Emotional Health and Your Heart

Emotional Health

Tears may be dried up— But the heart, never.
—Marguerite de Valois

What makes a healthy heart? Certainly a healthful diet that includes Omega 3 fatty acids, regular exercise, adequate sleep, very moderate alcohol consumption, and no smoking. But did you realize that your emotional health is actually a better predictor of heart health than your other healthful habits?

Scientist William Harvey (1578-1657) noticed a connection between heart and emotional health as early as 1625. Early physician William Osler said that the typical heart disease patient is “a keen and ambitious man, the indicator of whose engine is always ‘full speed ahead’.” Of course, to any woman reading Osler’s observation, it is clear that things have changed for our gender; today, heart disease is the leading cause of death for today’s woman, who seems always on the go and buffeted by conflicting demands.

Even so, the connection between emotions and heart disease is somewhat poorly understood. Anger, depression, anxiety, loneliness, and constant stress are the feelings that researchers have identified as putting women—and men—at risk for heart disease. Researchers and cardiologists Dr. Meyer S. Friedman and Dr. Ray Rosenman are credited with coining the term “Type A Personality” in the 1950’s as basically an angry person who possesses three traits: free-floating hostility, impatience, and insecurity. “Trait anger” has also been associated with sudden cardiac death. People who score high on hostility scales more rapidly develop atherosclerosis. Perhaps most frightening of all, a Harvard study shows that 1 in 40 heart attack survivors experienced an “episode of anger” two hours before their heart attack.

For women, perhaps the most pertinent emotional experience associated with heart problems is depression, because depression is much more common for women than for men. A recent study demonstrated that patients who were depressed were three times more likely to die in the year following a heart attack. Also, women were twice as likely as men to develop depression after a heart attack.
Many people think of a depressed person as someone who is so deeply sad, hopeless, and lethargic that they are unable to function, but this is not so. There is also minor depression, in which a person has only a few symptoms, and dysthymia, a low-grade level of depression that continues for two years or longer. Depression can also occur after a major life-changing event such as a move. Finally, depression can be caused by a medical condition, such as multiple sclerosis or diabetes.

The problem with depression is that a woman who is depressed is less likely to notice her physical symptoms, or to do anything about them. It is well known that people who are depressed have trouble complying with their doctor’s orders, including taking medication. A depressed woman is less likely to exercise or eat a healthful diet. All of these factors can lead to ill health, including heart disease.

Anxiety and chronic stress can also precipitate heart disease. Anxiety may be generalized—in other words, a person may worry and feel keyed up—much of the time, no matter what is happening, or it may be specific, as in a phobia of some kind. Obsessive-compulsive disorder, as well as its associated personality disorder, is also a manifestation of anxiety. Intense anxiety can trigger cardiac arrest as the heartbeat abruptly turns fast and uncoordinated. Fortunately, anxiety is one of the easiest problems to treat, and for most people it can be managed without medication.

Chronic stress—work woes, financial problems, troubled marriage, caregiving, and even environmental stresses such as natural disasters—have also been linked with the development of heart disease. In my practice as a psychologist who teaches people ways to manage stress, I can say that the problem for most women is “must disease,” as in “I must do everything—today!—and I must do it well, and I must please everyone.” The only “must” in my mind is that women must learn to relax!

Further proof that anger, depression, anxiety, and stress lead to heart disease comes from the improvements that occur when these states are treated. The well-known Recurrent Coronary Prevention Project studied over 1,000 men and women who received routine medical care and group counseling about risk factors, or care plus group therapy to modify Type A traits. Those who attended group therapy had a whopping 44% reduction in second heart attacks. A similar longitudinal study demonstrated that not only do people who receive stress management have a significant reduction in second cardiac events, they also save an average of $1,228 in medical costs per year.

A whole-person approach to cardiac disease prevention is critical. When anyone recommends that you see a behavioral health specialist—a mental health practitioner who specializes in mind/body approaches—to help in your quest for better health and a longer life, take heed. Don’t make that well-meaning person wheedle, cajole, and beg you to do something good for yourself. Remember “must syndrome”? That seems to include putting everyone else’s needs first. Women must learn to recognize the signs that they need help managing stress or anger, or ending depression or anxiety.

