Saturday, December 31, 2011

Dangers of taking Prednisone (Anti-inflammatory Steroid)

     Prednisone and other anti-inflammatory steroids (not to be confused with testosterone and the other anabolic steroids that athletes use) have an indicated medical use. Prednisone suppresses the immune reaction of the body, and is used when the immune reaction causes the immune system to attack healthy cells and organs. So it is used, for instance, in asthma, multiple sclerosis, poison ivy, polymyalgia rheumatica, swollen nerves, rheumatoid arthritis, systemic lupus, and a host of other diseases.

     However, just as  aspirin  goes throughout the body to suppress the formation of prostaglandins everywhere, anti-inflammatory steroids also go everywhere throughout the body to suppress the immune reaction in every organ, beginning with inhibiting the diapedesis of white blood cells through capillary walls to attack infected tissues and the reduction of immune surveillance of any fungi or other chronic infection that the body's immune system is keeping in check. It is of vital importance to be aware of the multiple possible effects of steroids and to protect the patient against these  putative negative effects. Otherwise, like Eleanor Roosevelt, the careless overuse of steroids can cause death from overwhelming tuberculosis and adrenal failure.

     I am therefore going to list some ordinary precautions that a physician should take before prescribing anti-inflammatory steroids for his/her patient. This list is neither exhaustive nor all-inclusive, but merely covers the fundamentals of good medical care. I firmly believe that doctors can do untold good or harm by the proper use or improper misuse of prescription drugs, which is why I have always read as much as I could about pharmacology and I subscribe to  the FDA drug-warning e-mail emergency list.

     Many patients have been infected with tuberculosis (TB) without being aware of it. If you have a robust immune system, you generally can confine live TB germs  to your lungs. But if you take enough prednisone for enough days, then the body's immune surveillance of the live TB germs in your body is suppressed, the TB germs multiply, and they can spread throughout your body and kill you. This occurrence has been well documented. Therefore, BEFORE your doctor starts you on an oral steroid, he/she should skin test you for TB, and treat you with isoniazid (INH) if your skin test is positive for as long as you are taking the steroid. (The precise dose and length of treatment with INH should be discussed with a pulmonary or infectious disease specialist).
And having received BCG vaccine against TB does not mean that a positive PPD (TB skin test) can be ignored.

     Second, there is a rather common intestinal parasite called strongyloides stercoralis. This nematode inhabits and is fastened to your distal colon, and its reproduction and spreading is also kept in check by your immune system. When the first kidney transplant patients were immunosuppressed, a number of them died from overwhelming strongyloides auto-infection. Therefore before your doctor starts you on oral or IV steroids, you should have a stool exam for evidence of intestinal parasites, especially strongyloides. Again, like ignoring a possible TB infection, omission can prove fatal.

     Third, and in the same vein, steroids also attack the part of the immune system that keeps live viruses under active suppressive surveillance. So if you have received a live virus vaccine (mumps, rubella, oral polio, yellow fever) or have a herpes infection in your eye, the prednisone should be deferred until one month after the vaccine or until the eye infection has been cleared. On theoretical grounds, you should also probably defer any steroid treatment if you have a bacterial abscess, such as acute diverticulitis.

     I should mention  here that your body's natural production of prednisone is approximately 7.5 mg/day, with a diurnal variation, so the peak levels are in the morning. The secretion of prednisone is controlled by a feedback loop to your pituitary gland, which secretes ACTH to stimulate the production and secretion of prednisone by cells in your adrenal gland.  If you take enough prednisone for a long enough period of time (and this amount and time should be determined by testing by an endocrinoligist), then the pituitary gland gets so suppressed that when you stop taking the exogenous steroid, the pituitary gland has lost its ability to manufacture ACTH, so the first time your body is stressed by an infection, your adrenal gland  will be unable  to make "stress doses" of prednisone and you will die in adrenal crisis.

