The Overdiagnosis of "Post Concussion Syndrome"

These days, many health providers are quick to diagnose patients with “post concussion syndrome” if persistent symptoms are reported after a known or suspected mild traumatic injury (also known as concussion). Interestingly, I have seen this diagnosis given to patients who do not meet any operational definition of concussion and/or who are less than three months post-injury. 

While diagnosing “post concussion syndrome” in patients who were never concussed or who are not yet in the persistent symptom phase is problematic, another problem is that many providers fail to realize is that there are no current consensus-based diagnostic guidelines for a condition with that exact name.
To be precise, the correct diagnostic terms are post-concussional syndrome (PCS) per the International Classification of Diseases-10th edition (ICD-10, 1992) and post-concussional disorder (PCD) per the Diagnostic and Statistical Manual of Mental Disorders-IV (APA, 1994). These criteria are listed at the end of this blog entry in Appendix A. 

While this may seem like a purely semantic argument at first, it is actually a distinction with a significant difference. To begin with, whenever a medical or psychological condition is diagnosed, one needs to know the specific criteria required to make the diagnosis. Without such criteria, diagnostic errors rise and confusion results when attempts are made to communicate about a particular condition. This is why, for example, there are clear and specific criteria for diagnosing multiple sclerosis (Polman et al., 2005). 

 Since there are many conditions that can initially present like multiple sclerosis, the use of formal diagnostic criteria helps improve diagnostic accuracy. The same holds true for all other medical and psychological conditions. That is, criteria should to be used to establish a diagnosis and the criteria should help distinguish the condition of interest from similar conditions. 

With this in mind, how can a diagnosis of “post concussion syndrome” have any real meaning if there are no current formal diagnostic criteria that anyone to refer to? The answer is that it can’t. So we then must turn to the diagnostic criteria for PCS and PCD and examine their utility. 

Serious problems with the definitions

The first question one may naturally ask is since there are two different criteria sets, how well do they agree when applied to actual patients? This question was specifically evaluated by Boake et al. (2004, 2005) who only found “limited agreement” to put it nicely. The reason for the limited agreement mainly centers around very different diagnostic thresholds. That is, after a concussion has been established, a PCS diagnosis only requires a patient to report a few symptoms to meet the diagnostic threshold. This is a very liberal diagnostic threshold since all of the symptoms are non-specific to brain injury. That is, the symptoms listed in the criteria set are often endorsed by normal controls without brain injury (e.g., college students), patients with major depressive disorder, patients with chronic pain, and personal injury claimants with no history of brain injury.
In fact, as McCrea (2008) summarized in his text, many of these groups report such symptoms at higher frequencies than patients with a history of mild traumatic brain injury (MTBI). In a fascinating study by Iverson (2006), he showed that about 90% of patients with a depressive disorder (with no recent history of brain injury) met liberal self-report criteria for postconcussional syndrome. 

Although patients may state that their symptoms began after the concussion, this is not always accurate since patients may exaggerate symptoms (particularly in compensation based claims), may unintentionally misattribute symptoms from another condition (e.g., whiplash, psychological conditions) to brain injury, or may underestimate the degree to which symptoms were present before the injury and overestimate the degree to which they were present afterwards due to expectations that people have about symptoms one should experience after a concussion (Mittenberg et al., 1992). 

Turning to DSM-IV criteria, a diagnosis of PCD requires the presence of cognitive difficulty on objective tests. Objective cognitive testing is often not feasible or practical for physicians, nurse practitioners, or other health care providers who do not have training in objective cognitive assessment. The other problem is that numerous prospective research studies consistently show that patients with a single mild TBI (and in some studies, multiple MTBIs) do not show evidence of cognitive impairment more than three months post injury (Belanger et al. 2005a, 2005b; Binder et al, 1997a, 1997b; Bleiberg et al., 2004; Dikmen et al., 1995; Frenchman et. al, 2005; Iverson, 2005; Larrabee, 1997; Pellman et al., 2004; Schretlen et al., 2003). 

Therefore, it is not all that likely that objective testing will reveal evidence of cognitive impairment more than three months post-injury, particularly when factors such as effort and motivation during testing are accounted for and when other possible etiologies are considered such as psychiatric disorders. This is important because DSM-IV requires that a diagnosis of PCD is not given if the presentation can be explained by another mental disorder.  

Since one criteria set is overly liberal (ICD-10) and another is overly conservative (DSM-IV), it should not be surprising that Boake at al. (2005) found that only 11% of TBI patients (90% mild, 10% moderate) met PCD criteria whereas 64% of patients met PCS criteria. It should be noted that the researchers used a liberal threshold to define a cognitive difficulty (one standard deviation below the mean) since the DSM-IV criteria provide no guidance in this area. This liberal threshold results in a higher degree of false positive classifications since many normal controls obtain scores one standard deviation below the mean.

Another problem is that the definitions of concussion put forth by ICD-10 and DSM-IV are inadequate. Specifically, ICD-10 requires a loss of consciousness (LOC), yet national and international definitions (including one later adapted by the World Health Organization, which is responsible for ICD-10) clearly states that LOC is not required for a concussion diagnosis. Strict adherence to the ICD-10 criteria would result in removing vast numbers of patients who were concussed (but who did not lose consciousness) from being eligible for the diagnosis. 

Although DSM-IV does not restrict concussions to those who experienced LOC, the criteria only lists a few manifestations of concussion and does not provide a precise definition. Regardless, both criteria sets make it clear that it needs to be established that a patient suffered a concussion before a diagnosis of PCS or PCD can be made. In clinical practice, however, I have seen many cases where patients who suffered head injuries (yet do not meet operational definition for MTBI) are diagnosed with “post concussion syndrome.” This would be akin to saying that you are having a post-game show without having a game first. It does not make sense.

What to do from here?