Here are some concrete tips that you can implement today to help strengthen your emotional health:

  • Understand what triggers a stress response for you. Either eliminate the trigger or find new ways to cope.
  • Develop a daily relaxation practice: yoga, meditation, journal writing, biofeedback, guided imagery, walking, etc.
  • Limit exposure to negative people and events.
  • Develop an optimistic outlook. You don’t need to be a Pollyanna, but when the odds are with you, you have every right—and deserve—to feel positive.
  • Increase positive social support. Join a club, volunteer, get active in church, etc.
  • Talk to a psychotherapist if you have stress, anxiety, depression, or excessive anger that doesn’t resolve within a few weeks after your efforts to change.
Your physical health doesn’t end at the invisible line that you’ve drawn between on your neck between your body and your brain. Your physical health largely depends on your emotional well-being. If you have cardiac disease or wish to prevent it, all the fish oil and 30 minute walks you can possibly do may not be enough if you are unhappy. As a woman, you deserve a better quality of life. Change is always possible, and if you cannot do it alone, help from your physician or a health psychologist is always available.

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What is Duane Syndrome

Duane Syndrome

What is Duane Syndrome?

Duane syndrome (DS) is an eye movement disorder that is present at birth and characterized by a limited ability to move an eye inward towards the nose, outward towards the ear or in both directions. The frequency of DS in the general population of individuals with eye movement disorders is approximately 1-5%. About 40% of patients develop esotropia, a head turn toward the eye to maintain single binocular vision, or they maintain a straight head but accept esotropia, and suppression, if available.

A child with Duane Syndrome

My son was born with DS and diagnosed around 18 months of age. I had noticed a slight “lazy” eye and discussed it with our pediatrician. The recommendation was to watch it until he was a year old. As the year progressed the eye became worse and we were referred to a pediatric ophthalmologist. During the initial visit eye exercises, dilation and a vision screening were completed. The signs and symptoms the ophthalmologist discussed were: the upshoot or downshoot of the eye, a head tilt or turn and eye misalignment.

As early as three months old, my son had a head tilt that seemed flirtatious in nature and then linked to his reoccurring ear infections. As I understand the diagnosis, the head tilt is a natural solution to correct the double vision an individual sees, or to align the eyes. Photographs were the best tool in reviewing his symptoms; there were not many where he was looking straight at the camera, more common are pictures where his head is tilted to the right. The head tilt is so that he can see what is in front of him. More noticeable is his head turn where it appears he is trying to look behind him but actually looking to the right.

Developmentally he is right on target and has not appeared to be hindered in any way. My son is all boy and very adventurous. Climbing and running seems to come as natural as sitting up. He frequently trips or falls in very familiar spaces, sometimes over his own feet. My guess is that this is both developmentally normal and attributed to Duane Syndrome. There are times when he has trouble with depth perception, for example when food is located in a certain location to the right he appears not to see it, in reality he seeing double. Instinctively he eliminates the area by not acknowledging that there is food available.

He is now almost 20 months and will be having surgery to help alleviate the head tilt/turn. The surgery will take the existing muscle and split it into two muscles. This will not “cure” DS but reduce the side affects and improve alignment.

The most frustrating part of DS is trying to make sense of all the information. As a person who has never experienced DS, or double vision, it is hard to imagine what your child is experiencing. The most helpful resources have been internet groups where other families share their experiences and resources.

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Headache

Some great ideas for headaches.

Headache


Brew Up Some Rosemary - Rosemary helps keep blood vessels dilated. Use 1 teaspoon of rosemary per cup of hot water, cover, and steep for 10 minutes. Strain, and sip a cup three times a day. Or Try Ginger. Ginger inhibits a substance called thromboxane A2 that prevents the release of substances that make blood vessels dilate. In other words, it can help keep blood flowing on an even keel, which is essential in migraine prevention. Grate fresh ginger into juice, nosh on Japanese pickled ginger, use fresh or powdered ginger when you cook, or nibble on a piece or two of crystallized ginger candy daily.

