Reflections From A Chair

My first internship was very interesting. I was with a mobile crisis team for Gouverneur Hospital in New York City’s Lower East Side. Basically, relatives, friends or even strangers would call us if they noticed that someone was acting bizarrely. And in New York, it took a lot to fall into that category.

Our job was to assess the person. If they were a danger to themselves or others, we arranged for hospitalization at Bellevue. If they weren’t dangerous but needed treatment, we would set up an appointment for follow-up care. And sometimes the person obviously would benefit from therapy or medicines but wasn’t dangerous and declined our offer. In those cases, we would thank them for their time and leave.

The psychiatrist on the team at the time was Dr. Mirjana Blokar. She was a great teacher. Dr. Blokar was a beautiful, elegant woman. She was always dressed and coifed immaculately and in the latest fashion. She had a trace of a Middle-European accent and was charming. (If you’re thinking that I had an unrequited crush, you might be right.)

Anyway, one day we get a call about a woman who would go out on to the streets at night and seem to bring odd things home. The caller noted that there was a terrible smell coming from this person’s apartment.

So, Dr. Blokar, the driver (forgive me for not recalling his name but he was excellent, too) and I went off to visit this woman.

We got to the apartment and immediately noticed the smell. Dr. Blokar knocked on the door and the woman appeared. [Almost all the time, the person did not know that we were coming because we made our trips based on tips from callers.] Dr. Blokar introduced us and asked if we could come in. The surprised woman led us to her living room.

I have never before or since seen anything like that apartment. The woman told us that she had a habit of making nightly trips to the garbage cans on the street corners. She would bring home virtually everything that was in the trash.

The apartment was filled with this stuff. Imagine, briefly if you will, what might be in a New York City garbage can. And she literally had every type of garbage from floor to ceiling. There were narrow paths from one room to the other. I saw what must have been world record size cockroaches at eye level in the mounds boldly looking about for their next meal.

The stench inside the apartment was overwhelming.

The woman asked if we would like to sit on the couch as we chatted. Dr. Blokar gently declined the offer and we remained standing.

As Dr. Blokar conducted the interview, I was sure that this was going to end up in an involuntary hospitalization at Bellevue.

However, as the evaluation progressed, it became clear that this woman did not have a thought disorder, was not psychotic and had no intention of harming herself or anyone else. She simply had a compulsion to hoard things she found on the city streets and in the trash.

To our surprise, her son emerged from a bedroom mid-way through. He also was competent and posed no danger to anyone. He intensely disliked his mother’s hoarding but found that he could not stop her. He did the best he could to look after her and be helpful.

After a while, Dr. Blokar offered the woman an appointment for outpatient medication evaluation and therapy. She politely said no thank you. Soon after that, the meeting ended and we left.

I was confused. Why had we not involuntarily hospitalized her? At the time, I thought that there must be some grounds for that given her irrational habit of collecting garbage and the condition of the apartment. I speculated that since the contrast between Dr. Blokar’s personal habits and this woman’s could not have been more stark, the doctor would be especially prone to take action.

However, Dr. Blokar started explaining the condition of hoarding and its relationship to obsessive compulsive disorder. That day, I learned valuable lessons about psychiatry, the law, civil rights and tolerance for other people’s idiosyncrasies. While this might be a matter for the landlord or the Department of Health to take up with her, it did not constitute a case of psychiatric emergency qualifying for involuntary hospitalization.

I relate this memory here because the Anxiety Disorders Association of America has posted an instructive podcast and detailed informational material on hoarding.

I think you will find it interesting.

The Medical News recently posted and article entitled: Research suggests potential new treatment for anxiety disorders and depression.

The article reviews the study A New Role for FGF2 as an Endogenous Inhibitor of Anxiety, which was published by The Journal of Neuroscience on May 13, 2009.

The article reminds us that “(p)revious human studies…showed that people with severe depression had low levels of FGF2 and other related chemicals. However, it was unclear whether reductions in FGF2 were the cause or effect of the disease.”

FGF2 wears several hats in the human body. According to Wikipedia, FGF2 plays a role in “excessive anxiety…wound healing…tumor development.” Further, FGF2 is “a critical component of human embryonic stem cell culture…”

The researchers studied rats that were genetically bred for high anxiety and low anxiety. They “found lower FGF2 levels in rats bred for high anxiety compared to those bred for low anxiety.”

The study’s lead researcher, Javier Perez, PhD, at the University of Michigan, states that “We have discovered that FGF2 has two important new roles: it’s a genetic vulnerability factor for anxiety and a mediator for how the environment affects different individuals. This is surprising, as FGF2 and related molecules are known primarily for organizing the brain during development and repairing it after injury.”

In other words, persons with genetically low levels of FGF2 are at higher risk for anxiety.

The researchers also looked at the complex interplay between the environment and FGF2 levels.

Very interestingly, “Perez and colleagues found that giving the high-anxiety rats a series of new toys reduced anxiety behaviors and increased their levels of FGF2.” So, changing and enriching the environment has an effect of anxiety reduction and increasing FGF2 levels.