     Now, for completeness, let me list some of the documented conditions  that the chronic use of steroids can create in your body, which, while damaging, are rarely fatal, although they can be permanent:

high blood pressure
congestive heart failure
salt and water retention
bleeding stomach ulcer
insulin-dependent diabetes
ocular cataracts
insatiable appetite
clotting problems
tendon rupture
pseudotumor cerebri

     Needless to say, not all of these side effects happen to all users of steroids, but it is probably prudent to start any patient, male or female, on a drug such as Fosamax that can prevent osteoporosis when steroids arfe started, so long as there is no concomitant esophagitis or gastritis.

     But of course, if the steroid treatment is necessary for your continued good health, such as reversal of an asthmatic attack, treatment of kidney failure caused by lupus, certain bullous dermatoses, then the above risks should not stop you from taking the medicine.



Wednesday, December 28, 2011

Anger Part II--Anger grows out of Frustration

     Anger seems to be amplified frustration, so the questions are (a) what makes us frustrated, and (b) what amplifies it? It seems that frustration is created by the loss of an object, either property or a person, either a real  loss or a fancied or predicted/feared-for loss. We get frustrated and angry in a traffic jam because we are deprived of freedom of movement. We even honk at the "slowpoke" driving in front of us because we are frustrated at our inability  to drive faster. Righteous anger is a special category because then we justify our anger by saying that it is directed at a sinner or a breaker of society's laws or mores who therefore deserves both scorn and anger, which may be amplified by our own  frustration and anger at never having participated in "sex, drugs, and rock and roll" as the hippies of the '60s did.

     It seems that frustration is caused by loss plus the inability to do anything about the loss. (It is notable that in classical psychodynamic theory depression is also caused by a loss. Could the strictures of society then explain why more women  than men get depressed, and more men  than women get homicidal with rage?) This immediately harkens back to a baby's instant anger when deprived of his/her rattle. Society may have taught us how to channel and not act on the rage we feel from being frustrated, but we have never learned how not to feel frustrated. Giving trophies to all the members of all the little league teams' players rather than just to the winners does not prevent adult feelings of frustration in later life; it just makes the sensation rarer and therefore more difficult to deal with.

     So unlike what all mental health practitioners tell us, it is the reaction and negative feeling of frustration that is inborn, and not anger. We must therefore ask what tools our family and society has given us to help us prevent our frustration from exploding into anger, and why, under certain circumstances, our feelings of frustration are relieved by exploding into anger. Of course society accepts our getting furious at ourselves if we drop and break something---we are instantly angry at our loss, and everyone empathizes with us. In a somewhat similar way society understands our getting angry when our favorite team loses, although what it is about the loss that led to  our frustration is less clear since  in that  case nothing tangible was taken from us.

     Therefore the thrust of anger management courses should be to teach us how to prevent frustration from escalating into anger, rather than assuming we will get angry and then teaching us how to control it. You should't  deal with an alcoholic by teaching  him/her how to behave when drunk.  By the time we get angry we are already near a dangerous flash point. And it is much more common than we think----boredom, for instance is low-level anger. We are frustrated that we are wasting our time doing whatever it is that is boring us, and then angry at ourselves or others  for our not getting up and doing something else. We know deep down that the only thing we have to spend that is uniquely ours is our time, and the time we spend  doing something we do not want to do (schoolwork, housework, visiting with inlaws) generates resentment, frustration and eventually anger.

     The surest recipe for frustration-amplification-anger is the knowledge that the loss cannot be reversed, thereby adding a feeling of impotence to our frustration. It is all well and good for Omar Khayyam to have written "The moving finger writes.......", but the reality of the irreversibility of time can be a very bitter pill to swallow. Thus when a loved one commits suicide, we become angry because (a) the loved one left us without warning us or seeking permission and (b) it is totally irreversible. Similarly, in a divorce, the children tend to be angriest at the spouse who leaves, no matter what the justification, since it is the act of leaving that certifies the divorce-to-be. In the same vein, when one of a divorced couple gets married, the other spouse and children often get angry all over again because a re-marriage demonstrates to one and all that the marriage is really over.