Even if you've never had a migraine, you've almost certainly encountered other kinds of headache. Tension-type headaches are the most common variety. Marked by tightness in the head, neck and shoulders, they affect more than 75 percent of all headache sufferers, according to the American Council for Headache Information.

Sinus headaches are notable for pain or pressure in the cheeks, forehead or brow area and almost always accompany a sinus infection. Most people who assume they have a sinus headache, however, actually have migraines or tension-type headaches.

Cluster headaches (so named as they arrive in groups, or "clusters" with attacks lasting weeks or months, then stop and start again weeks or months later) are relatively rare, affecting only about one percent of the population. Of those, only 15 percent are women.

  1. During the past year, nearly 90 percent of men and 95 percent of women have experienced at least one headache, according to the American Council on Headache Education.
  2. Tension-type headaches are usually a steady ache rather than a one-sided throbbing. They can occur frequently or even every day.
  3. Although tension-type headaches can occur at any age, they are most prevalent between the ages of 30 and 39 and are more common in women than in men.
  4. Nearly 90 percent of people with sinus headache symptoms are likely suffering from migraines, according to the National Headache Society.
  5. The pain of a cluster headache has been described as far worse than childbirth.
Headaches, coming in clusters, or feeling like a sinus headache is nothing to let go. Pay attention to your body, pay attention to how often your headaches occur. Keep a journey or log for your doctor. There are other causes of headaches and only you can describe best what you are experiencing.

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Pulmonary, Gastrointestinal, and Musculoskeletal, Not Just Cardiac

Musculoskeletal

Anyone who experiences chest pain often feels a sense of alarm. People have been taught to see a physician for chest pain because it may be a heart attack. There is nothing wrong with such a concern. However, it does not mean that all episodes of chest pain are from coronary artery disease. There are other causes, including non-cardiac ones.

Cardiac Causes

Cardiac chest pain that isn't a heart attack can involve the outside of the heart. Normally, it sits within a fibrous sac called the pericardium. This sac can become inflamed (pericarditis) from various causes, including infection (e.g. virus, tuberculosis), autoimmune conditions (e.g. rheumatoid arthritis, systemic lupus erythematosus), uremia from kidney failure, certain medications, and radiation injury. The pain is usually in the center of the chest and is notably worsened when one takes a deep breath (pleuritic chest pain), swallows, or lies down. In contrast, this same pain can be lessened with sitting up and leaning forward.

A physician may hear a frictional rub when listening to the heart with a stethoscope. In some cases, the physician may order an echocardiogram, ultrasound of the heart, to see if there is fluid accumulation around the heart. It may be a small or large amount. In the worse case scenario, the amount of fluid is large enough to squeeze the heart and impair blood flow. This can be corrected with insertion of a needle through the chest wall and into the pericardium to drain the fluid (pericardiocentesis).

Other cardiac causes for chest pain include angina, myocardial infarction, and aortic dissection, all of which have already been discussed elsewhere.

Pulmonary Causes

Chest pain involving the lungs is uncommon, but it can happen. Occasionally, it can occur with pneumonia, constriction of lung airways (bronchospasm), or a blood clot or other material that travels through the veins and gets stuck in the lung (pulmonary embolism). Another cause is air within the lung cavity (pneumothorax). This can happen with trauma, like from a bullet or knife puncturing the lung, but it can also occur spontaneously, particularly in those with chronic obstructive pulmonary disease (COPD) whose lungs are susceptible to popping at fragile portions. Besides air, fluid can accumulate in the lung cavity (pleural effusion) from various causes. Other conditions involve the lining of the lung cavity (pleura), such as a respiratory infection with coxsackie virus B.

Gastrointestinal Causes

Gastroesophageal reflux disease (GERD) can cause chest pain, particularly one that is more dull and lasts a while. Spasm of the esophagus produces chest pain that feels similar to cardiac angina.

Interestingly, nitroglycerin relieves esophageal spasm pain very much like cardiac anginal pain, which is why esophageal spasm is known to mimic angina. Pancreatitis, cholecystitis, and peptic ulcer disease are rare causes of chest pain.

Musculoskeletal Causes

Muscle strain, rib fracture, and inflammation of the rib cartilage (costochondritis) cause pain from the chest wall itself. This type of pain is worsened with breathing, movement, or pressure over the pain site. However, if it occurs in someone prone to cardiac angina, the clinical picture can become confusing.