Boake et al. (2005) noted that “…further refinement of the DSM-IV and ICD-10 criteria for PCS is needed before these criteria are routinely employed.” My opinion is to avoid use of these terms entirely because the criteria by which they are based upon are too flawed and were only designed for research purposes. Using a term that has no criteria associated with it such as “post concussion syndrome” does not solve the problem either. What most people mean when they use this term is that the patient had a history of a concussion followed by numerous symptoms. However, as was noted earlier by the Iverson (2006) study and in the review by McCrea (2008) such a standard is too non-specific to brain injury and overly-inclusive. This is a significant problem because patients will interpret the term as meaning that all of their symptoms are caused by brain injury when this is likely not the case. 

While the patient may feel better initially when receiving a diagnosis of PCS because it provides medical validation he/she has been seeking, it can also make the situation far worse in the long run because other potentially treatable conditions such as posttraumatic stress disorder, major depressive disorder, personality disorders, as well as psychosocial factors may not be recognized as contributory, causing the patient to continue to suffer with symptoms far longer than is needed. 

My advice to physicians, nurse practitioners, non-neuropsychologists, and other front-line health care providers dealing with patients more than three months post-injury is to document the medical history in the note, state whether there appears to be a history of head injury or MTBI (if appropriately trained to assess this) and to then state that the patient is experiencing persistent symptoms but that the cause is unclear and needs to be further evaluated through a neuropsychological evaluation. A rule out diagnosis of cognitive disorder NOS can be listed for billing purposes. It should be explained to the patient that the cause of the symptoms are unclear and that further evaluation is needed to determine this. 

Disclaimer: The author of this entry is a board certified clinical neuropsychologist..  

REFERENCES
 

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association. 

Belanger et al. (2005a). The neuropsychological impact of sports-related concussion: A meta-analysis. Journal of the International Neuropsychological Society, 11, 345–357. 

Belanger et al. (2005b). Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis. Journal of the International Neuropsychological Society, 11, 215-27. 

Binder, L.M. et al. (1997a). A review of mild head trauma. Part I: meta-analytic review of neuropsychological studies. Journal of Clinical and Experimental Neuropsychology, 19, 421–431.

Binder, L.M. et al. (1997b). A review of mild head trauma. Part II: clinical implications. Journal of Clinical and Experimental Neuropsychology, 19, 432–457.

Bleiberg, J. Duration of cognitive impairment after sports concussion. Neurosurgery, 54, 1073-80.

Boake et al. (2004). Limited Agreement Between Criteria-Based Diagnoses of Postconcussional Syndrome. The Journal ofNeur opsychiatry and Clinical Neurosciences, 16, 493–499.

Boake et al. (2005). Diagnostic Criteria for Postconcussional Syndrome After Mild to Moderate Traumatic Brain Injury. The Journal of Neuropsychiatry and Clinical Neurosciences 2005; 17:350–356.

Dikmen, S.S. (1995). Neuropsychological outcome at one-year post head injury. Neuropsychology, 9, 80–90.

Frenchman, K.A. et al. (2005). Neuropsychological studies of mild traumatic brain injury : a meta-analytic review of research since 1995. Journal of Clinical and Experimental Neuropsychology, 27, 334-51.

Iverson, G. (2006). Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Archives of Clinical Neuropsychology 21, 303–310

Iverson, G. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301–317.

Larrabee, G. (1997). Neuropsychological outcome, post concussion symptoms, and forensic considerations in mild closed head trauma. Seminars in Clinical Neuropsychiatry, 2, 196-206.

McCrea, M. (2008). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.

Mittenberg et al. (1992). Symptoms following mild head injury: Expectation as aetiology. Journal of Neurology, Neurosurgery, and Psychiatry, 55, 200-4.

Pellman et al. (2004). Concussion in Professional Football: Neuropsychological Testing - part 6. Neurosurgery, 55, 1290-1305.

Polam et al. (2005). Diagnostic criteria for multiple sclerosis: 2005 revisions to the McDonald criteria. Ann Neurol. 58; 840-846.

Schretlen et al. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International Review of Psychiatry, 15, 341–349.

World Health Organization (1992). International statistical classification of diseases and related health problems - 10th edition. Geneva, Switzerland: World Health Organization.

Appendix A

ICD-10 Definition: Post-concussional syndrome

Listed below are the diagnostic criteria for PCS from ICD-10.

“Note: The nosological status of this syndrome is uncertain, and criterion A of the introduction to this rubric is not always ascertainable. However, for those undertaking research into this condition, the following criteria are recommended: 

A. The general criteria of F07 must be met. The general criteria for F07, Personality and Behavioral Disorders Due to Brain Disease, Damage and Dysfunction, are as follows:

G1. Objective evidence (from physical and neurological examination and laboratory tests) and/or history, of cerebral disease, damage, or dysfunction.

G2. Absence of clouding of consciousness and of significant memory deficit.

G3. Absence of sufficient or suggestive evidence for an alternative causation of the personality or behavior disorder that would justify its placement in section F6 (Other Mental Disorders Due to Brain Damage and Dysfunction and to Physical Disease).

B. History of head trauma with loss of consciousness, preceding the onset of symptoms by a period of up to four weeks (objective EEG, brain imaging, or oculonystagmographic evidence for brain damage may be lacking).

C. At least three of the following:

(1) Complaints of unpleasant sensations and pains, such as headache, dizziness (usually lacking the features of true vertigo), general malaise and excessive fatigue, or noise intolerance.
(2) Emotional changes, such as irritability, emotional lability, both easily provoked or exacerbated by emotional excitement or stress, or some degree of depression and/or anxiety.
(3) Subjective complaints of difficulty in concentration and in performing mental tasks, and of memory complaints, without clear objective evidence (e.g. psychological tests) of marked impairment.
(4) Insomnia.
(5) Reduced tolerance to alcohol.
(6) Preoccupation with the above symptoms and fear of permanent brain damage, to the extent of hypochondriacal over-valued ideas and adoption of a sick role. 

DSM-IV Definition: Post-concussional disorder

 

 A. A history of head trauma that has caused a significant cerebral concussion.

Note. The manifestations of concussion include loss of consciousness, post-traumatic amnesia, and less commonly, post-traumatic onset of seizures. Specific approaches for defining this criterion need to be refined by further research.