Perhaps, then, genetically low levels of FGF2 might be compensated for in part if the environment is made interesting, fun, and relatively low stress.

On the other hand, according to The Medical News, the researchers “found that FGF2 treatment alone reduced anxiety behaviors in the high-anxiety rats.”

How does FGF2 specifically impact anxiety? The Medical News summarizes the studies findings:

“Finally, the findings suggest that part of FGF2′s role in reducing anxiety may be due to its ability to increase the survival of new cells in a brain region called the hippocampus….Although the researchers found that high-anxiety rats produced the same number of new brain cells as low-anxiety rats, they found decreased survival of new brain cells in high-anxiety rats compared to low-anxiety rats. However, FGF2 treatment and environmental enrichment each restored brain cell survival.”

Thus, in one of life’s many cruel twists of fate, people who are vulnerable to anxiety because of low levels of FGF2, also suffer from increased levels of cell death at times of stress. The cell death makes them less able to cope with the environmental and other precipitants to their anxiety. Those who would benefit the most from increased brain cell growth and survival are deprived of it due to genetically low levels of FGF2.

This study also sheds a very engaging light onto the age old question of nature versus nurture. It would seem, from this study, that neither nature nor nurture by themselves can adequately explain why some people are more anxious than others. Rather, it is a complex interaction of both genetic and environmental factors.

Future studies might be able to identify new medications to bolster levels of FGF2 as well as to identify changes in a person’s lifestyle and environment that support FGF2 levels and the consequent improvements in cell growth and anxiety reduction.

The Atlantic this week has an article entitled Surviving Uncertainty: A Few Tips by Lane Wallace.

As part of her credentials on this matter, she notes that:

“I’ve flown small aircraft on five continents. I’ve been stranded alone on a glacier in shorts and tennis shoes. I’ve found myself in the middle of rapidly destabilizing situations in African countries.”

She finds it helpful to

• Focus on the present.
• Keep perspective. Ask yourself, “what’s the worst thing that happens here?”
• Separate what you can’t control from what you can, and then focus on taking action on those items you can control.
• Learn to prioritize what’s essential, and loadshed everything else.

Take a few minutes to read her informative article by clicking here.

The Globe and Mail reviewed “The Spirit Level: Why More Equal Societies Almost Always Do Better,” by Richard Wilkinson and Kate Pickett, Allen Lane.

The reviewers write that:
“This is the authors’ “big idea”: People’s health depends on the quality of their social relationships, and the most important determinant of the quality of social relationships is the level of inequality.”

The book argues that as inequality increases so, too, does infant mortality, illiteracy, obesity, mental illness, incarceration, homicide, drug use and teenage pregnancy. Life expectancy decreases where inequality rises.

It’s well worth the time to read the article.

Yesterday, May 11, The University of Queensland in Australia, announced results of research into the safety and effectiveness of kava for treating anxiety.

Wikipedia tells us that:

1. Kava (Piper methysticum) (Piper Latin for “pepper”, methysticum Greek for “intoxicating”) is an ancient crop of the western Pacific. Other names for kava include ?awa (Hawaii), ‘ava (Samoa), yaqona (Fiji), and sakau (Pohnpei). The word kava is used to refer both to the plant and the beverage produced from its roots. Kava is a tranquilizer primarily consumed to relax without disrupting mental clarity. Its active ingredients are called kavalactones. In some parts of the Western World, kava extract is marketed as herbal medicine against stress, insomnia, and anxiety.

There have been some concerns about the safety of kava and some countries have banned it’s use or sale. Makaira’s Kava Kava Blog gives details about the legal status of kava in various countries.

Back to the recent research, the researchers in Australia found that

• The aqueous Kava preparation produced significant anxiolytic and antidepressant activity and raised no safety concerns at the dose and duration studied. Kava appears equally effective in cases where anxiety is accompanied by depression. This should encourage further study and consideration of globally reintroducing aqueous rootstock extracts of Kava for the management of anxiety.

The emphasis on “aqueous preparation” is due to concerns that other means of making the substance, chiefly ethanol and acetone extracts, may lead to liver damage.

I have no previous direct or indirect knowledge about kava and so this information is posted chiefly as a topic to be watched for further developments and research.

You can read the article from the University of Queensland here. And the article published in Psychopharmacology can be found here.

In a thought provoking article, Sleep study at Pitt is a researcher’s dream job, in the Pittsburgh Post-Gazette, the role of sleep in mental health is explored.

Some of the many interesting points from the interview of Dr. Anne Germain are:

• “…there is growing evidence that sleep problems are actually the cause of many psychological and physical illnesses, rather than a side effect of them.”
• “‘Whether we’re dealing with depression, anxiety or post-traumatic stress disorder, when we target sleep problems, we can have a significant improvement in people’s daytime functioning,’ she said.”
• There are ” two effective therapies available to reduce or eliminate nightmares….
  One is an older high blood pressure medication called prazosin.
  [The other is] imagery rehearsal therapy, it provides ways for people to rewrite their nightmares into less threatening dreams, and it is effective in more than 90 percent of people who have tried it…”
• And, of course, “the vast majority of people need between 6 1/2 and 8 hours of sleep a night to function well.”