Final Words

The purpose of this overview is to clarify that not all chest pain is related to the heart. This does not mean that chest pain can be self-diagnosed. Given the risk taken with ignoring chest pain, it is recommended that a physician evaluate the symptom for a definitive determination.

References

  • Goroll, Allan H. "Evaluation of Chest Pain." Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 5th ed. Ed. Allan H. Goroll and Albert G. Mulley, Jr. Philadelphia: Lippincott, Williams, & Wilkins, 2006. 125-139.

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Advanced Directives

Advanced Directives

Advance directives are legal documents that allow control over decisions such as what care should be provided when capacity to make decisions is lost. There are two primary types. Firstly there is a Living Will and secondly a Durable Power of Attorney for health care. These are recognized and defined documents by statute with the aim of providing a legal tool by which people can express their wishes. However, they are not the exclusive means available to express wishes. Any authentic expression of a patient's wishes should be respected.

An advance directive cannot be completed after a patient becomes mentally incapacitated and it does not become effective until after incapacity has been determined. If an advance directive has been prepared, an authorized surrogate must be identified to make medical care decisions.

A living will expresses a patient's preferences for end-of-life medical care. State laws vary greatly regarding scope and applicability of living wills.

A living will allows people to express preferences for the amount and nature of their medical care, from no care to maximum care. Detailed treatment preferences are desirable because they provide more specific guidance to practitioners. A living will cannot compel health care practitioners to provide medical care that is medically or ethically unwarranted.

To be valid, a living will must comply with state law. The living wills should be written in a standardized way. It should be appropriately signed and witnessed. Living wills go into effect upon (1) the loss of ability to make health care decisions or (2) the existence of a medical condition specified in the directive—typically a terminal condition, permanent vegetative state, or the end-stage of a chronic condition. State law provides a process for confirming and documenting the loss of decisional capacity and the medical condition.

Durable power of attorney for health care is a document in which one person names another person to make decisions about health care and only health care.

While a living will states a person's specific preferences regarding medical treatment, a durable power of attorney for health care designates an agent to make health care decisions. People who have both a living will and a durable power of attorney for health care should stipulate which should be followed if the documents seem to conflict. Because predicting future circumstances in all of their complexity is virtually impossible and because the durable power of attorney for health care designates a decision maker who can respond to here-and-now circumstances, a durable power of attorney is far more practical and flexible than a living will. The agent is granted the power to discuss medical alternatives with the physicians and make decisions if an accident or illness incapacitates the person. In most states, a health care practitioner involved in the care of the patient cannot serve as agent for health care matters, unless the practitioner is a close relative. The durable power of attorney for health care can include a living will provision or any other specific instructions but, preferably, should do so only as guidance for the agent, rather than as a binding instruction.

The durable power of attorney for health care should name an alternate in case the first-named person is unable to proceed the role for certain reasons. Two or more people may be named to serve together or alone. The use of the durable power of attorney for health care is valuable for adults of all ages. It is especially critical for unmarried couples, same-sex partners, friends, or other individuals considered legally unrelated who wish to grant each other the legal authority to make health care decisions and to ensure rights of visitation and access to medical information.

Physicians should obtain a copy of a patient's living will and durable power of attorney for health care. The contents should be reviewed with the patient while the patient is still capable, and make it part of the medical record. A copy of the durable power of attorney for health care should also be given to the patient's appointed agent and another copy placed with important papers. The patient's attorney should hold a copy of all documents.

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Will New Proposals Pull the Plug on E-cigs?

E-cigs

It’s a typical scene in many UK bars and restaurants. While rain lashes down, smokers shiver outside under shelters or in doorways, indulging in a habit that’s illegal indoors.

Inside though, a group of people seem to be flouting the law. They are smoking what appear to be cigarettes, yet don’t have the smell of burning tobacco or ever need putting out.

They are smoking, or rather "vaping," electronic cigarettes - an innovation that’s not only regarded in some quarters as being much healthier than traditional cigarettes, but is inexpensive and legal to use indoors.