B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory.

C. Three (or more) of the following occur shortly after the trauma and last at least 3 months.

1. becoming fatigued easily (2) disordered sleep (3) headache (4) vertigo or dizziness, (5) irritability or aggression on little or no provocation, (6) anxiety, depression, or affective liability (7) changes in personality (e.g., social or sexual inappropriateness) (8) apathy or lack of spontaneity.

D. The symptoms in criteria B or C have their onset following head trauma or else represent a substantial worsening of preexisting symptoms.

E. The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. In school age children, the impairment may be manifested by a significant worsening in school or academic performance dating from the trauma.

F. The symptoms do not meet criteria for Dementia due to Head Trauma and are not better accounted for by another mental disorder (e.g., Amnestic Disorder due to Head Trauma, Personality Change Due to Head Trauma.

1 of 6 Cell Phones Contaminated with Feces

You may want to think twice before biting your fingernails or picking a piece of food out of your teeth, especially if you just shook someone’s hands. In England, researchers recently found that one in six cell phones was contaminated with feces (poop). This is based on 390 samples taken across 12 cities. The study provided further evidence that people are simply not washing their hands properly after going to the bathroom…or not washing them at all.

If this is happening in England, it is most certainly happening in the U.S. And not only on cell phones, but on shopping carts too. The same shopping carts that little children rub their hands all over and try to put their mouths on. Grocery stores contain hygienic wipes to wipe down a cart when you walk into the store. Use them.

One of the main dangers of fecal contamination is becoming ill from E.coli bacteria. The illness can not only cause food poisoning but it can also kill you, as was noted in a previous blog entry on the dangers of bean sprouts.

One of the more interesting aspects of the study was that people were not honest about their hygiene practices. That is, while 95% of respondents said that they washed their hands with soap and water when possible, that 92% of phones and 82% of hands were contaminated with bacteria, 16% of which contained E. coli. In other words, people say one thing but then the evidence shows something else, a phenomenon I am well familiar with as a clinical neuropsychologist.

Reference: Article on CNN.com.

New ADHD Guidelines and the Omission of Neuropsychology

Recently, the media has reported that the American Academy of Pediatrics (AAP) has broadened its 2000-2001 guidelines for the diagnosis of and treatment of ADHD. While the prior guidelines focused on children from ages 6 to 12, the new guidelines cover ages 4 to 18. The story is being covered by the media with lead-ins such as saying that AAP is “expanding the age range for diagnosis and treatment.” This is technically not true.

The fact is that the diagnostic criteria for ADHD have already been in existence in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (Text-Revision), referred to as DSM from this point forwards. This is the book, published by the American Psychiatric Association, which mental health and medical professionals refer to for making diagnostic decisions in this particular subject area.

There is nothing in the already existing ADHD criteria in DSM that prevents a diagnosis of ADHD in a four-year-old child. While the DSM mentions that it is difficult to establish the diagnosis before age 4 or 5, there is nothing that states the diagnosis cannot be made at age 4 (or earlier). In fact, part of the DSM criteria for ADHD is that the symptoms should be present before age 7, although this has been a subject of debate and will reportedly be changed to a higher age level in the next edition of DSM due out in 2012.

What AAP is really suggesting here that is new is that pediatricians should initiate evaluations of ADHD at age 4 if the child has academic or behavioral problems and symptoms of inattention, hyperactivity, and impulsivity. The new guidelines state that “primary care clinicians” should determine if the DSM criteria are met (which means the problems need to be present in more than just one setting, not only in school or only home).

While these guidelines are laudable, I am left to wonder how primary care clinicians (e.g., pediatricians, nurse practitioners) are going to be able to do this given the combination of time-limited visits and a very busy schedule. It is important to keep in mind that according to DSM criteria, there are 9 inattention symptoms, 6 hyperactivity symptoms, and 3 impulsivity for a total of 18 possible symptoms to cover with the parent. Some parents tend to go into a lot of detail when discussing these items and so going over the criteria properly can be quite time intensive. The new AAP guidelines also say that the PCP should also interview teachers and other school and mental health clinicians involved in the child’s care to make the diagnosis. In an ideal world, this sounds great, but most PCPs simply do not have the time to do this.

Speaking of not having time to do things, the new guidelines state that the primary care clinician should rule out alternative causes besides ADHD. This is another good standard, consistent with DSM, but it is also very time intensive. Why? Because the list of possible reasons why a child can have academic, behavioral, and attention problems is very extensive. Psychological and psychosocial explanations (e.g., depression, anxiety, parental divorce, abuse) are possible explanations and the guidelines correctly state to assess these conditions as well as for developmental disorders such as learning disorders and language disorders. Physical explanation such as sleep apnea would also need to be ruled out.

While a primary care clinician can easily refer a patient for a sleep apnea study and order other tests to rule out a physical cause of ADHD-like symptoms, what primary care clinician is going to have the time to go over all 18 symptoms, interview teachers and other sources of information, evaluate for a learning disorder, and evaluate for psychological causes of the symptoms? None who I know of. For example, evaluating for a learning disability is going to require time intensive psychological testing and primary care clinicians simply do not administer IQ tests and test of academic achievement.

The AAP guidelines explicitly acknowledge the time limitations involved in these types of evaluations and the need for collaboration with mental health professionals. Who do they suggest referring such patients to for additional evaluations? Child psychiatrists, developmental behavioral pediatricians, neurodevelopmental disability physicians, child neurologists, or child or school psychologists. While I have no opposition to any of these professions playing a role in the diagnostic process, there is one major omission in these guidelines: the field of clinical neuropsychology.

Clinical neuropsychology is the field of psychology that studies the relationship between brain functioning, emotions, behaviors, and thinking. Considering that ADHD is a neurological condition affecting the brain that affects behaviors and thinking abilities, referring a patient for a neuropsychological evaluation is certainly something a primary care clinician should consider. Why? First, a neuropsychological evaluation involves the objective assessment of thinking, behaviors, and emotions. That is, the patient’s performance on tests of attention and impulse control, for example, is compared to groups of children the patient’s age with no history of neurological damage.

