Wednesday, 10 April 2019

Managing worry in generalized anxiety disorder for Health

The news about the Zika virus possibly causing microcephaly in infants has everyone talking about — and worried about — mosquitoes. It’s not just the Zika virus that can be spread by mosquitoes; these insects also spread other illnesses, such as malaria, dengue, chikungunya, yellow fever, West Nile virus, eastern equine encephalitis, and Japanese encephalitis.

It should be said that most people who are bitten by mosquitoes don’t get sick with anything. But if you are living in or traveling to an area where these illnesses are prevalent, it’s important to know the four best ways to protect yourself and your family:

    Choose your clothes wisely. Lightweight long sleeves and long pants are your best bet; spraying clothing with insect repellent may help even more.
    Create barriers between you and the mosquitoes. Staying inside, in air-conditioned buildings or buildings with good screens that don’t let in mosquitoes, is one way to do that. You can also use mosquito netting; you can use it around beds and also around baby strollers. Spraying the netting with insect repellent is a good idea.
    Watch out for standing water. That’s where mosquitoes breed. If you can empty it out, do that. If you can’t, don’t hang out near it.
    Use insect repellents. The most effective one is DEET (N, N-diethyl-meta-toluamide). Mosquitoes don’t like how it smells, so they stay away from it. The higher the percentage of DEET in the repellent, the longer the protection: 10% protects for a couple of hours, 20% about twice that.

How to use insect repellent effectively and safely

DEET does have side effects. The most common one is skin irritation, and it’s important not to use it on areas with scratches, cuts, or rashes. If ingested, it can cause nausea or vomiting. Ingesting large amounts of it, or using high percentages for long periods of time, can lead to neurologic problems such as seizures, but this is very rare.

The American Academy of Pediatrics says that percentages up to 30% are safe in children — but you shouldn’t use it on babies younger than 2 months old. For best protection, the Centers for Disease Control and Prevention recommends using at least 20%.

There are other insect repellent options, too:

    Oil of lemon eucalyptus (or PMD, the man-made version), which can be very effective and is safe. It shouldn’t be used on children under 3 years old, however — it’s not well-studied enough.
    Picaridin, which can be very effective against mosquitoes (but not so much against ticks — so keep that in mind if you need protection against both). It can cause mild skin irritation or irritation of the eyes if you get some there.
    2-undecanone (IBI-246), a chemical naturally found in various plants. It can protect for up to 4-5 hours and is nontoxic.
    IR-3535, which is the active ingredient in Avon insect repellents (and some others as well). It lasts for about 2 hours. It can cause eye irritation if you spray it there by accident, but is otherwise very safe.

The Environmental Protection Agency has a great tool to help you find the insect repellent that works best for your particular situation. No matter what you use:

    Make sure a grownup does the spraying.
    Never spray directly on the face; spray it on your hands and use your hands to apply it to the face (and then wash your hands!)
    Always spray in an open area, to limit how much you end up breathing in.
    Reapply if truly needed, but do so sparingly.
    When you come home at the end of the day, wash everyone up well with soap and water — and be sure to wash any sprayed clothing before it’s worn again.

To learn more about mosquito-borne diseases and how to protect yourself, visit the website of the Centers for Disease Control and Prevention. I’ve been receiving many questions from my patients who are pregnant (or trying to get pregnant) who want to escape the Boston winter weather for warmer vacation climates, but are worried about Zika virus. Currently causing a widespread outbreak in Brazil, Zika virus is thought to be the causative agent of microcephaly in babies whose mothers were infected during pregnancy there.

I’ve been stressing that my patients should check out the CDC Zika travel notices, which warn against travel to popular winter vacation destinations in the Caribbean, Mexico, and Puerto Rico. Although there is no evidence that pre-pregnancy exposure to Zika is problematic, I have also been reinforcing to my patients that they should avoid travel to these endemic regions if they are currently pregnant or trying to get pregnant, and I’ve also been advising delaying getting pregnant for a couple of months after returning from one of these endemic areas. There have been reports that, rarely, Zika can be transmitted sexually from men to women. Therefore, men should use condoms if they have been exposed to the virus and their partner is pregnant. It is not known how long the virus may remain in semen.