Monday, December 26, 2011

Anger Part I

     I decided to write a blog about anger, because it is a condition for which there is no reliable drug treatment  and which is also not classified as a psychiatric disease. There are anger management courses offered, but a recent article in a German newspaper reported that the leader of an anger management course stabbed one of the attendees three times. Even Freud did not write a monograph on the psychiatric cause(s) of anger, probably because it is such a primary response that its origin is  inborn. He did talk about eros and thanatos, which can be thought of (very loosely) as the need for love and the death wish, and treated them as innate,, because he could find no convincing explanation for the existence of war, let alone torture. It clearly must have something to do with thinking, because man is the only animal who tortures, one of the few animals who kills his own kind, and the only animal that commits suicide.

     All babies have an inborn need for love and for human contact, and have the capacity for immediate anger which is usually shown by yelling and getting red in the face. When very young, they usually can be soothed at once by nursing at the mother's breast. No one yet understands what makes a baby colicky, and a noted female pediatric psychiatrist wrote an article about how when her baby became  colicky she was almost driven crazy, even though she knew full well that she had not caused the condition nor was there any successful way to treat it.

     I would like to approach the problem of anger from a different viewpoint: Isn't it more difficult for a totally satisfied person to really  get angry and lose his/her temper? When we are satisfied, anger is furthest from our mind  because we are pre-occupied with the happiness of our state. Whether it is achieved by being in love, or being high  on life or drugs or jogging  or  anything else that gets our  mental endorphins flowing, there is no room for anger. No one knows what chemicals in the brain get increased or decreased  when anger surges; we only know the chemical result which is an outpouring of adrenalin, etc.

     By the same token, we do not understand what really triggers and escalates  anger. It is obvious that it is usually displaced from the real object of  our anger to a surrogate at whom it is emotionally safe or acceptable to display the anger. The trivial example is that your boss yells at you so when you get home you kick the dog. A more subtle displacement is the phenomenon of road rage, with or without gunshots. What is the real source of your anger that is discharged by "losing it" at the driver who cut you off on the freeway? What is the real source of anger when you yell at your spouse or children? Who or what are you angry at when you punch a hole in the wall? The question is what the other person's actions symbolize to you or threaten that is of vital concern to you, and whether or not the anger is generated by your frustration at being unable to address the cause of your anger directly. As an aside,  what damage has been done to your psyche when your parents have suppressed your  need for anger so completely that you "never get angry"?

     All mental health workers agree that the emotion of anger is a normal and natural one and only becomes a problem when it escalates  out of your control, driving you to an action that you would never have done in a "normal" state. That is, in a state of anger, actions that would normally be egodystonic to you become temporarily egosyntonic, as if you are temporarily not the person you recognize as yourself ( "Dr Jekyll, let me introduce you to Mr. Hyde".) And why are there people who walk around in a state of chronic anger?
We often feel ashamed or embarrassed after such actions when we "cool down", and vow never to let such a thing happen to us again, much as an alcoholic vows to stop drinking after his/her first  blackout or arrest for drunken driving, or really severe hangover.

     It is as though we become temporarily insane, in that we lose conscious rational control of our behavior. We rant and rave and yell and strike at people or things both emotionally and physically. Who doesn't recall, for instance, the TV picture of Paul O'Neill, the all-star right fielder of the New York Yankees, kicking the water cooler or slamming his hat or bat down in the dougout whenever he made out? Was that due to his nature or his nurturing or a combination of the two?

     If anger is a state of temporary insanity, to use that word loosely, is it that we slip  the bonds of  "civilized" behavior, or is it that there is a parallel being inside of us who is irrational and can erupt by escaping our control under certain emotional stimuli? There is no good evidence for either explanation. And we certainly have no idea why certain thoughts or ideas or concepts infuriate certain people and make them "see red". Very often our anger response is greatly out of proportion to the triggering incident. This is a sure sign that what/who we vented our anger at is not the true focus of our anger.

To Be Continued.....