While some critics note that the testing results may not always generalize to real-world environments, the fact is that these tests are the only way to objectively assess the patient’s actual cognitive abilities outside of grades in the classroom on academic tests. Behavioral checklists can be used and scored but at the end of the day they are still measures dependent on subjective opinions and have their own set of limitations.

While it is true that the ADHD criteria in DSM do not require neuropsychological testing to make the diagnosis, neuropsychological evaluations are not only about testing. Neuropsychologists are able to spend far more time on a single case than a primary care clinician and thus they can do a more detailed evaluation of symptoms, perform a detailed review of medical and academic records, and perform detailed evaluation of possible co-morbid psychological disorders. Neuropsychologists are also experts in a wide variety of other neurodevelopmental conditions (such as learning disorders) that can masquerade as ADHD and thus the evaluations can rule out or rule in other possible causes that can lead to better treatment.

Admittedly, clinical neuropsychologists need to publish studies showing that diagnostic evaluations for ADHD improve outcome. Recognizing this need, the American Academy of Clinical Neuropsychology recently funded a study by Dr. Mark Mahone from Kennedy Krieger Institute and the Johns Hopkins University School of Medicine entitled “Incremental Validity of Neuropsychological Assessment in Identification and Treatment of ADHD.” We will await and see the results of this study.

In sum, families and primary clinicians should consider referring patients to clinical neuropsychologists in the development of ADHD. While neuropsychological evaluations have limitations, limitations also apply to the other professions who the AAP guidelines suggest referring patients to. The fact that not a single national neuropsychological organization was consulted in the development of these guidelines is troubling and one has to wonder whether the omission was purposeful. After all, it is not as if pediatricians and the school psychologists they consulted with have never heard of neuropsychologists. I will be contacting the AAP and request a response and will post the response if it is provided.

Disclaimer: The author of this blog entry is a board certified neuropsychologist.

Don't Worry, Be Happy

Today’s is part II of a special guest blog entry by my colleague, Dr. Christine Allen. Dr. Allen is a psychologist who is also an executive and life coach. She has over 20 years of psychotherapy experience, is past President of the Central New York Psychological Association (CNYPA), awarded the CNYPA Psychologist of the Year in 2008, serves on the governing Council of the New York State Psychological Association, and is an adjunct psychology professor at Syracuse University. She runs Chris Allen Coaching and can be followed on Twitter here.

In yesterday’s blog entry, Dr. Allen ended it with the following question: So what are some take-aways on how to increase well-being and happiness? Here are some suggestions.

• Increase savoring by focusing on the moment; enjoy healthy pleasure in the here-and now.

• Increase engagement and flow, especially through meditation and mindfulness; limit passive activities such as TV and “screen time”.

• Practice kindness; it increases your own well-being and that of others (the “pay-it forward” concept has been found in hard research to be very real).

• Practice daily gratitude or blessings.

• Identify and use your unique strengths daily and in new ways (e.g., check out

www.authentichappiness.com for a cost-free way to identify strengths).

• “WWW”: Identify concretely “what went well” today--preferably write it down and ask others, such as your children, what went well for them.

• Behavioral economists suggest that “satisficing” (which means going with “good enough”) is better than “maximizing” (always trying to get the absolute best deal) for happiness. People who research endlessly to get “the best deal” are more unhappy with their choices.

• Cultivate optimism: Seligman’s book, “Learned Optimism” can help you learn how: you don’t have to be a Pollyanna to find ways to tame those negative messages. These messages are our brain’s way of trying to protect us from disappointment and disaster, but they actually prevent us much of the time from living fully.

For more ideas and information, check out Seligman’s book, Flourish or for a more personal take, read Gretchen Rubin’s, The Happiness Project

Guest Blog Entry. The Happiness Hype: What’s All the Buzz About and Is it Worth It?

Today’s is part I of a special guest blog entry by my colleague, Dr. Christine Allen. Dr. Allen is a psychologist who is also an executive and life coach. She has over 20 years of psychotherapy experience, is past President of the Central New York Psychological Association (CNYPA), awarded the CNYPA Psychologist of the Year in 2008, serves on the governing Council of the New York State Psychological Association, and is an adjunct psychology professor at Syracuse University. She runs Chris Allen Coaching and can be followed on Twitter here.

You would have to be completely disconnected from TV, YouTube, movies, Facebook, Google and even newspapers and magazines if you have not heard about or been exposed to information about “happiness” lately. Some people are quick to dismiss this topic as another form of constantly chasing more....and always comparing ourselves to others. There were even recent articles that rate different geographical locations as being “the happiest” places to live. Is happiness competition the new way of “keeping up with the Joneses”? Or is it really something worth pursuing?

Happiness has been viewed as important throughout human history. Aristotle in

particular wrote that, “Happiness is the meaning and the purpose of life, the whole aim and end of human existence.” The language of the “pursuit of happiness” is embedded into the fabric of our society through the Declaration of Independence (although as Ben Franklin allegedly said, “The U. S. Constitution doesn't guarantee happiness, only the pursuit of it. You have to catch up with it yourself”).

But what is happiness and is it attainable? I have always liked the idea expressed by Nathaniel Hawthorne that, “Happiness is like a butterfly which, when pursued, is always beyond our grasp, but, if you will sit down quietly, may alight upon you.” Thus, happiness is not a goal in itself, but perhaps a side effect of other, meaningful, goal-directed activity.

Still I don’t completely like the idea of just sitting around and waiting, so what to do? I recently finished reading Flourish, the newest book by the prolific Dr. Martin Seligman, who is considered the “Father of Positive Psychology.” In this book, he talks about the concept of “well-being” rather than about happiness per se. He believes that just like the concept of “weather”, where we measure wind, cloud cover, humidity, temperature, etc, “well-being” involves looking at a number of measures, not just how “happy” overall we are with our lives. He uses the mnemonic called PERMA, which stands for Positivity (or positive emotion), Engagement (or “flow”), Relationships, Meaning, and Accomplishment to explain “well-being.”

