there is still concern by many people [including some physicians and pharmacists] that prescribing amphetamines to people with ADHD puts them at risk of becoming addicted. While there seems to be virtually no risk of addiction if amphetamines are prescribed for people with ADHD, there is a risk associated with others using amphetamines who do not have ADHD and this risk is a health concern in the United States. 

TMI AND TMW [TOO MUCH INFORMATION AND TOO MANY WORDS]

It took me awhile to learn what TMI meant even though I work with a lot of people who seem to be burdened by knowing too much about others. I have come to see that their feeling burdened is related to their feeling and acting responsible for others. This "responsibility" is a burden because even though people seem to like others to take responsibilty for them it is actually not possible to do this. If you take responsibility for others you are then at the mercy of what they do and how they act toward you. Those people depend on you being in charge of them but they are also ambivalent about this as  we all know at some level that we must be responsible for our selves. We then resent anyone who takes responsibility for us. Then when you try to stop being responsible for others, they will frequently get very upset as they are not used to being responsible for themselves.

So what about TMW [something that I made up]. This represents my awareness that people who know too much about others are also prone to talking too much about the people they feel responsible for. It is a way of dealing with feeling responsible as the more words spoken the more indirect the communication is and it allows people to continue to not take responsibility for themselves. It is like giving them an out so they can keep blaming others for things that they are responsible for. I have encouraged people who come to me to speak to others directly and calmly and with few words. Even saying "yes" or "no." I also strongly encourage people to listen to others without their personal reactions as this reduces the liklihood that you will know too much [TMI] and use too many words [TMW]. 

Well, what is the big deal about TMI and TMW? Well, we need each other and it is hard to have an actual relationship with someone if they are not being responsible for themselves and knowing too much [TMI] and using a lot of words [TMW] are indications that this is going on.

The universe needs all of us to actually listen to each other and recognize our shared humanity.

COMBATING LONELINESS

I listened to a Podcast from "OnBeing" guided by Krista Tippet as she interviewed Vivek Murthy who is the Surgeon General of the United States. The focus of the podcast was on how to "Be A Healer." It was very moving as Dr. Murthy's compassion and love for others came through as he discussed healing others which involves supporting them to become "whole." To be healers, we first need to observe and experience life and receive the joy that is all around us. This also requires that we not allow ourselves to be distracted by all the messages that promote money, winning, taking sides and the "us against them" mentality, as a way of defining who we are. Dr. Murthy says that being whole is not connected with being wealthy. He also states that to heal ourselves and our relationship to others we must listen, learn and love.

I have repeatedly seen that listening to others is critical to having healthy relationships. This also includes listening to ourselves. We can't listen to others or ourselves if we are caught up in the divisiveness and blaming others. This stress will keep us from being confident and being connected to others and from being happy. So, we must choose to let go of stress and blaming others and then choose to listen to others and actually be with others and not feel lonely.