Most e-cigs consist of three parts – a battery, a chamber containing a heating element (referred to as an atomiser) and a cartridge containing a filter soaked in liquid, usually made up of nicotine extract, flavourings and propylene glycol, a chemical used in many foodstuffs. It is this that, when heated, produces the "‘smoke’" or vapour.

For smokers or anyone trying to quit, this all sounds too good to be true. And perhaps it is, due to a proposed change in the law which could soon see manufacturers of electronic cigarettes, or e-cigs as they are more commonly known, come under close scrutiny.

Proposals For Regulation Of E-cigs

This month, the Medicines and Healthcare Products Regulatory Agency (MHRA), announced proposals to regulate e-cigs, which are currently classed as an unlicensed nicotine containing product, so that they are classed as a medicine. This would mean that any manufacturer/supplier of these products would have to apply to the MHRA for a medicines marketing authorisation, something that at a reported cost of 1.4 million pounds, could prove far too costly for many companies.
As a result, many manufacturers and users of e-cigs are concerned that the pharmaceutical industries could move in and effectively monopolise the market, marketing these products in the same way as nicotine patches, gum and inhalers.

Either way, this leaves consumers in an uncertain position, especially as many have found that e-cigs helped them quit where other methods have failed.

One such person is Jackie, an e-cig user from Hull, who says: “I was a 20 a day smoker for 20 years - I'd tried various methods of quitting then heard about e-cigs and out of pure curiosity bought one. I had an open mind about it - I wasn't really expecting to quit. However, I immediately went from 20 cigarettes a day to three or four, then quit completely. That was nearly five months ago and I'm still amazed at how easy it was for me.”

She’s not alone. A quick look online at one of the many e-cig forums reveals a worldwide network of contented ex-smokers who have finally managed to quit for good. Many report that their health has improved.

But, despite their testimonials, doubts remain in the eyes of some as to the safety of e-cigs and it is this concern which lies at the heart of the MHRA's proposal. Since its development in 2004, there has been little research into the e-cig, largely due to the cost of commissioning scientific tests.

Are E-cigs Safer Than Traditional Cigarettes?

Tests that have been carried out, however, suggest that this is a much safer product than traditional cigarettes, with Dr Joel Nitzkin, chair of the Tobacco Control Task Force for the American Association of public health physicians, saying: “We have every reason to believe that the hazard posed by e-cigarettes would be much lower than one percent. So, if the nicotine in e-cigarettes is the same as in prescription nicotine replacement therapy products, we can assume that the hazard posed by e-cigarettes would be much lower than that posed by regular cigarettes."

His views are echoed by some other healthcare experts. Indeed, while the MHRA raises its concerns, one UK-based e-cig company, Intellicig, has recently seen its product made available at every pharmacy in Greece.

The MHRA report states the need for some form of regulation to ensure that e-cigs are a safe product, saying: "We know from work done by the Food and Drug Administration (FDA) in the United States that laboratory analyses of e-cigarette samples were found to contain carcinogens and toxic chemicals, against which general product safety legislation could not protect. Bringing all current unlicensed NCPs into regulation would eliminate these issues and ensure that smokers had products of the requisite quality, efficacy and safety to eliminate or reduce the harm from smoking."

Choosing The Right E-cig For You

Naturally, there is a bewildering range of e-cigs on the market, many varying wildly in quality and price, so it would seem to be logical that consumers are protected. However, some e-cig manufacturers claim that customer choice would be greatly limited if the product were only available from pharmacies and/or on prescription.

So, with a wide range of products at present to choose from, which one should someone wishing to try e-cigs go for?

For anyone who wants something that looks and feels almost exactly like a cigarette, try the EVOlution from Intellicig, a leading UK manufacturer. Alternatively, for products which take the concept of e-cigs to a more space age level, try the Jantystick (a small silver box) or eGo – a black e-cig resembling a 21st century cigar.

E-cig users are being invited to have their say on the MHRA proposals via its website.
Ultimately, whether e-cigs become an accepted NRT product or not remains to be seen, but many ex-smokers would strongly argue that e-cigs have helped them quit for good where other methods have seen their attempts to kick the habit go up in smoke.

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