When researchers assess happiness, on the other hand, they are usually looking at a unidimensional concept like positive emotion or life satisfaction only. Seligman’s idea of well-being offers us greater opportunity to consider how to design a meaningful and fulfilling life, because even the more pessimistic types of people have the opportunity to increase well-being through developing in other ways, such as improving relationships or increasing accomplishment.

To flourish according to the PERMA principle, we need to look for opportunities to increase positive emotion through savoring our pleasures and amplifying our good feelings. We also become happier when we are actively engaged... “in the zone” so to speak. Time passes without awareness when we are engaged fully in what we are doing, whether it be having a conversation, playing tennis, or cooking a meal. This means being fully present, not distracted with our smart phones, Facebook, etc. Also, the better the quality of our relationships with others and the more we build these relationships, the deeper our satisfaction with life will be. Identifying core values and living these everyday is crucial to establishing a fulfilling, “purpose-driven” life. The philosopher Nietzche was the one who said, “He who has a why to live can bear with almost any how.” So develop a sense of purpose--what you want your life to stand for.

Finally, Seligman recently added a sense of accomplishment; while endlessly pursuing achievement out of a sense of perfectionism is unhealthy, dedicating yourself to the accomplishment of important goals, whether they be personal or professional, definitely adds to a sense of well-being.

Lots of research suggests that happiness matters; it’s not just hype. A meta-analysis of 300 studies with over 275,000 people found that people with greater levels of positivity lived longer, had better health, happier marriages, and made more money. So what are some take-aways on how to increase well-being and happiness? Stay tuned tomorrow to find out, in part II on this special guest blog entry.

Attack of the killer bean sprouts

Many people are well aware that undercooked meat is dangerous because it contains harmful bacteria such as salmonella and E. coli. To counter this, you are supposed to cook meat thoroughly, and use common sense food preparation methods such as hand washing, and avoiding cross contamination when preparing raw meat.

What many people do not realize, however, is that bean sprouts can be just as dangerous as raw meat. Yes, bean sprouts. Why? Because the sprout seeds can easily become contaminated in the fields where they are grown. Bean sprouts need to be grown in a warm and moist environment. Such environments are the ideal setting for bacteria to grow, including salmonella and E. coli. Some of the sprout seeds can also become contaminated by animal manure where they are grown.

In Germany, contaminated bean sprouts killed 42 people and caused about 4,000 food-born illnesses. In fact, in June 2011, bean sprouts were the source of a major E. coli outbreak in that country. There have been 40 worldwide food outbreaks linked to bean sprouts since 1973. The largest outbreak was in Japan, which killed 17 people in 1996 and affected 6,000 people. Outbreaks have also occurred in the United States.

In the United States, the Food and Drug Administration has done a good job promoting safe manufacturing practices. Nevertheless, if you eat raw bean sprouts, you are putting yourself at risk for developing a foodborne illness from harmful bacteria. The risk is greatest on young people, senior citizens, and people with weak immune systems.

To be safe, it is best to avoid bean sprouts at restaurants because you have no way of knowing how well they were cooked, unlike meat, which you can inspect. If you want to eat bean sprouts at home, health officials suggest immersing the sprouts in boiling water and cooking them thoroughly to kill harmful bacteria.

Lastly, keep in mind that bean sprouts can actually contain toxins and that to reduce risk, people should not eat large quantities of bean sprouts on a regular basis. 

The Chinese Elephant Man

You’ve all heard of the Elephant Man and have perhaps seen the famous movie of the same name. His real name was Joseph Merrick and he lived in the 1800s. His body was grossly deformed due to the presence of disfiguring tumors.

RECOMMENDED BOOK: The Elephant Man

He was mentally and physically tortured by his disease and was keenly aware of how his appearance affected others. He ultimately died when trying to sleep like a normal person but the weight of the tumors in his head, crushed his trachea and caused him to suffocate. An autopsy revealed a broken neck. Here is a picture of Mr. Merrick when he was alive.

I remember watching The Elephant Man movie as a teenager in my basement one evening and being profoundly affected by sadness that someone would ever have to go through such a terrible experience. It has always made me reflect on my life and deal with life stressors much easier by putting things in perspective. There is not much in life we can go through that would be worse than such an experience.

In doing some reading on the Elephant Man, I came across the name Huang Chuncai, also known as the Chinese Elephant Man. The picture at the top of this blog entry was taken after he had 33 pounds of a tumor removed from his face in 2007. He had another 4.5 pounds removed in January 2008 and another 10 pounds removed in late 2008. Despite this, the rare genetic condition known as neurofibromatosis, which causes nerve tissue growth, was expressed in such an extreme from in Mr. Chuncai that he can never look normal and the goals of the surgeries are to make him recognizably human.

Below is a video of how he appeared before and after surgery, but it is obviously disturbing so be warned before viewing. The case is remarkable, sad, and inspiring all at the same time. If Mr. Chuncai can get through his days and find some positives (see the video) there is no reason that any of us cannot either, even when we hit rock bottom.

Exercise & Eat Fruits & Veggies All You Want: You're Still Going to Die

It is well known that eating fruits and vegetables and maintaining a regular exercise routine provides various health benefits to the body. It is also well known that this is not easy to do because there are so many other tasty food competitors out there and so many leisure activities that do not involve exercise. If it was easy or preferable to eat vegetables over other types of snacks, children’s books and TV shows these days would not be trying to convince children that eating a carrot tastes just as good as a chocolate chip cookie. Even Cookie Monster can’t say that with a straight face.

The reason why so many people need to listen to music on a jog, jog with a partner, watch TV on a treadmill, or read a book while on an exercise bike is because they are trying to distract themselves from an activity that is usually not that fun on it’s own. That being said, there are some people who enjoy running on it’s own due to their body being sensitive to the release of endorphins (pleasure producing chemicals) but this is an experience I have never had, despite doing my fair share of jogging and trying without success to get high from it (i.e., joggers high).

