Questions Answered (I Hope)

I’m going for the hat trick: three posts in one day. I hope I’m not overloading anyone with information. I think everyone knows cocaine use is not good and I’m a sure only small fraction of people care about Michigan State football. To be honest, I’m not too sure I care about Spartan football, so I don’t know why I write anything about it.

Anyhoo, awhile back JC wrote a post/letter concerning some medical issues, then Emily followed up JC’s questions with some of her own. So I’m going to try to attempt to answer those questions. I know this was not done in a timely manner. I apologize and remember I’m only a medical student. I think I give sound advice and I’m up to date with the literature, but I’m not a doctor yet.

I’ll address Emily’s questions first, because they have shorter answers.

Emily,
It has been hypothesized that females actually display more attention deficit symptoms and males have more hyperactivity in the spectrum of attention deficit hyperactivity disorder (ADHD). Although you seem to be having trouble with your concentration a key diagnostic criteria for ADHD is the presence of either attention deficit or hyperactivity in two or more separate settings BEFORE the age of seven. You don’t fit those criteria. However, the inability to concentrate is often a cardinal symptom of mood disorders, i.e., adjustment disorder, depression or anxiety. You have made a huge transition to law school from undergrad in a new town with scarce financial resources. You are also about to take your first set of law school final exams and in one class you seem particularly concerned. I would say your inability to concentrate would be more likely related to those issues and not ADHD. The anxiety is often treated medically with selective serotonin reuptake inhibitors (SSRI’s), benzodiazepines, like alprazolam (Xanax), or busprione. Relaxation techniques and exercise are also helpful in relieving anxiety. Psychotherapy is a mainstay of management, however, good psychologists are hard to come by and often insurance companies do not cover the cost. As for adjustment disorder, there are no treatments and this usually resolves with time.

The exercise-induced asthma is how my asthma initially presented. I often would wheeze after my run or especially after playing basketball in a dry IM building. Then one night at Jeni’s cousin’s house it was very smoky with cigarette smoke and I had my first asthma attack, which is not fun. Soon after that I began waking up from my sleep wheezing. I was given an albuterol inhaler, but I abused that because I needed to use it too often. Eventually I was placed on Advair 100/50. Your two brothers have asthma and our entire family has very bad allergies. You most likely have asthma. The best treatment for asthma is a long acting beta-2 agonist combined with a steroid and an albuterol rescue inhaler for acute exacerbations. Advair has fluticasone (a steroid) and albuterol (a short acting beta-2 agonist) and is an outstanding medication for control of asthma symptoms. If your symptoms persist, you should see a doctor and be given Advair.

JC,
One of the reasons I love neurology is because it is all about localization. If a person has a neurological symptom, the goal of the neurologist is to localize exactly where this lesion is in the nervous system. So with the constellation of symptoms/questions I tried to think of one area in the body that could produce those symptoms. I did that, but I don’t think that is your problem. It was just fun to do.

The hypothalamus is a small structure located in the middle base of the brain and plays a role in several biological functions from initiating sleep to hunger and satiety to releasing hormones that are involved in the body’s metabolism. The suprachiasmatic nucleus (SCN) in the hypothalamus is involved in the initiation of sleep, the ventromedial nucleus controls hunger, while the ventrolateral nucleus detects satiety – or the feeling of fullness – and the hypothalamus also releases thyrotropin releasing hormone (TRH), which stimulates the anterior pituitary to release thyroid stimulating hormone (TSH), which then in turn stimulates the production of thyroid hormones, triiodothyronine (T3) and thyroxine (T4). Therefore, a disruption in the hypothalamus could cause symptoms such as insomnia, specifically difficulty falling asleep, trouble recognizing hunger and fullness as well as hypothyroid symptoms, such as lethargy, weight gain, cold intolerance, dry skin, brittle hair and oligomenorrhea/amenorrhea (in females).

I don’t think you have a hypothalamic problem. But it’s just interesting to see how all of those symptoms could be connected. However, I do believe some lab work is in order. I would start with thyroid function tests, such as TSH/Free T4. A high TSH and low T4 would be indicative of hypothyroid and this could explain several of your symptoms. Hypothyroid is easily treated with levothyroxine (Synthroid or Levoxyl), which will increase the level of T4 and will bring you back to your baseline energy level as well as increase your metabolism and slow any weight gain.

A binge/purge diet can be seen in people who are very busy, like you, who travel a lot and cannot find the time to eat. Then when they do find time, they eat a lot. It’s not a great way to eat because not eating will slow the metabolism and then all the food consumed later takes longer to be burned off. That’s why bulimics are awful at losing weight whereas their eating disorder counterparts, anorexics, are much more successful by simply starving themselves…which is obviously even more unhealthy. If you could make your schedule a little more time friendly, finding time to eat on a regular basis would not be as difficult and would probably help with any lethargy you feel during the day.

Finally, some of your sleeping problems could be addressed with the medication ramelteon (Rozerem). Ramelteon is a melatonin receptor agonist that acts in the SCN of the hypothalamus to help in the initiation of sleep. Melatonin itself is a powerful sleep stimulator and over the counter melatonin supplements could be used as a sleep aid. Better sleep would also improve all of the symptoms you have asked about, because it will allow your body to become familiar with a routine.

I hope I’ve addressed all of the questions and I hope that at least some of this helps. Sorry it was too long, I hope no one got diarrhea as they have in previously long posts by me. But I can address that at another time.