When it is absolutely necessary to travel to these places while pregnant, such as for urgent family or business issues, mosquito bite prevention is key. You can avoid bites by using insect repellent, wearing appropriate attire to shield your extremities, and staying in places with windows, screen doors, or air conditioning. EPA-registered insect repellents that contain ingredients such as DEET, picaridin, and IR3535 are safe for use during pregnancy. The CDC website contains detailed information on how to avoid mosquito bites.

I’ve also received questions about vacation travel to areas such as Florida and Hawaii that are close by places with Zika transmission but not currently listed as experiencing an outbreak. So far, there has been no mosquito-borne Zika transmission in the United States, so these destinations are a good warm-climate option.

According to the CDC, only 1 in 5 people infected with Zika virus will become symptomatic. The characteristic clinical findings are a sudden fever with rash, joint aches, or conjunctivitis (reddening of the whites of the eyes), usually within 1 to 2 weeks of infection. Other reported symptoms include headache and muscle aches. The illness is usually mild, with symptoms lasting for several days to a week. The actual rates of infection with Zika virus, maternal-to-fetal transmission, immune response, exactly what the relationship is between Zika virus and fetal microcephaly, abnormal brain development, or other adverse pregnancy outcomes are not currently known. My wife recently asked me, “Why do you assume you’ll die before me?”

Her question caught me by surprise. But it’s true, I have made that assumption. So, I answered, as matter-of-factly as I could, with one word: statistics.

I knew that, on average, women live longer than men. In fact, 57% of all those ages 65 and older are female. By age 85, 67% are women. The average lifespan is about 5 years longer for women than men in the U.S., and about 7 years longer worldwide.

It’s not hard to see the gender gap among the elderly. A glance around most nursing homes or assisted living facilities in the U.S. often tells the story: women will usually outnumber men, and the magnitude of the difference is often striking. I’m also told that when a man moves into a residential setting dominated by the geriatric set, he tends to be popular; and that’s especially true if he still drives.

Advertisers know this as well. I recently saw an ad for an organization called “A Place for Mom” that helps families find assisted living or other services for senior citizens. And while they help men as well as women, the name of the company reflects how much bigger the elderly female market is.
So why do men, on average, die first?

There are many reasons why the ratio of men to women (which is roughly equal in young adulthood) starts to favor women over time. Among the most powerful factors? Men tend to

    take bigger risks. Some of the reason seems to be “biological destiny.” The frontal lobe of the brain — the part that controls judgment and consideration of an action’s consequences — develops more slowly in boys and young men than in their female counterparts. This likely contributes to the fact that far more boys and men die in accidents or due to violence than girls and women. Examples include biking, driving drunk, and homicide. This tendency toward lack of judgment and consideration of consequences may also contribute to detrimental lifestyle decisions among young men, such as smoking or drinking to excess.
    have more dangerous jobs. Men far outnumber women in some of the riskiest occupations, including military combat, firefighting, and working at construction sites.
    die of heart disease more often and at a younger age. In fact, men are 50% more likely than women to die of heart disease. The fact that men have lower estrogen levels than women may be part of the reason. But medical risks, such as poorly treated high blood pressure or unfavorable cholesterol levels, may contribute as well.
    be larger than women. Across many species, larger animals tend to die younger than smaller ones. Although the magnitude of this effect is uncertain in humans, it tends to work against male longevity.
    commit suicide more often than women. This is true despite the fact that depression is considered more common among women and women make more (non-fatal) suicide attempts. Some attribute this to the tendency for men to avoid seeking care for depression and the cultural norms that discourage men from seeking help for mental illness.
    be less socially connected. For reasons that aren’t entirely clear, people with fewer and weaker social connections (including men) tend to have higher death rates.
    avoid doctors. According to the Agency for Healthcare Research and Quality, men are far more likely to skip routine health screens and far less likely than women to have seen a doctor of any kind during the previous year.