While I am all for exercising, try to get my fair share of it, enjoy eating fruit (in fact, I just had some grapes), and like some vegetables, I also like sitting in my reclining chair, eating pepperoni pizza, and eating fried food. I try to keep it in balance, not going too far to either extreme. This is consistent with my view that the ancient Greek philosophers got it right when they said that life is best lived when lived in moderation. In other words, don’t do too much in excess but also do not deprive yourself.
If you are reading this and absolutely love exercising every day and eating nothing but a vegetarian or vegan diet, then that’s great and this blog entry does not apply to you. But if you do not like it or do these activities under the false belief that they are going to cause you to live until you are 100, and/or automatically going prevent you from getting a serious disease such as cancer, then this blog entry does apply to you.  The fact is, life is short and no matter how many carrots or apples you eat or laps you run, you are still going to die. What’s worse is that you could die from a cause that has nothing to do with diet or exercise (e.g., a car accident). Also, following a strict diet and exercise routine may do nothing at all to stop a spontaneous cancer from developing or from dying before your natural life expectancy.

My dad was a good example of the above. He religiously ate a salad every night and exercised almost every night after working a grueling full-time schedule. When I asked him why, he stated he was trying to prevent cancer. At age 59, he was diagnosed with esophageal cancer despite the fact that he never abused alcohol or had gastroesophageal reflux disease. He was dead within a year. I’m willing to bet that if he knew this was going to happen that he probably would have ate a few more junky snacks and watched a few more DVDs with a bowl of buttered popcorn. My maternal grandmother on the other hand, had the worst possible diet imaginable and smoked like a chimney, yet lived until age 78. I would never advocate the lifestyle she lived but the point is that while you have some control over your mortality, that control is limited and not absolute.

Famous exercise guru, Jack LaLane, is another good example. He avoided meat (except fish), avoided snacks, ate only two meals a day (skipping lunch), ate raw vegetables, egg whites and fish for dinner, ate hard-boiled egg whites, a cup of broth, oatmeal, and soy milk for breakfast, and he exercised for two hours a day. And after all of that…he still died of pneumonia.

Some will counter that LaLane would never have lived as long as he did (age 96) if it was not for his diet. Maybe. Maybe not. Unfortunately, genetics plays a major role. For example, many people do not know that his mother lived until age 89 and I am willing to bet she did not follow the same type of diet and exercise routine as her son. Sometimes, luck (or lack of it) also plays a role. For example, there are many people who go for a jog on a busy road, get hit by a vehicle, and either die or suffer a severe traumatic injury. And there have been a slew of people who have died from eating cantaloupes and other fruits and vegetables due to contamination with deadly bacteria (such as e. coli). The same can happen with other food products of course, but realize that fruits and veggies are also one of them.

My last point has to do with people who are either a) torturing themselves by eating bean sprout sandwiches, tofu burgers, and dry rice cakes when they would rather eat something tastier or b) working full-time and coming home to spend several hours exercising at the expense of some other activity they would rather do (e.g., family time, watching a movie, playing a game). Realize that life is short in the big scheme of things and that you should feel free to treat yourself once in a while and relax.

In the end, eat healthy for the most part and exercise, but don’t feel like you can never eat a piece of fried chicken or skip a day or two at the gym because you are afraid that it is going to kill you. It’s when unhealthy foods form the main part of your diet and a sedentary lifestyle becomes chronic that these pose a health risk. Be smart, live a balanced life, and enjoy the many tasty foods and leisure activities that life has to offer because you never know when it is going to end.

Disclaimer: The comments in this blog entry should not be taken as medical advice but are personal opinions of the author. For medical advice, please seek that from your physician. 

Related Blog Entries:

1. When Fruits and Vegetables Kill
2. Michael Clarke Duncan Turns Vegetarian, Loses Weight, and Dies of a Heart Attack
3. How Fruits and Vegetables Killed Steve Jobs

Ten Alternatives to Corporal Punishment

Yesterday, I wrote a blog entry entitled “Why Corporal Punishment is Wrong.” At the end of the article, I stated that I would describe my top ten tips for effectively teaching children good behavior and discipline without hitting them. Without further ado, here they are:

1. Instill a good sense of moral values with your child from a very early age. Teach the Golden Rule (“Treat other people the way you would want to be treated”) as the basic principal underlying personal interactions. Remind children of this whenever they violate the Golden Rule and remind them that they would not like it if someone behaved to them in the way they just behaved to someone else.

2. Model positive behaviors when you are upset. Try not to scream, curse, or physically act out in front of the child so you do not model the very behaviors that you do not want the child to do when upset. No one is perfect and you will occasionally slip up, but when you do, admit the mistake. It is frustrating and confusing for a child to see double standards in behavioral expectations and rules.

3. If the child makes a mistake in behavior (e.g., does not say thank you) correct it immediately and explain what was wrong and why.

4. Teach the child that there will be consequences for undesirable behaviors in the form of privilege withdrawal. Try to use a warning first unless the undesirable behavior is particularly problematic. Many children will tell you that this is actually the worst type of punishment because they do not want their toys taken away from them, do not like being grounded, do not want their phone or ipod taken away, etc.  

5. Follow through with threats of consequences. If you say you are going to take a privilege away but do not follow-through with this after an undesirable behavior, then the child is not going to believe you and will continue with the behaviors. Ideally, a warning will ultimately suffice to modify behaviors because the child will learn that you mean business when you issue a warning. Do not give in to temper tantrums as the child will only learn that this is an effective way to get out of the punishment.

6. Only allow the child to get the privilege back by doing something positive and desirable rather than just giving it back the next day or later in the day.

7. Talk with the child about why the privilege was taken away, what he/she did that was wrong, why it was wrong, and how to handle the situation differently next time. Tell the child what they need to do to get the privilege back, to apologize to anyone who was affected by the behavior, and most importantly, always tell them that you still love them and give them a hug at some point. It is important that you have a positive bond with the child to most effectively provide discipline.

