Medicine For People!

November 2014: Medicine for the Mind

Medicine for the Mind

  • Medicine for the Mind
    • Anxiety and Adrenaline
    • Vitamin D: "They're all happy now!"
  • Facebook
  • New Office Hours

Ebola, Shingles, Flu: Knowledge vs Fear

The death rate from Ebola in developed countries appears to be less than 20%, whereas up to 90% die from it in Africa. Though most of us survive type A influenza, up to 50,000 Americans a year die from it. How do we know? Why do they die? What is different about the Ebola and flu virus? Shingles virus never goes away once you catch chicken pox, but for the most part lives quietly in the spinal cord. Why do some viruses, like Ebola, kill so easily and others, like the chicken pox virus, become little more than a nuisance?

As well, other viruses such as polio, smallpox and West Nile have important lessons to teach us.

Knowledge can extinguish fear. Learn how to protect yourself on Thursday evening at 7 p.m. at the Port Townsend Yacht Club at 2503 Washington in Port Townsend. Lecture fee $10.

Medicine for the Mind

Oft-times, if you the patient don't request something you need at the doctor's office, you'll never get it. Here are two things on the menu you may not know about, both with an effect on the emotions.

Anxiety and Adrenaline

Tom had come to see me for a rash. It turned out to be one easy to identify and treat, but as we finished he said somewhat sheepishly, "There something else I like ask you about, Doctor. I know I appear pretty easy-going, but you mentioned my rapid pulse at the beginning of the visit, and my white-coat hypertension, so I have to tell you that I can get pretty excited really easily." I asked if he ever reached the point of panic, and he replied "No. But sometimes it will just start with some minor thing. I just get a little anxious and then I start to worry about the anxiety and I kind of wind up and up until my pulse is racing and I really feel jumpy."

I explained to Tom that he was not alone in this experience. My personal view is that our contemporary world presents so much stimulation that many peoples' nervous systems go frequently into overdrive. If it isn't the overflowing floods of email, or the seductive media presentation of wonderful things we could have or people we could be, or sensationalized news like Ebola---you see how the list goes on. Our ancient fight or flight response, which prepared us admirably for the occasional tiger, is now being set off many times a day. That's what was happening to Tom.

I explained that his anxiety was highly likely to be an overproduction of adrenaline. This is not something we can easily test for in the laboratory. Usually I give people a trial of an adrenaline blocker called propranolol. Developed over fifty years ago, propranolol blocks the effects of adrenaline on certain receptors but not others. These receptors have the name beta-receptors, so we now call propranolol and subsequent similar agents beta-blockers. Propranolol has a much briefer action than the other medications, which makes it ideal for Tom's type of anxiety. If a person starts to feel anxious and takes a tablet of propranolol, within 20 minutes it can blunt that jittery feeling. The vicious cycle of mild anxiety leading to more and more anxiety is broken. Many people come back and tell me how happy they are with this simple and inexpensive medication.

Propranolol for Surgeons

Sometimes it's not easy to sell someone on a pharmaceutical. We would all prefer to let nature take care of our ills, to tend to ourselves as a gardener does to a plant. In that case I tell them that many physicians take propranolol before performing surgery. I heard about this in 1983 in Arlington, Washington where I worked in the emergency department. As it happened we were very near the outpatient eye surgery center, and I had a chance to observe the eye docs in action. One had a microscope through which I could look as the same time as he worked. He asked if I noticed how still his instruments were, then revealed that the secret was propranolol. For no matter how stationary his hands might appear to the unaided eye, under high magnification most people's hands can be seen to tremble as the muscles adjust and readjust to hold a certain position. So he took propranolol when his morning started. It didn't cloud his judgment or his intellect, and his surgeries went much better.

Performance musicians have come to me and asked for propranolol by name. It's so easy for musicians in front of a huge audience to imagine failure and embarrassment. This anxiety can destroy a performance. No matter how many times one has practiced or how good a musician one is, it's still possible to stand in front of Carnegie Hall with violin in hand and just freeze. Musicians know that if they take propranolol just before a performance, the cycle of fearful thoughts and secondary paralyzing adrenaline outflow can't be maintained, and the stage fright will go away. Their mind is unclouded, every note still lively within them, and they can perform much better.

Aside from musicians and certain surgeons, I run into no one who pays much attention to this medication. It's not effective for true panic disorder. But when someone like Tom comes to me with intermittent anxiety out of proportion to what's really going on, I suggest a trial of propranolol. Most of the time it works.

When Not to Take Propranolol

When people ask about side effects, I tell them that they don't want to take it before they run a marathon. A marathoner counts on that second wind, and that second wind comes from adrenaline. Also, if a person takes propranolol several times a day for months, some people become depressed and apathetic. I tell people that the pharmacy computer will probably warn about this, but to pay no attention. No surgeon, musician, or patient has ever reflected back to me that this is a problem, for they take it only once in a while.

And what about Tom? When I saw him for his annual check-in a few months later, he told me that propranolol did the trick. He only needed it about once a week. In fact, just knowing he had a couple tablets in his pocket was sometimes enough to help him get past some minor stress.

Vitamin D: "They're all happy now!"

Paul lives in Port Townsend and fishes in Alaska. At his last visit he confessed that sometimes the winter weather in Alaska made him blue. I suggested we measure his vitamin D level, low vitamin D levels being responsible for seasonal affective disorder in many people. Paul laughed. "Oh yes, that's right. That's the big news in Alaska. Everyone's taking vitamin D. They're all happy now."

So, readers, if the coming of the clouds and the short days distresses you, let us check your vitamin D level. The laboratory computers seem to be happy with the level of 30 ng/ml. The last time I spoke to actual vitamin D researchers, they thought we are healthiest with a level in the range of 40 to 60. Even if you take vitamin D, it's worth testing your level to be sure you aren't too low or too high. Our ability to assimilate vitamins varies a great deal, so there's no "book dose" I can give you and assure that you will be in the sweet spot.


New Office Hours

To repeat last month's announcement, you can now see our up-to-date hours of operation. When Doctor Rienstra is out of town, the office will be open Mondays and Thursdays only, from 8 am to 10 am.

Our two RNs have babies at home, so we do not have a nurse working every day. For nursing services such as laboratory and injections, please call in advance to avoid unnecessary waiting. As always, if your insurance covers care at a Medicare or Medicaid clinic, we still can care for you out of network and in coordination with those clinics.



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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.