The uneven playing field for boys starts early. The Y chromosome tends to develop mutations more often than X chromosomes and the lack of a second X chromosome in men means that X-linked abnormalities among boys are not “masked” by a second, normal version. Survival in the womb is also less reliable for male fetuses (for uncertain, and probably multiple, reasons). Developmental disorders are also more common among boys; some of these could shorten life expectancy.
What we can do to help men live longer

While there’s not much that can be done about some of these factors, others are modifiable. For example, since men tend to avoid medical care far more often than women, getting men to report symptoms (including depression) and go for regular follow-up for chronic medical problems (such as high blood pressure) could counter some of the tendency for them to die younger.

It’s also worth noting that the survival gap between men and women reflects an average tendency among large numbers of people. In fact, plenty of wives predecease their husbands. Individual risk factors (such as smoking, diabetes, or a strong family history of breast cancer) can outweigh the general tendency for women to live longer.

Perhaps we’ll be more successful in the future in avoiding preventable, premature death among men (and women) — and, because many of these efforts will have a bigger impact on men, the gender gap among the elderly may eventually narrow. Until then, my wife and I will do what we can to stay healthy. But, statistics don’t lie. I’ll probably die first. If you had chickenpox as a kid, there is a good chance you may develop shingles later in life. “In fact, one in three is predicted to get shingles during their lifetime,” says Dr. Anne Louise Oaklander, director of the Nerve Unit at Harvard-affiliated Massachusetts General Hospital.

The same varicella-zoster virus that causes chickenpox also causes shingles. After the telltale spots of chickenpox vanish, the virus lies dormant in your nerve cells near the spinal cord and brain. When your immunity weakens from normal aging or from illnesses or medications, the virus can re-emerge. It then travels along a nerve to trigger a rash in the skin connected to that nerve. The rash often appears on only one side of your body. The most common locations are the chest, back, or stomach, or above one eye.

Most cases of shingles cause severe pain and itching, and can leave scars. Fluid-filled blisters develop, break, and crust over during and a few weeks after an outbreak. You also may feel sick or fatigued, with a slight fever or headache. However, it is possible to have rashes that are so mild they’re not even noticed.
Seek treatment right away

Many people have the mistaken impression that, like poison ivy, shingles is a nuisance rash that fades on its own. “But in fact a shingles rash should alert people, especially in middle or old age, to seek immediate medical help,” says Dr. Oaklander.

Rapid treatment with one of three antiviral drugs, acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir), can shorten a shingles attack and reduce the risk of serious damage, such as:

    Long-term pain. Pain that lingers in the area of a healed shingles rash is called postherpetic neuralgia. This often-disabling pain can last several months to a year.
    Prolonged itching. Many people are left with an itchy area from their shingles, which can be as disabling as chronic pain. It is most common on the head or neck.
    Damage to vision and hearing. Pain and rash near an eye can cause permanent eye damage and requires an urgent ophthalmological exam. When the nerve to the ear is affected, it can permanently damage hearing or balance.
    Strokes and heart attacks. A PLOS Medicine study that tracked about 67,000 people ages 65 and older who were newly diagnosed with shingles found that stroke risk more than doubled in the first week after the shingles diagnosis. The same study reported an increased risk for heart attacks in the three months after shingles, but the additional risk dissipated after six months.

Prevent shingles with vaccination

The Centers for Disease Control and Prevention recommends that almost all people ages 60 and older be vaccinated against shingles, whether or not they had chicken pox in their youth or have had shingles before, says Dr. Oaklander.