8. Reward the child for positive and desirable behaviors. This can be spontaneous at times but also consider implementing a system in which the child earns points for positive behaviors. Earn enough points and the child receives an award (e.g., 10 points earns a cookie). The points can be in the form of tangible objects (marbles, tokens stored in a jar) so the child can monitor progress better. Points can be taken away for undesirable behavior and regained with positive behaviors. For more information on this topic, do an internet search for “token economy.”

9. Talk with your child from an early age about societal expectations and demands. Teach them from an early age why learning, reading, staying in school, and staying out of trouble are important. Teach them about staying away from drugs, alcohol, cigarettes, other children who get into trouble, and age-inappropriate violent media. Talk with them about the consequences of bad behaviors and/or a poor education in childhood and adulthood (e.g., suspensions, jail, homelessness, low income). The content of these conversations will obviously depend on the child’s age.

10. Surround the child with positive role models. This can be real role models such as parents, siblings, other family members, and friends but can also apply to positive fictional role models on television (e.g., He-Man or Franklin as opposed to Jason and Freddy Krueger). 

Why Corporal Punishment Is Wrong

Corporal punishment, the technical word for physically striking someone (usually a parent striking their child) as a form of discipline, simply makes no sense. Many people like to dispute this by saying something such as “I had a spanking when I was a child and I turned out ok so it could not have been that bad.” Well, sure, maybe you turned out all right in the end, but that does not mean that punishment was the reason. After all, people overcome all sorts of adversity during childhood such as poverty, serious, medical illnesses, and being bullied, but that does not mean that those were good experiences. While we all need to learn to deal with the many adversities that life throws at us, there is no need to create an additional needless adversity for children that is within our control to stop.

The context of this blog entry is that today, a man in Orlando Florida, was arrested for humiliating a child (that he was not even the parent or legal guardian of) on a video he posted online by shaving off the child’s hair, threatening him with a belt, beating him with a belt, and then making him do push-ups and sprints as a form of boot camp. This was all done because the child got in trouble in school and the man was concerned that the child would go to prison one day. Valid concerns. Invalid approach…which is why he was later arrested. While this man’s behavior may have been considered acceptable 20 years ago, today it is considered a form of child abuse.

Inspiration if Diagnosed with a Serious Illness

If you or a loved one were diagnosed with a serious medical illness, particularly a terminal illness, it is very easy to get depressed, particularly if you read statistics on the internet on how long you are expected to live. The famous scientist, Stephen Jay Gould, found himself faced with a prognosis on 8-months to live after being diagnosed with a particularly deadly form of cancer known as mesothelioma. To read more about mesothelioma see this entry on asbestos.

After the diagnosis, Gould wrote a brief essay that came to be a source of inspiration for many people in similar situations. He lived a productive life for twenty years after the diagnosis. Not bad for someone given eight months to lived. Below, I have reproduced Gould’s essay, entitled “The Median is Not the Message.” Please read it over, share it with friends, and most importantly, pass it on to anyone you know of who was diagnosed with a serious medical illness (particularly cancer).

Pale Skin and Vitamin D

If you have pale skin like me, you know that the sun can feel like your arch-enemy. Summer time means lathering up with sunscreen and wearing a hat to avoid getting scorched. Sometimes, it seems that no matter how hard you try, you later find an area of sunburn on you. Some of the burns will make you look more lobster-like than others.

Shade is your best friend and many times it is just easier to stay in doors. The benefit about not exposing yourself to more sun is that you reduce exposure to harmful ultraviolet rays that can cause skin cancer. The flipside, however, is that by avoiding the sun, your body will not convert it into vitamin D. While vitamin D is found in some foods such as salmon, milk, and cheese, you may not get as much from your diet than you need. Many people would be surprised to know that there are very few foods in nature that contain vitamin D. So, it probably should not have come as a surprise that when I went for a routine blood test last year, that I had a low vitamin D level. The solution is easy: vitamin D should be available at your local grocery store or pharmacy as a supplement.

Why should you care if your vitamin D level is low? Well, for one, vitamin D helps build strong bones so you are more likely to suffer broken bones if your vitamin D level is too low. More importantly, low vitamin D levels can also contribute to heart disease, cancer, multiple sclerosis, and diabetes mellitus.

So, if you are one of my pale and pasty friends out there, get your vitamin D level checked and if it is low, talk with your doctor about how much of a supplement you need. You do not want to overdo it in the reverse direction and take too much vitamin D because that can be harmful as well. As the Greek philosopher, Plato, once said, do things in moderation.

Suggested reading: Vitamin D For Dummies
 
Related blog entry:  Too Much Calcium Can Hurt Men's Hearts
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More EXTREME Body Parts: Part 2

Diversity in the human body and other living things is a fascinating topic. Last month, the most popular blog entry was on extreme body features. Due to the popularity of that entry, I decided to do some more research and bring you some more amazing extreme body parts. So…here we go again (all Guinness World Record holders).

1. WIDEST MOUTH: This is Francisco Domingo Joaquim "Chiquinho" from Angola. His mouth is 17 inches wide. By the way I am a Pepsi fan so this picture should not be seen as an endorsement for Coca Cola.

2. LARGEST BREASTS: This is Annie Hawkins-Turner (aka Norma Stitz). The around chest-over nipple measurement is 70-inches. I’ve spared you some other pictures but if you dare, you can search on-line for more.
3. LONGEST NOSE:

This record belongs to Mehmet Ozyurek from Turkey. This schnozz measures 3.46 inches long. I’d hate to be near one of this guy’s sneezes. 

4. LONGEST FEMALE LEGS: This record belongs to Svetlana Pankratova of Russia which are 5.9 inches. ZZ Top sure would have loved to have her for their Legs music video.

5. SMALLEST WAIST: This waist belongs to Cathie Jung, coming in at 15 inches. It almost looks unreal, which is what makes it all the more amazing.

6 & 7. LONGEST MALE AND FEMALE FINGERNAILS (EVER): These belong to Melvin Boothe (now deceased) which were 32 feet and 3.8 inches. To the right is Lee Redmond whose nails measured 28 feet and 4.5 inches.  I’m guessing they don’t use computers.