The vaccination that prevents chickenpox in children was used to develop a similar vaccine (Zostavax) that protects against shingles. “It reduces the risk of getting shingles by about half, and shingles rashes that still develop are slightly less likely to cause postherpetic pain, or other serious complications,” says Dr. Oaklander.

People with especially weak immune systems, such as those with cancer or anyone undergoing immunosuppressive treatments, should avoid Zostavax since the vaccine contains a weakened form of the live virus. Because Zostavax has only been available since 2006, it is still not yet clear if a single vaccination offers lifelong protection, but at this time, no booster is recommended.

A new shingles vaccine called HZ/su also may be helpful for older adults. A study published in The New England Journal of Medicine found that the vaccine was 97.2% effective among those ages 50 and older, and 97.9% effective for those ages 70 and older. And since HZ/su is not made from a live, weakened virus, it is safe to give to people with weak immune systems. This vaccine still needs to undergo further testing before it can be submitted for FDA approval, which may happen as early as this year. Everyone worries, but some people worry more than others. When worry is excessive, people may develop generalized anxiety disorder (GAD). In fact, close to a quarter of people who go to their primary care physicians with anxiety suffer from this.

In general, stressful events in childhood and adulthood, having strained economic resources, being divorced, and being female all put you at risk for GAD. But what do all of these different high-risk groups have in common psychologically? Why do they worry so much? And what can they do about this?
The surprising benefits of worry for people with GAD

A recent study explained why people with GAD worry so much — and the findings may surprise you. While many people think they are just worriers, they do not realize that they actually worry for a reason. Their worry is an attempt to protect themselves! If you’re wondering how such a nagging, persistent, annoying, and sometimes distressing psychological state can be helpful, you’re probably not alone. But the findings do in fact make some sense.

It turns out that worrying about something puts your mind into a negative state, but this helps, because when something negative does happen, you don’t feel that much worse. You’ve already been feeling bad. For people with GAD, it’s better to feel bad most of the time so that a negative event — someone being ill, sudden financial challenges, or rejection from a loved one — doesn’t have the power to create a massive emotional swing. It’s the sudden shift from a neutral or positive mood to a negative one that is of great concern to worriers. They will do anything to avoid this, include preparing to be miserable. They really hate the contrast of a situation unexpectedly going south. To people who aren’t worriers, this would sound counterintuitive, but they don’t have the same sensitivity to sudden emotional shifts. In fact, for them, worry is undesirable, whereas worriers find worry helpful.

This poses a dilemma for treatment, then. If someone has GAD, just asking them to lose the worry will not work. And if you have GAD, expecting your brain to simply stop worrying on command is a tall order. Another study has helped us understand that people who are prone to worrying are soft-wired to pay attention to threatening news, thereby building up a library of evidence in their brains that worrying is necessary. Think about it. On any given day, there are so many threatening things happening in the world — anything from new viruses, terrorist attacks, or political conflicts to a hostile email or upcoming storm are all real events. Yet, if you only pay attention to the threats, you have no space left in your brain to process anything else. Threat becomes your reality, and worry becomes your justifiable response. Anyone telling you to give up your worry will sound out of touch, to say the least.
What you can do to get your worry under control

As challenging as this sounds, there are things that you can do to retrain your brain to stop worrying. Cognitive behavioral therapy, a type of talk therapy where you simply revisit your assumptions in an attempt to reframe your thoughts, works according to some studies but not others.

It’s important to remember that you can benefit from other forms of talk therapy, though, and that you can benefit from medications as well. But if you want to try changing the way you think right now, prior to therapy or while you’re waiting, you might consider the following approach.

Rather than challenging yourself or someone else about worry, you can actually accept that the worry is serving a purpose — to avoid a sudden negative swing. Then, start to delve deeper so you can discover that the negative swing is probably less negative than you think. Giving up the struggle and control with worry, and accepting that it has not been helpful, is the next step. You can then re-examine your library of negative “proof” and swap out threatening realities for positive ones. In fact, this kind of deliberate optimism can protect you from GAD.

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