8. TALLEST LIVING MAN: This is Sultan Kosey from Turkey. He is 8 feet, 3 inches tall. Here he is with…Al Roker! Guaranteed Al asked him how the weather was up there.

9. TALLEST LIVING WOMAN: This is Yao Defen from China. She is 7 feet, 7 inches tall. I’d like to see her take on Yao Ming in a game of one on one.

10. WIDEST TONGUE: This is Jay Sloot from Australia, who has a 3.1 inch tongue width. One wonders if Gene Simmons is jealous.

Want more? Click for even more and more extreme body parts.

When Patient Advocacy Becomes Patient Enabling

Physicians, nurse practitioners, nurses, psychologists, physical therapists, and a whole host of other health care professionals entered their respective professions to help people. One part of being an effective health care provider is to advocate for your patient when they need it. If your patient (who is a mechanic) broke his arm and needs a note for the employer for a few weeks off, you provide it. If your pediatric patient (who suffered a severe traumatic brain injury) needs you to write a note regarding academic accommodations, your write it. If your stroke patient needs you to write a letter of medical necessity to the insurance company for why they need extra physical therapy for rehabilitation of a weak limb, you write that too. This is just common sense and while it can be seen as advocacy it is also sound practice.

Where patient advocacy starts to become problematic and can lead into patient enabling, is when there is: a) a lack of objective biomarkers to indicate the presence of a pathological physical condition and/or b) the patient is pursuing some form of compensation (e.g., disability application, workers compensation claim, no-fault insurance claim, and/or litigation). By objective biomarkers, this means that there are no significant abnormalities on blood tests, x-rays, MRI scans, physical exam, or other objective measures. When a and b are both present, the risk of patient enabling increases significantly.

In such cases, the health care provider is often left to diagnose, treat, and manage the patient based purely on subjective symptoms. The provider may also be asked to fill out disability paperwork (even on the first visit), fight insurance company denials for expensive tests, and be asked to refill pain medication prescriptions. While it may be easier to go along with these requests, if you are a healthcare provider how do you know that the patient is not exaggerating their presentation, that you are actually treating the true source of the problem, that you are not causing more harm than good in the process, that you are not enabling abnormal illness behavior, and that you are not enabling someone’s financial goals as opposed to medical treatment goals?  

This is a topic that rarely commented on in clinical notes or discussed with the patient. There are several reasons why this is the case, including but not limited to: a) an automatic proclivity among some providers to believe subjective symptom reporting is accurate based on a belief in the inherent truthfulness of others, b) a belief that reinforcing and “validating” symptoms helps the patient feel like someone cares and is thus more important than questioning if the symptoms are accurate, c) helping patients is equated to prescribing and ordering diagnostic tests targeted to each specific symptom, d) not realizing that the presentation may be exaggerated by failing to integrate evidence-based research findings into case conceptualization, e) not utilizing objective measures of treatment progress (or lack thereof), f) fear of complaints and litigation, g) it takes too much time to address, and h) not realizing that there are ways to more objectively and comprehensively evaluate exaggeration.  

As a caveat to this discussion, I want to be clear that there are patients with only subjective symptoms who may have a genuine medical problem that objective tests did not detect. A famous quote about this drives the point home “absence of evidence is not evidence of absence.” To be more accurate, however, the phrase should read, “absence of evidence is not always evidence of absence.” This is because many times a medical test is negative because there really is nothing medically wrong. In other words, many times, “absence of evidence actually is evidence of absence.”

This post should not be read to imply that patients with subjective symptoms, negative objective test results, and who are pursuing compensation should not be treated and advocated for. These types of decisions will always depend on the specifics of the particular case. However, in general, health care providers need to exercise much greater caution in such cases than in the ones described in the first paragraph.

A few tips are as follows.

1)      Use objective measures of treatment progress and require/request this of others who you refer the patient to for treatment. If the patient is not improving with a certain plan of care, it is time to change direction rather than continuing the same treatment for months to years. You may be surprised to find when doing this that the patient is actually reporting worse symptoms over time. If so, it is time to consider why and change course.

2)      Consider if the patient’s presentation significantly exceeds what would be expected based on scientific knowledge of the condition. If the presentation is not biologically plausible, it is time to consider a psychological explanation for the presentation, reexamine the diagnostic impressions, treatment, and advocacy efforts.

3)      Do not feel compelled to immediately fill out disability paperwork or other paperwork supportive of compensation requests without having some data to support your position. If a physical limitation is described as disabling, refer the patient for a functional capacity evaluation. If the patient claims cognitive impairment, send the patient for a neuropsychological evaluation so the role of psychological factors can be explored. These types of evaluations can provide very useful information about the reliability and validity of the patient’s symptoms that is based on objective data and supported by peer-reviewed research.

4)      Use data from the above evaluations to help guide decision making. For example if you find out the there is overwhelming evidence that the patient’s presentation is exaggerated, malingered, and/or caused by psychiatric as opposed to neurological problems, it is time shift the care to a psychiatric focus and only treat physical symptoms that can be objectively verified.

5)      Consider the possible harmful effects of continued treatment without employing reliability and validity checks. For example, if you are treating a non-existent attention problem with a neurostimulant you can be raising the patient’s blood pressure to dangerous levels. If you are keeping patients in physical therapy for gait imbalance who are not improving and who have a non-physiological gait pattern, you are restricting access to care for patients with genuine medical problems who need the service. The same applies for ordering diagnostic tests (e.g., CT scans which expose patients to radiation) that have very little chance of yielding any new information given what is already known about the case.

In sum, health care providers best help patients by using objective data to guide case conceptualization, treatment, and advocacy efforts. Sometimes, you need to be skeptical, sometimes you need to say no, sometimes you need to say something the patient may not want to hear, and sometimes you need to decide and communicate that there is nothing else you can do. This can all be done in a polite, caring, and respectful way. It does not mean that you have failed if all of your patients do not get better. Some will never get better and some do not want to. It’s just the reality of working in the modern day medical system.